The current health policy agenda in Wales and across the UK emphasises the value and importance of providing care closer to the patient's home or community. Healthcare services will need to change and adapt to meet this policy agenda (Welsh Government (WG), 2018), with the result that community nurses in particular will need to lead and deliver care in an increasingly challenging environment. Investing in the development of a skilled community workforce is imperative if these challenges are to be overcome. In Wales, there is an ever-increasing healthcare demand associated with an aging population, where individuals are living longer with complex coexisting long-term health conditions (WG, 2014). In achieving the aim of providing care closer to home, district nurses (DNs) may be seen as key players, reflecting their role as providers of care for patients within their own homes (Welsh Assembly Government (WAG), 2009). This view is supported by the Queen's Nursing Institute (QNI) (2009), which identified DNs as the main providers of care in the home and community setting. It is suggested that one in four people over the age of 75 years and one in two people over the age of 85 years require care from a community nurse at home.
Positive and demonstrable leadership within DN teams is key in supporting this provision of effective care for patients in the community setting (QNI, 2012). Leadership has been identified as one of the key skills, alongside governance and accountability, as essential to the sustainable delivery of safe, effective and person-centred care (WG, 2015). Similarly, it is recognised as one of the four pillars supporting advanced nursing practice (National Leadership and Innovation Agency, 2010), and leadership education is a key requirement within the district nursing Specialist Practice education programme (QNI, 2015). The relationship between nurse leadership and positive patient outcomes has been well documented (Wong et al, 2013; Carragher and Gormley, 2017). Similarly, the Francis Report (2013) and the Keogh Report (2013) highlight the consequences of failed leadership, both at an organisational and clinical level, on patient care.
Historically DNs have been identified as the ‘glue’ that holds together the complexity of the care interventions frequently required to support patients at home (Audit Commission, 1999), and it would appear that this continues to be the case today (QNI, 2014; Maybin et al, 2016). Maybin et al (2016) consider how quality in district nursing services might be determined and argue that it can be achieved in part if the disctrict nursing ‘leadership voice’ is heard at a strategic level in order to articulate DNs expertise and knowledge. Kumar (2013) suggests that effective leadership by health professionals is essential in modern healthcare settings, where the effectiveness of clinical leadership is measured through patient outcomes. However, there would appear to be little evidence exploring the nature of leadership in DN teams (Cameron et al, 2012), making the case for exploring clinical leadership within district nursing practice compelling.
The aim of this paper is thus to consider through a case study approach the importance of compassionate clinical leadership in district nursing practice in caring for patients with complex chronic wounds requiring palliative care. A leadership framework for clinical practice is developed, based on an anonymised case study (Nursing and Midwifery Council (NMC), 2018).
Defining leadership
While we might intuitively know what ‘leadership’ looks like, definitions are often coloured by the perspective of the individual and the context in which ‘leadership’ is being defined, with the result that we all have our own view of the concept of leadership (Kumar, 2013). Northouse (2016) describes how early definitions of leadership reflected the importance of the personal traits of the leader as an individual, with the followers remaining largely invisible. As the study of leadership developed through the 20th century, trait theories fell out of favour and leadership became defined in terms of the skills and behaviours of the leader and the effect of these behaviours on the followers. Northouse (2016) offers the following definition:
‘Leadership is a process whereby an individual influences a group of individuals to achieve a common goal’.
The strengths in this definition lie in the fact that leadership is acknowledged as a process and it recognises the relationship that needs to exist between the leader and their followers. It is the recognition of this relationship that has supported the development of more contemporaneous leadership theories during the latter part of the 20th century, such as servant leadership, authentic leadership and transformational leadership (Gopee and Galloway, 2017) (Table 1). The contribution of effective leadership to the delivery of quality and safety in healthcare service provision has been recognised (Wong et al, 2013). More specifically, transformational leadership has become widely advocated within the healthcare setting, with transformational leaders aspiring to effect significant positive change in services and organisational culture through their relationship with their followers (Fischer, 2017; Gopee and Galloway, 2017).
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Trait theory: |
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Functional theory: |
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Behavioural theory: |
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Contemporary theory: |
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An alternative view of leadership is proposed by Kouzes and Posner (1995), who introduce the concept of leadership as an art. Quinn (2017) suggests that this view of leadership sits well within nursing, which relies very much on the art of caring being at the heart of the nurse-patient relationship. Further, considering leadership as an art reflects the work of Carper (1978), who proposed a typology of nursing that acknowledges the element of aesthetics. This, Carper (1978) suggests, takes account of the relationships that develop within nursing practice and reflects the humanistic approach taken by nurses in their interactions with patients (Johns, 2002). It could be argued that this has resonance with the leader-follower relationship, which needs to be developed if clinical leadership is to be seen as effective.
Compassionate leadership has emerged as a more contemporary theory as a response to the view that modern healthcare systems have lost their ‘moral compass’ (de Zulueta, 2015). Bivins et al (2017) explore how compassion may be defined and highlight the complex nature of compassion, identifying that it incorporates a number of elements, including a need to understand the perspective of others and a desire to alleviate the sufferings of others. Compassion can be defined in terms of its moral and ethical dimensions, where not taking action would compound the suffering of others (Bivins et al, 2017). Within contemporary healthcare policy, compassion has been identified as one of the six Cs—core elements of nursing practice—and in this context, it has been defined as follows:
‘Compassion is how care is given through relationships based on empathy, respect and dignity—it can also be described as intelligent kindness, and is central to how people perceive their care’
In order that DNs might be able to embrace and demonstrate leadership within their practice, leadership education is embedded within the requirements of the District Nursing Specialist Practice education programmes (QNI, 2015). However, DNs appear to struggle to recognise their leadership role in practice as they strive to meet the ever-increasing demands on their service and the increasing complexity of care for their patients. As Charles (2016) points out, much of district nursing practice is carried out ‘behind closed doors’ in the patient's home and remains largely invisible. As a result, innovation aimed at addressing these demands is stifled and the quality of service provision is adversely affected. Using a framework may be one strategy in order to support DNs to articulate and demonstrate their leadership practice, stimulating change and innovation within district nursing services.
In relation to this particular scenario and supporting the care of community-dwelling patients with complex health needs more widely, West et al (2017) suggest a framework for compassionate leadership that reflects the multifactorial nature of compassion in nursing practice. This framework identifies four key elements: attending, understanding, empathising, and helping. With leadership being identified as the key to providing safe compassionate care (WAG, 2013), being able to demonstrate effective leadership in practice is a requirement of our accountability as practitioners (NMC, 2018). Further, compassionate leadership within organisations goes some way towards supporting a culture where change and innovation are welcomed and supported (West et al, 2017).
Case study
Sarah was a 45-year-old woman who was a single parent with two young children. Following abdominal surgery, she was referred to the district nursing service to drain what was thought to be an abdominal abscess. Unfortunately, biopsy examination identified this to be cutaneous metastatic deposits (Box 1), and following further investigation, a primary lesion was identified within the lung. The abdominal wound failed to heal and developed into a significant fungating vascular lesion that bled profusely on occasion. While palliative radiotherapy addressed this problem, the fungating lesion persisted and required daily dressing changes with guidance from a tissue viability and wound healing team.
Despite Sarah's deteriorating condition, her wish was to remain at home with her children, and a key aspect of compassionate leadership is this person-centred approach, which is particularly relevant when caring for patients like Sarah, where wound healing is not the primary goal of care. Political and organisational agendas frequently present DNs with ethical dilemmas, where scarce resources and budget limitations require DNs to take a utilitarian approach of doing the most good for the greatest number of patients. As a consequence, there is a risk that the person-centred approach to care is lost, to the detriment of patients with complex health and social care needs like Sarah.
Wound management has been identified as a key area of the district nursing practice (Friman et al 2010; QNI, 2013), with clinical responsibility for assessment and subsequent wound management decisions falling firmly within the district nursing role. It is evident that DNs are caring for patients with increasingly complex and chronic wounds, including malignant wounds and those requiring palliative care. The challenges faced by DNs in providing care for this particularly vulnerable group of patients are significant and exist on a number of levels. Patients with complex wounds present with very unique problems, requiring solutions that might lie outside of normal service provision. However, DNs can feel unsupported, which generates a culture of fear and lack of compassion and results in care that may be less than optimal. On a more personal level, addressing the professional issues of meeting the requirements of the code (NMC, 2018) when providing care that is constrained by the political and organisational agenda can add to the high personal burden for DNs providing care for this particular patient group (Table 2).
| Political | Organisational | DN team |
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In Sarah's case, these challenges were compounded by a lack of information sharing between the primary and secondary care settings, which made effective communication with the family very difficult at a time when it was vital to the provision of an appropriate plan of care for Sarah and her family. The high emotional cost to nurses caring for patients like Sarah with this type of malignant wound is also well recognised (Wilkes et al, 2003), along with the fact that the normal rules of wound healing do not apply in such cases. Thus, DNs have to draw on their experience to identify innovative strategies that will meet the needs of each individual patient.
It became evident that for Sarah, the goal of healing the wound was unrealistic, and an alternative approach to wound management was required. Doughty and Sparks (2016) identify that chronic wounds share certain characteristics in terms of the healing process, including a lack of bleeding at the time of the initial injury to trigger fibrin production and the production of growth factors, prolonged inflammatory phase, cellular senescence and reduced levels of growth factor receptor sites. In addition to these cellular factors, the development of chronicity within a wound is compounded by complex patient-related factors and comorbidities as well as factors related to the skills and knowledge of the healthcare professionals delivering care (European Wound Management Association, 2008). This is particularly important in caring for patients with malignant and fungating wounds; for these patients, a more palliative approach may be required (Box 2).
Alvarez et al (2007) define palliative wound care as ‘strategies that prioritise symptomatic relief and wound improvement ahead of wound healing’. Palliative wound care is not an excuse for poor care or for withdrawal of treatment options. Indeed, no specific therapies should be excluded if they could improve the patient's quality of life (Langemo, 2006; Ferris et al, 2007; Grocott and Grey, 2010). In Sarah's case this was a particularly important element of her care, in that active interventions in the form of palliative radio-therapy were effective in managing some of her distressing symptoms, including spontaneous bleeding and high levels of exudates. Because of the chronic nature of these types of wounds, much of the care will be provided in the home setting with the DN being the main care provider. It is also clear that the care and management of patients presenting with this type of complex chronic wound requires a multi-disciplinary approach, with the role of the DN as a leader in facilitating this care being key in achieving the principles of palliative wound care (Willis and Sutton, 2013).
The notion of compassionate leadership fits well with this scenario and addresses many of the challenges faced by DNs in caring for Sarah and her family. Ali and Terry (2017) suggest that compassionate leadership fosters the effective team working that is so important within the district nursing practice. In achieving this, compassionate leadership can ensure that the value of staff wellbeing is acknowledged and, more importantly, that patients felt that they are being cared for and not ‘just treated’. Compassionate leadership would also work well within the ‘quasi-family’ model of leadership identified by Cameron et al (2012) as existing within district nursing teams, with staff needing to feel cared for, nurtured and supported. The framework for compassionate leadership (West et al, 2017) explored in relation to the clinical scenario allows the DN as a clinical leader to demonstrate clearly the actions that address the needs of patients with malignant and palliative wounds (Table 3). These not only relate to addressing Sarah's particular needs, but also demonstrate how the compassionate leader can support team members to develop new and transferable skills for the benefit of the wider patient population.
| Compassionate leadership | Organisational | District nursing team |
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Attending
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Understanding
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Being empathetic
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Helping
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The compassionate leader is well placed to recognise and nurture the strengths and talents of every member of the team, acknowledging the value that each member brings to the team for the benefit of the patient. Taking the democratic and inclusive approach inherent within compassionate leadership allows the leader to support individual team members to develop their skills and confidence in caring for the patient. As a result of this, team members are supported in developing transferable skills, which will allow community nurses to meet the needs of all their patients while still allowing for a patient-centred approach to underpin the nurse-patient relationship. This represents a cultural shift away from the utilitarian, task-focused approach and reflects the ethos of contemporary healthcare outlined within the principles of prudent healthcare (Bevan Commission, 2013), where the patient lies at the heart of care.
The actions taken by the compassionate leader were key in this scenario, both for Sarah herself and for the team members caring for Sarah, and they demonstrate how the compassionate leadership framework can be used to support and inform patient-centred care in practice (Table 3). Sarah wanted to continue with treatment, as she held the view that her condition was still being treated and would get better, a view shared by her mother. Sarah continued to be cared for at home and the district nursing team worked collaboratively with community tissue viability specialist nurses, the community palliative care team and the oncology service to optimise Sarah's quality of life as well as support her family. Sarah was admitted to a specialist secondary care unit for management of her symptoms, but despite every effort being made to bring Sarah home, she died a few days later in hospital.
Conclusion and recommendations
Clinical leadership is complex and can be difficult to articulate. Drawing on a palliative wound care patient scenario, the role of compassionate leadership in district nursing practice has been explored, and a framework for practice has been developed based on the key elements of compassionate leadership. It is clear that compassionate leadership is well suited to developing community nursing practice more widely. The inclusive nature of compassionate leadership fosters the development of a safe and nurturing environment so that community nurses can learn both new and transferable skills for the benefit of the wider patient population, while providing individualised patient-centred care. The value of this approach cannot be underestimated when viewed in the context of diversity of the district nursing practice.
The health policy agenda continues to move the focus of the provision of care increasingly towards the community setting and away from secondary and tertiary inpatient care facilities—a move that is likely to continue given the pressures on resources and rising levels of demand. DNs are going to be the key health professionals who will be called upon to deliver these services. It is clear from the literature that along with a desire by clinicians to provide a more patient-focused service, there is a strong link between effective clinical leadership and positive patient outcomes. The contribution that leadership can make to the innovative development of community services within the present climate needs to be recognised and acted upon if DNs are to be able to address the challenges of care delivery in their daily practice.