There is currently a political move towards implementing person-centred care as an approach to keeping people well and avoiding unnecessary hospital admissions. Community nursing (CN) plays a vital role within this agenda. The challenge set by the Health Foundation (2014) is to move from traditional approaches of ‘doing for and to’ to ‘with’, requiring a fundamental shift in the way services are delivered as well as roles and responsibilities of both staff and patients. Drawing on research into the role of Specialist Practitioner District Nurses (SPDNs), the aim of this chapter is to illustrate person-centred practice within CN in the home. However, as CN practice extends beyond the home environment to the community, I propose McCormack and McCance’s (2010) Person-centred Nursing Framework can also be useful in broader population-based contexts of practice. I will begin by considering CNs’ roles in achieving person-centred outcomes. I will then introduce research I have undertaken and interpret some of the findings from a person-centred perspective before broadening the debate. The chapter will close with reflections on using the Person-centred Nursing Framework.

My research explored specialisation as experienced by SPDNs, often referred to as qualified DNs, within one NHS Board in Scotland. Eight participants with experience ranging from 7 to 26 years engaged with the study. I used interpretive phenomenological analysis to uncover what Heidegger referred to as ‘person-in-context’ (Smith 2007). The strength of this approach was in identifying what Heidegger referred to as being-in-the-world, which he suggested gets lost in everydayness. This approach revealed one interpretation of what it is like to be a SPDN, by looking beyond the everyday to implicit experiences in and of practice. Its strength was the ability to uncover what worked and what did not work as well as differences in practice (Smith et al. 2009). Through semi-structured interviews and audio-journals, two supraordinate themes were revealed: being expert and managing responsibility. Being expert was suggestive of person-centred approaches to care, although it appeared to be constrained at times by the care environment. This theme is the focus of this chapter. In the following sections, findings have been interpreted through the lens of McCormack and McCance’s Person-centred Nursing Framework.

Participants’ expertise was evidenced in their person-centred approach, not only to care, but also to team leadership. This was interpreted as being what Rogers (1961) referred to as being a skilled helper. His description was directed at therapeutic relationships between counsellor and patient, although Benner (1984) also used this concept in her attempt to identify what it means to be an expert nurse. In this study, being a skilled helper was extended to interactions with carers and the team. Participants’ approach in team leadership was demonstrated in the way some participants were enabling their team to problem-solve:

I think sometimes we maybe staff nurses will not see the bigger picture and it’s something you have to tease out of them…well what will we do about that? And have you thought about that? …because sometimes they will go in and follow more of a checklist approach as opposed to…because they haven’t been exposed to that higher level of assessment and thinking…’

INTERVIEWER: So what is the bigger picture that you’re talking about?

It’s that patient in their house and their life…not just what I’m going in to do, it’s not that task part.

Participant 002

However, there were also examples where helping was more concerned with ‘doing for’, reflecting old ways of working. This appeared to manifest for a number of reasons, including a perception of a lack of willingness of registered nurses in the team to make autonomous decisions and the need to assure competent staff delivering care as lone workers.

With the change of orientation of health and social care services, participants described using their expertise to address patient and carer expectations, which they perceived could at times be unrealistic of what the service was able to offer. The theme mediating complexity resonated with findings in a study by Skott and Lundgren (2009). They described this concept in relation to Home Health Nurses working with ethnic minority families in Sweden, mediating needs and expectation between patients and families. It is also reflective of the expertise literature where ‘mediation’ is a means of utilising theoretical and practical knowledge, or professional artistry and practical wisdom, which enables expert nurses to understand ‘wholeness’ or the ‘bigger picture’ (Hardy et al. 2009). Seeing the bigger picture allowed participants to promote person-centred outcomes. Participants’ approach, evident in their interactions with patients and families, described as sympathetic presence in McCormack and McCance’s framework, is also a hallmark of person-centred expertise. Demonstration of understanding and empathy extending here to carers and families in diverse situations is referred to as appreciation and attunement by Manley et al. (2005). The manner in which participants achieved this was typical of DN practice, suggestive of what Nagington et al. (2013) referred to as a discourse of friendliness, and Griffiths et al. (2010) referred to as ‘therapeutic chatting’.

Part of it is understanding where people are coming from, so you do need a little bit of background. The boundaries that carers are working from, you know…what to expect from families. It’s about influencing families not to expect too much of themselves. I see that in palliative care all the time. You know with the family – it’s not the patient that is struggling, it’s the families that’s struggling so it’s more knowing when to influence them to access services, to accept a little bit more care

Participant 004

Participants’ expertise in assessing patients and their home contexts, allowed them to consider and provide both in the moment and for a range of possible future outcomes. This anticipatory approach was a major theme in the study, linked to their responsibility for being proactive and prepared. Kennedy (2002) referred to this in her early work as ‘making visits work’. Her more recent work also found DNs use anticipatory care, although not the view of anticipatory care held by policy makers (Kennedy et al. 2011). Concurring with the findings of my study, SPDNs have the ability to tailor interventions for individuals, maintaining their independence and a ‘sense of self’. These findings suggest SPDNs contribute to avoiding unnecessary interventions and hospital admission.

The helping relationship is dependent on the ‘helper’ bringing part of him/herself to the relationship and the empathetic understanding demonstrated is mutually rewarding (Rogers 1961; Brownhill et al. 2013). One participant described how she worked to maintain visibility and availability within the community to encourage engagement with a particular ethnic population that had been ‘hard to reach’. Another used her skills to ensure a carer received the treatment and care they needed, whilst taking the opportunity to negotiate care of her husband. She described how her approach differed from that of her social work colleague, who approached the situation efficiently but with less sensitivity to the patient and carer. The social worker was also less concerned with anticipating future care needs than the SPDN, only appearing to problem-solve in the present. Titchen and Higgs (2001, pp. 274–5) refer to this as ‘using the whole self therapeutically to contact and work with the humanity of the patient’. This approach enabled participants in this study to ‘negotiate space to care’.

The extent of the emotional toll felt by participants in this study could have been in part due to their person-centred approaches, perhaps for a number of reasons. There was evidence of participants going ‘above and beyond’ to find solutions to keep people at home. Examples were cited of ‘knowing the patient’ and ‘knowing the family’, either in the present circumstances, or because of a family member having been previously cared for too. The increasing challenges of meeting patient and family expectations may also have contributed to an emotional toll. Brownhill et al. (2013) and Redshaw et al. (2013) suggest the reciprocal nature of person-centredness helps CNs, patients and carers cope with death and dying. The study by Redshaw et al. (2013) considered the role of bereavement support visits within McCormack and McCance’s Person-centred Nursing Framework. They proposed that relationships with carers, built as a consequence of caring for the patient, enabled CNs to assess how well carers might cope after death. They described ‘being present’ and ‘being open’ in their psychological support of patients and carers. They felt they were an outlet for carers following patients’ deaths, being viewed as non-judgemental and a confidant, even for those participants with whom they felt rapport was not the best. The bereavement visit, not always viewed as a priority by some managers, was viewed in this study as significant in ending a relationship and of achieving mutual psychological support.

There appears to be a disconnect between policies driving person-centred practice and the culture within health care. Organisational systems in this study were not perceived to be supportive in enabling person-centredness. Kennedy et al. (2011) highlight the lack of visibility of person-centredness in organisational criteria and in the allocation of time. Disler and Jones (2010) and Tomison and McDowell (2011) suggest ‘nursing need’ and ‘homebound’ as referral criteria hamper the ability to organise care packages, a particular issue for patients nearing the end of life. Kennedy et al. (2011) suggest the categorisation of task ‘masks’ the time needed for continuity of care, identifying and meeting patient/family wishes collaboratively and enabling patients and carers. Time enabled participants to be anticipatory in their approach to care, ensuring care coordination, particularly during out of hours. Jones (2001) argues that lack of time in nursing is due to the dominance of medicine, which does not commit fully to holistic practice. Carl May (2007) suggests that this is because tasks, rather than holistic care, are the means by which work is measured. He posits that this has currency within organisations, refers to this as ‘legitimate work’, and suggests there is a dissonance between holistic, person-centred practice and the adoption of business and process models by management to manage health care. Consequently, time and recognition are only allocated for tasks. In this study, participants feeling the need to shoulder responsibility could be a consequence of this mind-set, as could the feelings they described of not being valued by organisational management. Current approaches of safe, effective, person-centred care, advocated by policy (Scottish Government 2010; Department of Health 2014) are demonstrated throughout the analysis, but achieving this is time-dependent. If DN is to be recognised and valued by others, then this aspect of DNs’ role has to become legitimate work (May 2007). Kennedy et al. (2011) assert that to increase the visibility of the role, professional discourse should be altered to reflect person-centredness rather than being focused on task.

Kennedy’s early work in 2002 identified the different types of knowledge that enable SPDNs to adopt different strategies to ‘make visits work’, but my study goes further in highlighting participants’ ability to mediate complexity to ‘anticipate future care needs’, ‘finding solutions’ and ‘enabling carers to care’. This was illustrated by participants’ use of sophisticated communication skills, symbolised in the descriptions of ‘doing the dance around’, which enabled difficult conversations around current status, planned outcomes, coping, and ultimately death and dying.

You just realise. You just pick up on wee bits and pieces – cues that they are saying to you and the way they communicate with you. Sometimes they are waiting for you – you know they drop you the hint so they can give you the cue and you can say something back and do your dance around and…I think the first thing is that I’ll try and do a proper assessment first off and that I’m not just going on, oh I don’t think you’re managing here, so that I’ve got something to go on and speak to them about how she can’t get out of her chair and a culmination of your experience and your knowledge and your assessment skills

Participant 008

‘Being a detective’ was part of a quote illustrative of SPDNs’ ability to pick up nuances and recognise when a patient was deteriorating, achieved by having ‘my senses ablaze’. This is referred to by Watson and Rebair (2014) as therapeutic noticing, where noticing precedes verbal exchange and prompts action. Tanner (2006) suggests this leads to interpretation of the situation and is the first stage of clinical decision-making.

Participants in this study appeared to consider their expertise from what Kotzee (2014) refers to as an anti-intellectualist, ‘fluent’ standpoint, although my study has revealed SPDNs’ ability to articulate practice that, according to Rolfe (1998), is reflective of advanced rather than specialist practice. This may be due to the increased emphasis on the art of nursing, particularly in CN (Potter & Wills 2013) and on reflective practice (Schon 1983). Reflective practice is now a fundamental skill taught in nursing education and is developed in practice. While participants emphasised the role of experience in their development of specialist expertise, they did recognise the contribution of their Specialist Practitioner Qualification (SPQ) programme (Nursing and Midwifery Council 2001). However, their perception that managers favour experience over education does appear to be consistent with the work conducted by Harris et al. (2012). It also may be a contributory factor in the current debate of whether the SPQ programme is fit for purpose. Whichever aspect has been most influential in participants’ development into the role of SPDN, participants’ expertise in this study reflects McCormack and McCance’s person-centred practice and fits with the requirements of current policy driving care of patients within their homes. Their expertise in using strengths-based approaches to care management, balanced with an ability to manage teams to deliver care within communities, is pivotal in avoiding unnecessary hospital admissions.

The usefulness of McCormack and McCance’s (2010) Person-centred Nursing Framework in population-based contexts of CN practice has not previously been explored in the literature. Public health values, arguably person-centred, underpin the aim of public health, which is promoting healthy populations and reducing health inequalities (Marmott et al. 2010) through social and political effort (Box 18.1). As public health seeks to improve the health of populations, an adaptation of McCormack and McCance’s person-centred practice to one that is ‘people-centred’ could offer a means of service design and of evaluation of current integrated public health practice. However, I propose that the usefulness of such a framework would require some alterations. The intended outcomes of practice would be less concerned with therapeutic cultures and ‘care’ and more aligned to feelings of well-being, achieving a healthy start in life, resilience-building, building social capital, accessibility of services and justice. Other aspects of the framework would also require some shaping.