The qualified district nurse is vital in meeting the challenges in contemporary community practice, which has become more pressured during the ongoing COVID-19 crisis. The need to provide high-quality care with consideration of commissioning requirements has been challenging with the rapid rise in caseload numbers. According to Alderwick et al (2016), commissioning requirements including sustainability and transformation plans (STPs) were introduced by NHS England in response to challenges faced in health and social care, highlighted in the NHS Five Year Forward View (Department of Health and Social Care (DHSC), 2014; NHS England, 2016). This has since resulted in the development of the NHS Long Term Plan (NHS England, 2019), which sets out targets in achieving a new service model joining up care in the most appropriate setting, with community care being a main focal point. This focus of the transfer of care to the community setting has been highlighted as essential during the pandemic. NHS organisations in differing geographical fractions of the UK have been asked to work in partnership, with many clinical commissioning groups (CCGs) merging to counter health and social care concerns and examine service provision required to meet the needs of local populations to attain the targets set by the NHS Long Term Plan (DHSC, 2014; NHS England, 2019; NHS England, 2020).
Nursing is a passionate, enterprising profession that must respond to fluctuating pressures within health care and rise to the challenges set (Pringle, 2009). The COVID-19 crisis has set unprecedented challenges, with DNs needing to find new ways of working to meet the increase in demand. Within the role of the DN, there is a requirement to work innovatively with limited resources and to safeguard effective delivery of services from DNs, which are both high-quality and cost-effective (DHSC, 2010; 2013; Queen's Nursing Institute (QNI), 2015; 2017; 2019). To meet the challenges posed by both COVID-19 and future service provision, those with Specialist Practitioner Qualifications in District Nursing (SPQDN) require a high level of education both in university and practice.
Role of the DN in influencing future education and practice
The need to create a workforce that can deliver high-quality community care, meet commissioning requirements as well as address the shortage of qualified DNs, has been apparent for long, with calls for transforming nursing education into the new DN apprenticeship route (Henderson and Hassmiller, 2007; Benner et al, 2010; Institute for Apprenticeships and Technical Education (IATE), 2020). A challenge DNs encounter is how to navigate complex learning environments while managing an increasing scale of nurse practice despite working within difficult financial constraints and the challenges posed by COVID-19 (Pringle, 2009; DHSC, 2011; Seib et al, 2011; QNI, 2019). These challenges not only affect specialist practice, but also the progression of nurse education; therefore, curriculum development is essential (Benner et al, 2010; Seib et al, 2011; QNI, 2015; Nursing and Midwifery Council (NMC), 2018). In relation to the SPQDN educational programme and development of the DN apprenticeship, DNs must contribute to the provision of relevant, receptive, evidence-based training and education (Giddens and Brady, 2007; Van de Mortel and Bird, 2010; Seib et al, 2011; Kantar and Alexander, 2012; QNI, 2015; IATE, 2020). Previously, educational programmes have been criticised for being too grounded in tacit knowledge (Giddens and Brady, 2007; Tanner, 2009; Kantar and Alexander, 2012). An example of this within academia within the SPQDN qualification is an implied understanding that SPQDN students will become future leaders based on attaining the standards outlined by the NMC (2001). However, as discussed, as well as reaching NMC standards, there must also be consideration of the requirements of the future workforce (Benner et al, 2010; Royal College of Nursing (RCN), 2013; Addicott et al, 2015). DNs are well placed to influence curriculum development to deliver these demands in terms of contributing to the development of the new DN apprenticeship (NMC, 2018; IATE, 2019). One such requirement highlighted in practice is evolving advanced practice skills unique to the DN role in both clinical diagnostics and advanced prescribing. These skills are not a prerequisite to achieve the SPQDN qualification, but attaining these within the new DN apprenticeship would strengthen the qualification to meet the needs of the DN caseload and the challenges highlighted through the pandemic, as well as achievements of NHS Long Term Plan (DHSC, 2013; 2014; NHS England, 2019; QNI, 2019; IATE, 2020). Developing nursing skills such as prescribing and clinical diagnostics in the community was discussed widely within the Shape of Caring Review produced by Health Education England (HEE) (2015), aiming to guarantee high-quality nursing education to ensure services deliver high-quality care. The role of the DN is to contribute to such role development and, within practice, DNs are in the strongest position to provide robust leadership in delivering these new services (NMC, 2001; Yuki, 2010; Carr and Gidman, 2012; QNI, 2019).
SPQDN role in practice education
The challenges posed by the COVID-19 crisis have highlighted the role played by SPQDN educators in practice, teaching and educating future SPQDN leaders to provide excellent responsive community care. The role of the DN educator, which now incorporates two professionals-practice supervisors and practice assessors, both supporting SPQDN students in practice-should be to effectively work across both academic and practice settings to ensure quality within SPQDN education (NMC, 2018). In line with the NMC, QNI and future DN apprenticeship standards, DN educators must work towards creating professional status as a qualified SPQDN and educators teaching future DN team leaders (QNI, 2015; QNI, 2019; IATE; 2020). Johnson et al (2012) maintained that nurse education remains crucial to preserving professional prominence. At a time when funding and training courses to become DNs have been under threat of reduction, it is vital in clinical practice that the importance of supporting learning in role development is strongly demonstrated to ensure that NHS trusts and third-sector parties recognise the role as vital and use their apprenticeship as levy. Providing an effective learning environment for SPQDN students plays a pivotal role in creating professional identities for DNs fulfilling their responsibility in contributing to academia and provision of empirical learning in practice (Johnson et al, 2012; NMC, 2018; QNI, 2019). According to Adams (2013), there is a close link between structures in place in the practice environment and how individual DNs define themselves. The workplace setting inevitably moulds the individual, but equally, the individual also has the capacity to influence work practice and the organisation (Adams, 2013). This would suggest that DNs within the clinical arena can influence how their role is operationalised at a strategic level and, in clinical practice, they have the ability to influence and shape the future SPQDN workforce, something that is crucial at the moment (Adams, 2013; Kleebauer, 2016; QNI, 2019).
To ensure the quality of the SPQDN programme in both the traditional route and future DN apprenticeships, assurance must be reached that, within the learning environment, future SPQDN students themselves will become educators to continue the cycle and production of quality (RCN, 2013; QNI, 2015). The NMC Standards for Student Support and Assessment (SSSA) moves away from SPQDN practice teacher qualification to a model of practice supervisor and practice assessor in practice, a change for DN practice education (NMC, 2018). Advantages to the SSSA include the Practice Supervisor role being widened and the recognition of the contribution of a host of multi-professionals in DN education (NMC 2018). There is also the potential minimising of the risk of toxic mentorship by splitting the supervisor and assessor roles (Swazey and Anderson, 1996). There are concerns in the potential dilution of the quality of the practice assessor role in DN education. The practice teacher qualification required the undertaking of two postgraduate modules and is replaced by a non-credit workshop to prepare a practice assessor with no face-to-face contact or assessment required. Teaching and assessing is a profession with skills and knowledge above that which is taught in nurse education. This change threatens to de-value the quality of the assessment process by removing the high standards of preparation previously demanded. It will be a challenge, both for those preparing practice assessors and those undertaking the practice assessor roles to maintain quality in the DN assessment practice process. With the dissolution of the practice teacher role, it is vital that a level of education exists in teaching future DNs in practice. It is widely felt by academics and educators within the clinical arena that consideration should be given to the development of an academic teaching qualification for those assessing specialist practitioners above that of the SSSA standards, which only provide minimal education, with some areas developing online training to achieve these roles.
Current picture of SPQDN education
The SPQDN degree or postgraduate diploma provides the entrant the title of ‘district nurse’ when completed (NMC, 2001; Green, 2016). On completion of the course, the SPQDN student must have attained the official standards for DN education and practice, formulated by the United Kingdom Central Council (UKCC) in 1994 (UKCC, 1994). These standards form the basis of SPQDN education in both university and practice, leading to a recordable qualification (NMC, 2001; Green, 2016). The NMC standards are built upon the SPQDN exercising higher levels of judgement in clinical care, including assessment, planning, implementation and evaluation of specialist nursing care alongside effective leadership in the role (NMC, 2001; DHSC, 2013). The role of the DN in practice is to teach and assess as competent those undertaking the SPQDN to ensure that the highest standards are met in clinical practice for students who wish to become qualified DNs (NMC, 2001; Sayer, 2011; Hollinshead and Stirling, 2014). One essential role within district nursing is to ensure that education based on these standards maintains congruence with contemporary best practice; however, disappointingly, the DN qualification remains underpinned by standards and definitions written more than 20 years ago (Dickson et al, 2011). In response to this, the QNI and Queen's Nursing Institute Scotland (QNIS) worked collaboratively with senior groups from education, commissioners, the voluntary sector, the NMC and UK national governments to introduce voluntary standards in 2015 (QNI, 2015; Oldman, 2016). The intention of the QNI/QNIS Voluntary Standards for DN Education and Practice is to improve, not supersede, the existing NMC standards and enhance educational courses for current and future DN practice, aiming to provide holistic care, deliver complex caseload management and prevent avoidable hospital admissions (QNI, 2015; Oldman, 2016). Education also forms one of the four pillars within the QNI standards (QNI, 2015). These standards remain voluntary, with some believing this may produce inequity in interpretation and implementation in both practice and formalised DN education, leading to variations in benchmarks that future DNs reach on qualification (Montt, 2011). With the introduction of the new DN apprenticeship, new knowledge, skills, behaviours and duties will form unity across education provision to ensure that the standards to which modern-day DNs should be working are attained, thereby better reflecting practice (IATE, 2020). With many higher educational institutes hoping to commence courses by September 2021, students will then use the apprenticeship route to achieve the SPQDN once the traditional route becomes no longer viable for trusts in England due to continuing threats to funding across varying sectors. The DN apprenticeship course will be mapped against the NMC competencies to enable the qualification to be recorded on the register, but these still remain dated. It is hoped that new standards will be written by 2022, but in the ongoing COVID-19 health crisis, educators are concerned with how and when the new standards will be implemented.
Investment required
Alongside changes in curriculum and education provision and concerns around implementation of new NMC standards, there are apprehensions around failure of commissioners to acknowledge the qualification as a requirement in community nursing in the future (Longstaff, 2013). The QNI has campaigned for improved investment in SPQDN education, with the fundamental aim of reversing the decline in entrant numbers of new DN students and the number of courses being offered (QNI, 2015; Green, 2016; Oldman, 2017; QNI, 2019). Ultimately, in the clinical arena, with funding being provided through the apprenticeship levy for working towards the new DN apprenticeship standards, QNI standards with achievement of the NMC standards will be the only way to provide quality assurance for those who are given the job title of DN, providing benchmarks for standards of practice to which all SPQDNs should be working (NMC, 2001; DHSC, 2014; QNI, 2015; Green, 2016; QNI, 2019; IATE; 2020). For DN educators in clinical practice, instilling the QNI standards in the design and implementation of teaching strategies, as well as the NMC standards alongside the future knowledge skills and behaviours of the DN apprenticeship standards, serves to provide the highest outcomes in supporting learning across both practice and academia (NMC, 2001; DHSC, 2014; QNI, 2015; NMC, 2018; IATE, 2020).
Role of the DN in influencing curriculum
With shortages of DNs across the country ultimately affecting the quality of care provided, it is vital that DNs contribute to workforce development, including education provision (QNI, 2015; Maybin et al, 2016; QNI, 2019). To ensure this contribution, DNs in the clinical arena must continue to engage in links with higher educational institutions to influence curriculum development to ensure new proposed courses deliver against the requirements of the workplace (NMC, 2017; 2018). In clinical practice, this is being achieved through strategy meetings, which must form part of any apprenticeship (IATE, 2020). Maintaining strong connections through continuation of practice/educator forums held throughout the year at most universities are aimed at providing a platform for such links to be formed. Sarah Marquis, SPQDN Modern Matron at Lancashire and South Cumbria NHS Foundation Trust, says:
‘The complexity and skill required to be an effective SPQDN can only be achieved through a robust partnership with our university colleagues. As a SPQDN and qualified practice teacher, it is crucial that we understand the curriculum and the standards expected so that we can help mould our future DN leaders. There is nothing more rewarding than seeing a SPQDN student grow in confidence and bring their theoretical knowledge to life in the clinical environment.’
When discussing influencing curriculum development, it is vital that DNs understand the curriculum and how to promote the practice element to the adult learner within an effective learning environment (NMC, 2018). Adult learners require influence over personal learning and in integrating knowledge from theory into practice, which is said to expand through the application of adult learning (Knowles et al, 2011; Ruesseler and Obertacke, 2011). In clinical practice, knowledge of adult learning theory within curriculum delivery of bridging the theory practice gap supports the use of self-directed learning (Carnell, 2007; Ruesseler and Obertacke, 2011; Jokinen and Mikkonen, 2013; Curran, 2014). Learner-centred teaching and curriculum design is said to promote theory–practice integration into the workplace, leading to the creation of a quality workforce in the future (Drewitt, 2008; Speicher and Kehrhahn, 2009; Knowles et al, 2011; Jokinen and Mikkonen, 2013; Curran, 2014). Therefore, the DN role is to design, implement and evaluate learning strategies and the learning environment across both practice and academia, which ensures the creation of such a workforce (NMC, 2018; QNI; 2019). This will have the ultimate aim of increasing SPQDN numbers and developing the workforce to meet the challenges and demands highlighted here.
Conclusion
The NMC post-registration standards review has arrived at a critical time within community practice. The need to strengthen both the workforce and the qualification is highlighted as being essential in meeting the demands in community care. DNs have been at the forefront of providing high-quality nursing care during the COVID-19 crisis and have responded with emphatic professionalism to the sudden increase in caseload demands caused by rapid discharges from acute care, allowing hospitals to deal with COVID-19 admissions. The world of healthcare has dramatically changed, and district nursing must be contemporaneous to keep up. With CCGs requiring leadership to deliver the NHS Long Term Plan, DN education must evolve to meet these needs.
The role of the DN in practice is to educate, teach and assess as competent those undertaking the SPQDN course, supporting learning across practice and academia to ensure that the highest standards are met (NMC, 2001; Hollinshead and Stirling, 2014; Alderwick et al, 2016; NHS England, 2019; QNI, 2019). This is to safeguard the overall quality of the SPQDN role, ensuring the qualification continues to be a requirement of the DN job title (Adams, 2013; Alderwick et al, 2016; QNI, 2015; 2019). Changes through commissioning within the DN workforce make the dual clinical and educational role increasingly more complex, causing challenges to facilitation and assessment of students in practice and in creating an effective learning environment (Kenyon and Peckover, 2008; Haydock et al, 2011; Carr and Gidman, 2012). Therefore, there is a need in clinical practice to provide quality assurance on a strategic level to ensure those commissioning the service can see the value in the continuance of the SPQDN qualification to safeguard provision of the highest standards within the practice (QNI, 2015; 2017; 2019). Further, it is vital to ensure that NHS trusts continue to fund future education via the apprenticeship levy.
DNs must engage in links with higher educational institutions to influence curriculum development to confirm that the future DN apprenticeship delivers against the requirements of the workplace. In relation to DN education, it is essential that DNs in practice contribute to providing relevant, contemporary education, such as advanced diagnostics and prescribing, to ensure that the highest standards in patient care are met within the practice-learning environment (Addicott et al, 2015; QNI, 2015; 2017). There is a requirement in clinical practice to safeguard the quality of SPQDN education, with the need to ensure those providing teaching and learning in practice have the necessary qualifications to be able to provide this to the highest standards. To maintain this level of quality, it is suggested that DNs assessing SPQDN students should be educated to a higher level than that provided by the SSSA, through documented education teaching knowledge and skills.
KEY POINTS
- Continuation of the district nurse (DN) qualification is vital to benchmark standards of practice
- DNs have the ability to influence and shape future Specialist Practitioner Qualification in District Nursing (SPQDN) workforce through documented teaching and learning in practice
- DNs should engage with curriculum development to ensure SPQDN education, including DN apprenticeships, meet the requirements of commissioners, practice population and achievement of the NHS Long Term Plan. DNs are is in the strongest position to provide robust leadership in delivering these services
- DNs hold a responsibility to continue quality education of future SPQDN students. Consideration to the level of education required to teach and educate specialist practitioners in the practice environment needs to be discussed.
CPD REFLECTIVE QUESTIONS
- What is your role as a district nurse (DN) in educating Specialist Practitioner Qualification in District Nursing (SPQDN) students within the practice environment?
- What forum can you use to engage with your local higher education institutions to ensure courses developed meet the requirements of DN practice?
- How can you work with commissioners and NHS trust leads to demonstrate the quality of the DN role and the continuance of the qualification as a requirement of the title/role?
- What level of education do your DN educators hold and how can this be protected to maintain quality in the future?