Deborah Glover, BSc (Joint Hons), Dip. Care Policy & Management, RGN: Editor PCNR
Crystal Oldman became Chief Executive of the QNI in November 2012. Crystal trained as a nurse at University College Hospital, London and worked in the NHS for 16 years at UCLH, the Middlesex and Great Ormond Street Hospitals. She moved to a career in community nursing in 1982 and working with some of the most deprived communities in west London
In 1994, she joined Buckinghamshire New University to develop the community nursing programmes, completing her academic career as Dean in the Faculty of Society & Health, where her role included the development of partnerships with external agencies to promote research and assist in workforce development...
In 2012, Crystal joined the Queen’s Nursing Institute, a charity founded by William Rathbone and Florence Nightingale in 1887 as their Chief Executive. She has overall responsibility for the delivery of the QNI mission to improve and enhance the care of patients in the home and community.
The offices of the QNI are in a street straight out of a Dickens novel. I half expected to see Fagin’s boys tumbling from their den to do a (dis)honest day’s work (although I am sure they would be getting excellent health care from a local community nurse…). Inside the terraced building was a cornucopia of district nursing history. Bound journals dating back decades had me laughing gently at the old advertisements, while noting that some issues such as ‘bed sores’, are perennial.
Community nurses have always had skills in spades. I have to admit, I always felt ‘safer’ working in the hospital environment – I knew where the arrest trolley was and that if there was a crisis, there was generally a grown-up somewhere in the building to help! Community nurses have to be resilient, flexible and willing to examine and change practice or ways or working. The latter seems to be more and more prevalent in today’s NHS. However, the Queen’s Nursing Institute is a source of support to nurses and provides a voice for them on many levels.
District nursing had begun in 1859, when William Rathbone, a Liverpool merchant, philanthropist and later an MP, employed Mary Robinson to nurse his wife at home during her final illness. He retained her services so that people in Liverpool who could not afford to pay for nursing would benefit from care in their own homes. He worked with Florence Nightingale to develop the service, but when too few trained nurses could be found, Rathbone funded a nursing school in Liverpool specifically to train nurses for the 18 ‘districts’ of the City; and so organised ‘district nursing’ began. Manchester, Salford and other cities followed suit, and the Metropolitan and National Nursing Association was set up in 1874.
The founding of the Institute was the next step in co-ordinating and setting national standards for District Nurse training across the country. The Queen’s Nursing Institute (QNI) was established in 1887 by the grant of £70,000 from the Women’s Jubilee Fund. In 1889 a Royal Charter named it ‘Queen Victoria’s Jubilee Institute for Nurses’ and gave it the objectives of:
- providing the ‘training, support, maintenance and supply’ of nurses for the sick poor
- establishing training homes and supervising centres, and co-operating with other bodies
- establishing Branches as necessary
1927 saw the birth of the National Gardens Scheme (NGS) as a fundraising initiative of the QNI. In 1980, NGS became an independent charity in its own right but has remained a vital supporter of the QNI’s work.
The name of the Institute was changed to the ‘Queen’s Institute of District Nursing’ in 1928 and to the Queen’s Nursing Institute in 1973. Nurses have not trained at the Institute since 1968, but the QNI continues to support community nurses in any specialty through project funding, professional development, information networks, and financial and personal assistance.
The QNI is the independent voice of community nursing; it also promotes best practice and influences policy which may affect community nurses. Much of this is achieved through the national network of Queen’s Nurses. Is asked Ms Oldman if she felt the concept of a Queen’s Nurse was outdated or something special?
“The scheme was reintroduced in 2006 after a gap of 40 years. We recognised that that nurses were doing some amazing things in the community, and that this passion could be tapped to provide a wide-reaching voice for the QNI. We wanted to acknowledge these people as leaders, innovators and ambassadors for nursing and excellence in patient care”.
Today's Queen's Nurses include district nurses, GP practice nurses, school nurses and others who are experienced in working in people's own homes, in clinics, or in other community settings.
“To become a QN, a rigorous process is followed; as well as providing information about qualifications, employment and training; applicants have to write an essay on how they improved, and continued to improve patient care. The QNI obtains references from the nurse's employer, and asks for feedback from patients. Applications are then assessed by an independent panel”.
“Becoming a QN shows commitment, but has rewards, as one may be called upon to contribute to health policy or be the representative voice regarding all aspects of care, through the Department of Health, NHS England and others. For example, a number of our BME (Black and Minority Ethnic) QNs are currently working with NHS careers to promote nursing as a career to people from BME communities If the QNI isn’t representative of the community we serve, we aren’t really doing our job”.
This led to a discussion on the changing nature of community nursing, particularly how to meet the diverse cultural needs of patients. How can we manage this?
“I would say that we have to approach this in two ways. We have to educate nurses in community training and in practice about such differences, and how the NHS and other agencies are working with communities to address these. We also need to ensure more nurses are recruited from BME populations which reflect the communities we serve to give a richer skill and knowledge mix of practitoners, but also to help understand diverse cultural norms and health needs”.
The acuity of patients being cared for in the community is far higher than when I was nursing. It seemed (and I stress the word seemed!) then that few patients were discharged with an IV, let alone a peg feeding tube or dialysis stent. Again, this has meant a major change to the skills and knowledge required by nurses. I suggested to Ms Oldman that home care may not always be the best option for patients. For example, Stephen Hawking’s wife felt that her home had become a ‘hospital ward’ and that this had changed atmosphere of house – it was no longer a home. Do we intrude on family life?
“Of course not all patients feel safe at home, particularly if they live alone. But end of life studies have clearly demonstrated that many patients want to be at home. Such care is what community nurses are excellent at, but both funding and support is needed for patients and their families”.
Ms Oldman has been in post a little over a year now. I asked her what the highlight of the year has been for her.
“Gosh, too many to mention really!” When pressed, Ms Oldman admitted:
“I am pleased that the profile of the QNI has been raised. We are now a critical friend of government, prepared to hold up a mirror to community nursing policy and practice, but in a non-alarmist, solutions focussed way. No sabre rattling! We highlight good practice, but also acknowledge the issues, and where possible, provide solutions. Admitting issues is the way forward – we have to examine practice and declare where things are wrong”.
“We also want to ensure that when we are giving an opinion or making a suggestion it is based on fact. For example, there was much anecdotal evidence that the number of district nurses being trained was dropping year-on-year, so we decided to look at the figures. We contacted the course leaders of every university with an NMC approved programme and asked for their figures. From this, we produced the ‘Report on District Nurse Education in England, Wales and Northern Ireland 2012/13, which provided evidence of complete disinvestment in DN training, raising questions about the future of community nursing. Interestingly, a third of those universities are now working with health education boards to redevelop or develop the course. We will repeat the study at the start of 2014”.
These findings of course tie in with the current ‘skill-mix’ debate, and the issue was also raised within the report.
“We have bid for funding to undertake a study to ascertain the difference a recordable DN qualification makes to care and service delivery. Again if we want to discuss the value of district nursing, we must have the evidence to prove their value”.
I had recently seen a Tweet from Ms Oldman regarding terminology in nursing, particularly ‘acute’ and ‘community’, and ‘primary care’ and ‘secondary care’. She feels strongly that we need consistency.
“For example, to a GP, primary care is anything that happens outside a hospital. To a community nurse, it’s everything outside a hospital except for the GP! In addition, as alluded to earlier, not all ‘acute’ care is undertaken in hospital; nor is acute care just about physical care. Community mental nurses manage mental health acuity up to a point”.
“We need to know what we are comparing and break down existing care barriers. Nurses in secondary care need to know what community nurses do. Remember, all community nurses will have worked in a hospital for at least three years. Secondary care nurses may have only two weeks community placement experience. I myself worked with a QN recently; her caseload reminded me that community nurses care for patients across the social and wealth spectrum and requires different skills for each”.
“To facilitate this common language and breaking down of barriers, the QNI has been encouraging community nurses (as part of their continuing professional development), to ‘make friends with their local hospital’ and invite a ward manager to spend a day in the community, or follow a patient home after discharge. Eileen Sills, Chief Nurse and Director of Patient Experience at Guy’s and St Thomas’s Integrated Trust recently spoke of realising what a scary place community was, but that secondary care staff could learn much from community nurses”.
Finally, I asked if she though new ways of working and care delivery such as Any Qualified Provider posed a threat to community care delivery or the essence of community nursing. Ms Oldman felt it was too early to tell, as some nurses report very little difference to their working day, while others could sense immediately their new employer’s lack of experience in managing community nursing services.
Whatever the future for community nursing and the professionals involved, the QNI will be there to support and provide a voice.