District nurses (DNs) are qualified nurses who have undertaken further graduate level specialist training in order to autonomously lead a team to deliver nursing care in the community (Department of Health (DoH), 2013). Over the past 15 years, the number of DNs meeting this definition has fallen rapidly and consistently (Royal College of Nursing (RCN), 2012; Addicott et al, 2015). There is also a continued reduction in the numbers of DNs holding a Specialist Practice Qualification (SPQDN) (Lintern, 2016). Attrition, neglect and underinvestment (Longstaffe, 2013) are some reasons for the decline; yet, the demand on the community services workforce has increased following the Health and Social Care Act 2012. The ‘post-Francis’ expansion (Francis, 2013) has further affected the nursing workforce, with hospital nurses remaining in secondary care and not moving to community care at previously observed rates (Maybin et al, 2016).
Previous studies recognise the need for reinvestment in the SPQDN (DoH, 2013; RCN, 2013, 2016; QNI, 2014a, 2016; Pellet, 2015; Bliss and Dickson, 2016). Reports on DN education demonstrate an increase (25%) in the number of DN students due to qualify (QNI, 2014b; QNI 2016). However, this will not be sufficient to meet the increased demand to replace those retiring (Maybin et al, 2016). The DN workforce is aging, with 74% DNs currently aged 45 years and over (RCN, 2013). NHS workforce statistics recognise a 48% drop in full-time equivalent DNs between 2000 and 2014 (Health and Social Care Information Centre [HSCIC], 2011; 2015), and this trend has continued with a 13.6% decrease observed between 2014 and 2016 (HSCIC, 2016). However, these statistics cover organisations under the remit of the NHS. Because of the Transforming Community Services policy (DoH, 2011) under which non-NHS providers are taking over these services (RCN, 2013), 17% of community nurses and DNs are not employed by NHS trusts (QNI, 2014a).
The current national shortage of DNs has resulted in some band 5 community nurses being promoted to band 6 leadership positions despite not holding SPQDN (Longstaffe, 2013). Consequently, there has been the non-standardised use of titles for people doing the same work, which arguably devalues the SPQDN and reduces the need for DNs. Commissioners and employers consider quick-fix educational modules to equip staff with caseload and team management skills (Smith, 2010). The DN role is very complex and challenging to quantify (Pellet, 2015). The attributes and skills associated with this role include caseload and crisis management, complex care assessment and management, prevention of hospitalisation and leadership (Barrett et al, 2007a, b, c). Among these, leadership has long been under the remit of DNs (DoH, 1992; NMC, 2008), particularly in the last decade with the introduction of advanced nurse practitioners and clinical nurse specialists (Toofany, 2007).
As of June 2018, there are 4327 DNs in England (NHS Digital, 2018). In 2017, there were 44 DNs (NHS Digital, 2018) and 6 student DNs working for the trust involved in this project. A review of the literature revealed a paucity of primary research on SPQDN and district nursing. There is a clearly gap in research on this matter, particularly in the context of leadership. The King's Fund provides an insightful view of quality in district nursing services and suggests a growing gap between capacity and demand as well as a significant shortage of ‘suitably trained’ nurses (Maybin et al, 2016). However, whether ‘suitably trained’ means possessing SPQDN remains unclear. To our knowledge, no studies link the SPQDN to leadership. Cameron et al (2012) explored leadership in community nursing teams and recognised that band 7 nurses had more strategic objectives, whereas band 6 nurses placed higher importance on personal relationships and the need to form a ‘quasi family’. However, the authors did not examine the relevance of SPQDN. Thus, the aim of the present study is to establish the value of the SPQDN and consider the need for investment in leadership roles by examining the case of one rural community trust in the UK.
Methodology
This study used an exploratory mixed-methods design with the Delphi technique, which involves a group communication process that aims to predict future events or occurrences (Ulschak, 1983; Turoff and Hiltz, 1996; Ludwig, 1997). As an iterative process, the Delphi technique is designed to combine expert opinion to gain group consensus (Lynn et al, 1998). Establishing what constitutes ‘expert opinion’ is often the cause of controversy with the technique. Flostrand (2017) argue that the experts selected should have truly lived experience in order to foretell the future, and forecasting is an integral part of a managerial role. Nursing staff in band 7 and above roles hold more strategic views (Cameron et al, 2012), and professional managers make decisions and influence findings (Hsu and Sandford, 2007). Therefore, an inclusion criterion for this study was that all participants had to hold senior (bands 7–9) positions, including nurse educators, workforce planners and service leads, as per the RCN (2013) recommendation. All participants needed to be NMC registrants so that they could be identified as ‘nurse’ experts and have access to emails to be able to complete the e-Delphi forms. Participants were recruited via email using a consent form, flyer and participant information sheet. Thirty-two nurses were invited, of which 10 agreed to participate. Among these 10 panellists, nine held SPQDN, although this was not an intentional part of the recruitment strategy. Seven panellists were band 7 nurses, while three were band 8 nurses.
The Delphi technique, by its nature, precludes true anonymity. However, the concept of quasi-anonymity was adopted (McKenna, 1994), wherein the researcher was allowed to know which panellist produced each response but the panellists remained anonymous to one another. The use of quasi-anonymity ensured confidentiality of panellist details in accordance with the agreed ethics approval.
This study followed the classic e-Delphi design, in that it included three or more rounds of questioning as this is when consensus was achieved, and was delivered via electronic means, namely, email (Keeney et al, 2011). Responses to round one were limited to three, curtailing the possibility of generating unwieldly amounts of information (Keeney et al, 2006). Thus, 30 responses/statements were analysed from round one, during which a single question was asked to establish the value of the SPQDN: what is the future for district nurse specialist practitioner qualifications in [the trust] for band 6 leadership roles?
Panellists were provided a brief background of the topic as part of the information sheet in order for them to understand the context of the research question (Duffield, 1993).
Data were analysed using Yin's (2016) five-phase cycle (Figure 1).
Round one data were inputted into NVivo 10 to display themes. Maxwell (2013) recommends a conceptual framework to aid analysis. Figure 2 demonstrates the conceptual framework developed from analysis after refining and integrating themes via NVivo. Responses were then quantised as part of the coding process. Quantising is the process of coding and analysing qualitative data quantitatively (Polit and Beck, 2017). Delphi has been criticised because of the lack of rules around administration and validation (Sackman, 1975). To reduce bias in the subsequent Delphi rounds, each round was peer reviewed by two nurse academics. Data were collected between April and August 2017.
Responses from round one were presented to the panellists as four core themes: SPQDN, clinical practice educators, leadership and workforce. Rounds two and three consisted of a close-ended questionnaire using a three-point Likert scale. The consensus level was set at 51% as this follows the concept of majority rules and was considered within another Delphi study (Loughlin and Moore, 1979). Any relevant statements that did not gain consensus were re-discussed in round three.
Results
Round one
Five responses that did not answer the open-ended question ‘What is the future for district nurse specialist practice qualification in [the Trust] for band 6 leadership roles?’ were rejected. These responses were either irrelevant and/or could not be quantised. For example, the statement given below can neither be agreed nor disagreed with, as it is a factual statement:
‘currently [the trust] has only 3 practice teachers employed who have the recordable teaching qualification to sign off NMC standards for CSP [Community Specialist Practice] course. Therefore, only 6 places are being made available for this year’ .
However, this rejected statement still provides some insights. A lack of educators significantly affects the ability to support students. Later on, the same panellist says that: ‘[the trust] has secured funding for 8 places for CSP [Clinical Specialist Practice] training for academic year 2017/18’; therefore, two places were not filled due to the lack of clinical practice educators.
Round two
Tables 1 –4 present data from the responses in round two. Consensus was achieved on 84% of the responses.
| Statements | Outcome |
|---|---|
| ‘there is recognition that the specialist qualification leads to enhanced quality of care and effective caseload management for patients’ | 6/10 agree |
| ‘the (DN) role is extremely valuable’ | 10/10 agree |
| ‘I have always championed the need for B6 case managers to hold the qualification, as the role is very broad and the further training to registered nursing is required to understand this.’ | 7/10 agree |
| The job title should be changed ‘from case manager to district nurse as it had more value as a title’ | 6/10 agree |
| ‘B6 nurse should be able to take a flexible approach to learning building towards BSc or MSc using modules appropriate to needs of patient population in addition to the core modules around history taking, assessment, professional issues, research/service review and prescribing.’ | 9/10 agree |
| ‘practitioners that undertake a specialist qualification will as a result develop both their clinical and managerial skills’ | 7/10 agree |
| ‘no commitment is given that the nurse will have a band 6 DN role once qualified.’ | 8/10 agree |
| ‘the DN role is pivotal to [the trust] delivering effective, efficient patient care’ | 9/10 agree |
| ‘there is a future for specialist practitioner qualifications in providing care close to home’ | 10/10 agree |
| ‘it is essential to have those with the specialist practitioner course within a team of B6 leaders in the community’ | 7/10 agree |
| ‘I feel the trust would benefit from making the course compulsory’ | 5/10 agree |
| ‘all community nurses B6 should have or be working towards a BSc or MSc qualification in clinical practice but not…. Specifically to community’ | 3/10 agree |
| Statements | Outcome |
|---|---|
| There is a ‘lack of clinical practice educator availability to train and assess district nurse specialist practice’ | 7/10 agree |
| Currently DN students are ‘mentored long arm due to practice teachers no longer holding their own caseload. This can impact on the quality of the robust assessment process and role modelling opportunity that walking alongside practice teacher affords.’ | 6/10 agree |
| In the context of SPQDN students for the academic year 2017/18: ‘we…are looking at placing them in the optimum clinical learning environment to ensure they have a positive and quality placement experience’ | 8/10 agree |
| ‘Inadequate preparation for the role by CPEs for [the trust] who provide support to complete the course.’ | 6/10 neutral |
| Statements | Outcome |
|---|---|
| ‘Practitioners that undertake a specialist qualification will as a result develop both their clinical and managerial skills.’ | 7/10 agree |
| ‘In order to achieve this, the care in the home needs to be delivered by a team that is led by skilled clinicians that truly manage their caseloads.’ | 10/10 agree |
| ‘we need to invest in succession planning’ (for DN roles). | 10/10 agree |
| ‘leadership is on all levels and does not just focus at the district nurse case manager role.’ | 8/10 agree |
| Access to the SPQDN ‘is a good means of succession planning to the organization.’ | 10/10 agree |
| ‘The current course does not include enough on the topic of leadership so if it's the leadership roles that being looked at I feel further competency development is needed then just the specialist practitioner course.’ | 4/10 agree |
| Statements | Outcome |
|---|---|
| ‘Unless [the trust] included a recommendation for the specialist qualification in the case manager job description with the limited availability of LBR training it is difficult for the training to be supported in teams.’ | 7/10 agree |
| ‘[The trust] should continue to build on it DN workforce’ | 10/10 agree |
| ‘An increase in the amount being trained as from now, which will go some way to fill the gaps’ | 8/10 agree |
| ‘They (B6's) need to be equipped in order to undertake this and that is the reason why we should continue to support and encourage staff to undertake a district nurse specialist qualification.’ | 9/10 agree |
| ‘Funding of education for specialist practice may be more of a challenge in the future with reductions in Health Education England funding but might transfer over to apprenticeship funded from the employer levy (skills funding agency levy against employers).’ | 6/10 agree |
| ‘the future for SPQ district nurses are positive as we need to recognize that the demographics of the organisation demonstrate that many are aged over 50 years and will be in a position to retire in the next few years’ | 8/10 agree |
| ‘[The trust] continue to sponsor training for the DN qualification at all levels’ | 6/10 agree |
| The SPQDN ‘offer development opportunities to existing [the trust] staff’ | 9/10 agree |
| ‘There are less individuals in the trust with this qualification’ | 5/10 agree |
Round three
One panellist's statement caused some ambiguity in round two; ‘all community nurses B6 should have or be working towards a BSc or MSc qualification in clinical practice but not….specifically to community’. Therefore, the statement was divided to establish consensus within the panel. Nine panellists responded in round three, and the panel agreed (67% consensus) that ‘all band 6 nurses (in a case manager/DN role) should have or be working towards a BSc or MSc qualification…’. However, they disagreed (56% consensus) that ‘this qualification does not have to refer to community specifically’.
Discussion
Specialist Practice Qualification in district nursing
Previous research equivocally recognises the value of the DN role and the need to reinforce it (RCN 2013; QNI, 2009; QNI, 2014a; QNI, 2016; Pellet, 2015; Maybin et al, 2016), and the present study confirms this opinion: a 100% consensus was achieved on the DN role being considered extremely valuable, and 7 panelists agreed ‘It is essential to have those with the specialist practitioner qualifications in providing care close to home’. A ‘flexible approach to learning’ with use of a modular approach was recommended by the study participants. Work-based learning provides an opportunity to address and develop this proposed flexible approach, particularly as the work is the curriculum (Wareing, 2010), and many universities offer a modular approach to achieving SPQDN (QNI, 2016).
Clinical practice educators
There is an inconsistency between our findings and previous literature regarding the availability of health education funding. Studies have suggested that the lack of funding for SPQDN from Health Education England is a contributory factor for the reducing number of DNs (QNI, 2014a; QNI, 2016; Pellet, 2015; Maybin et al, 2016). However, the response from one panellist in round one suggests that funding is available but the lack of practice educators is the reason for limited student places. Clinical practice educators play a pivotal role in the achievement of SPQDN as they assess and sign off on the practical element of the course; they must have a practice teacher qualification, as outlined by the NMC standards (NMC, 2008). Thus, it appears that the lack of educator availability is affecting the number of student DN places, not the lack of funding. The QNI (2016) mentions the use of long-armed practice teacher support in conjunction with ‘sign-off mentors’ as a means of addressing the deficit; in 2014/15, 37.2% of SPQDN programmes used this approach as a pragmatic solution.
Leadership
As shown in Table 3, perceptions of leadership varied among the participants of this study. One panellist reported that ‘the current course does not include enough on the topic of leadership’. This variation may be explained by the fact that the trust used two programmes from separate higher education institutions for staff development. The statement ‘leadership is on all levels and does not just focus at the district nurse CM [case manager] role’ generated an 80% consensus in agreement. This theme was also found in the study by Cameron et al (2012), wherein band 5 nurses perceived that everyone in the community team had leadership skills. There is a growing body of research that effective leadership lifts the performance of healthcare organisations (Castro et al, 2008; Mountfort and Webb, 2009; Roebuck, 2011). Research also suggests that staff engagement is a significant element to transformational leadership (Collins, 2015), and Wong and Cummings (2007) found a positive relationship between transformational leadership and improved outcomes.
Previous studies suggest that the SPQDN is transformational and equips DNs with the knowledge and skills to effectively lead teams (Pellet, 2015; Bliss and Dickson, 2016). One panellist stated that ‘practitioners that undertake a specialist qualification will as a result develop both their clinical and managerial skills' (which generated a 70% consensus in agreement). Therefore, the panellists believe the SPQDN does effectively equip DNs to be leaders.
It was the significant shortage of DNs that led the QNI (2009) and RCN (2013) to strongly recommend reinstatement of the DN role. Succession planning could provide a solution for addressing the deficit of DN numbers; one panellist stated that ‘we need to invest in succession planning’, and another considered the SPQDN to be a ‘good means of succession planning to the organisation’. Both these responses generated a 100% consensus in agreement. Succession planning has gained momentum in the United States as the nursing shortage is a global problem (Bolton and Roy, 2004; Carriere et al, 2009; Griffith, 2012). Further, turnover is higher among first-line leaders (Swearingen, 2009), and Titzer et al, (2013) recommend a deliberate strategy to ensure an adequate leadership pipeline. Therefore, a core recommendation from the present study is that SPQDN form a part of succession planning strategies.
Workforce
With the policy ambition of transforming primary care (NHS England, 2014), the primary care workforce will need to expand. Health Education England (2015a) reported a 6.5% nursing vacancy rate across both the acute and community sectors. Following the Francis report (2013), the demand for nurses in the acute sector has risen significantly. Health Education England (2015b) suggests that nurses are not moving to community services at the rate previously observed. The theme of dwindling numbers is apparent within this study; one panellist suggested that ‘…the demographics of the organisation demonstrate that many are aged over 50 years and will be in a position to retire in the next few years’, which generated an 80% consensus in agreement. In the future, workforce planners may need to address the inevitable shortage of DNs; a pragmatic decision should consist of investment and funding streams. One panellist highlighted the use of the ‘apprenticeship funded’ route.
Lafond et al (2014) illustrated that community health services account for approximately £10 billion of the annual NHS budget (2012/13). One panelist also recognised the resource restraint:
‘with an increase in an ageing population, this brings with it an increase of patients with complex health needs. Resources are already tight and the aim is to keep patients at home. In order to achieve this the care in the home needs to be delivered by a team that is led by skilled clinicians that truly manage their caseloads.’
While this response was not further discussed in round two, it does recognise and support the impact of the challenges from the frontline. Ultimately, the right person with the right skills needs to be delivering care, Cook (2011) considers the SPQDN as a means of providing adequate training.
Study limitations
Our study has some limitations. The first round had a qualitatively design, and such designs tend to be impossible to generalise, as they focus on an inductive, exploratory approach (Lincoln and Guba, 1985) and work with small non-representative samples (Brewer and Hunter, 1989). Our study sample was small (10 participants) but purposively selected. An unintended bias also may have been formed as the majority of panellists (90%) possessed SPQDN. Thus, our findings may not be generalisable to other organisations and should be interpreted with caution. The lack of funding for the present study was the reason for the limited sample size and restricted data collection mechanism. The generalisability of our finding is also limited because this was a single-profession, centre, UK-centric study. Future research should include participants who are members of multidisciplinary teams and perhaps, even service users.
The limitations of using Delphi did not become clear until the project was well underway. The use of pre-determined consensus levels (in an effort to ensure reduced bias from the researcher) could be viewed as reductionistic. Manipulation of the Delphi process to generate the appropriate findings also poses a problem. A lack of formal, universally agreed guidelines is a key disadvantage of Delphi techniques, particularly from a methodological viewpoint (Turoff, 1970; Sackman, 1975). In the present study, each round was peer reviewed in order to minimise bias.
Another methodological limitation has to do with the Likert scale with a neutral category, particularly when considering the creation of subsequent rounds. Future research should instead use a two-scale (agree/disagree) questionnaire to encourage decisiveness.
Conclusion
Findings from panellists in a rural community trust in the UK recommend continued investment in the SQPDN for band 6 leadership roles. Senior nurse managers from this project's panel consider the DN role to be extremely valuable and agree that the trust should continue to build on its DN workforce. Succession planning is one solution to address the shortage in DN staff, and the use of apprenticeships may provide a funding stream for this valuable qualification and role. The SPQDN could be funded via an apprenticeship scheme following the shape of caring review (Health Education England, 2015b). Indeed, trailblazers for a SPQDN apprenticeship model are currently being reviewed in Leeds (QNI, 2017), and there is positivity on the development of apprenticeship standards (QNI, 2018). However, the shortage of clinical practice educators will make this goal more challenging to achieve, for this particular trust, and for others attempting to adopt this solution, and needs to therefore be addressed. Further, more robust research into the value of the SPQDN is warranted in the future.