Delivering care closer to home for children and young people is part of the national and devolved governments' health agendas (Welsh Government, 2018a). Children's community nurses (CCNs) aim to enable families to sustain and maintain ‘normal’ family life and ensure that children have the best quality of life achievable (Carter and Coad, 2009). CCNs are considered ‘the bedrock of pathways for ill and disabled children’ (Department of Health, 2011) and provide expert nursing care for children in their own homes and schools (Queen's Nursing Institute (QNI), 2018). However, despite these aims, and although a substantial amount of care for children occurs in community settings, the image of a community nurse is often perceived as a role that delivers basic work, requiring little complexity, technical knowledge or activity (van Lersal et al, 2016). This perceived view of the role is frustrating for CCNs.
According to the Welsh Community Nursing Strategy (draft), recommendation 8:
‘The need for children's community nurses and the provision of professional networks to underpin these must be central to the development of the health organisation Community Nursing Strategies.’
Yet a Royal College of Paediatrics and Child Health (RCPCH) 2017 audit (RCPCH, 2018:54) demonstrated that in England only 14.9% of acute general children's services are supported by a children's community nursing service that operates 24 hours a day, 7 days a week. The percentage is likely to be lower in Wales. Working in a service that cannot fully maximise the role to provide leadership, care and support to children in community settings (NHS England, 2015) can appear fragmented and diminish the contribution that CCNs can make to enabling children to have the best possible health outcomes. Thinking that you could ‘do more’ is demotivating. As Maslow (1943) explained within his hierarchy of needs, human beings have an innate need to maintain their self-esteem and respect, which can be difficult if they feel they have let down their colleagues or families.
Further, when considering the CCN's roles and responsibilities, it is important to take account of the Nursing and Midwifery Council's (NMC) (2018) code, which includes a standard to ‘practise effectively’. This clearly states that nurses must:
‘Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues.’
One way to meet this requirement is through participating in ‘community of practice’ professional networks. The idea of a ‘community of practice’ was discussed by Lave and Wenger in 1991, and further developed by Wenger (2000) into a concept for participation, engaged collective learning, and of knowledge construction within a social learning space.
The current Oxford English Dictionary defines a network as ‘an interconnected group of people … specifically a group of people having certain connections’ (https://www.oed.com); it is about interacting with others to exchange information and develop contacts. Networking is also described as a deliberate and conscious act, it does not happen by accident and the key idea is ‘exchange’ (OpenLearn, 2019). Both parties should gain from the interaction. Seminal work by Covey (2013) suggested that we need to maintain emotional ‘bank accounts’ with colleagues through networking. By this he meant the trust we build up when we meet and form relationships and, using the bank account as a metaphor: ‘deposits’ can mean being smiley, being polite, remembering names and being respectful, whereas ‘withdrawals’ can be seen as being rude, interrupting and dismissing others' roles and responsibilities.
Both authors of this paper delivered CCN courses in separate universities. They were approached by 10 CCNs who reported feeling isolated and uncertain during times of service redesign and change. The CCNs explained to the nurse academics that, despite them working prudently—providing care to children when needed as befits the needs and circumstances of an individual child (http://www.1000livesplus.wales.nhs.uk/home)—some colleagues dismissed their contribution to the delivery of high-quality and safe care.
The authors and the nurses brainstormed ideas, and agreed that a community of professional practice clinical network was the best solution. Band 5 and 6 nurses raised the idea of such a community of practice network being run by, and exclusively for, CCNs. At the time, opportunities for CCNs in Wales to network were limited, so the need to gain support through a community of practice was urgent (Cunningham et al, 2012; Terry et al, 2015). This article describes the development and ongoing progress of this collaborative professional clinical network and offers suggestions for colleagues to develop similar networks.
Professional networking
The CCNs decided that their community of practice networking meetings were to be separate from formal managerial meetings. Although team meetings have the purpose of supporting staff, and providing and receiving information about the organisation, structure and delivery of services, they are usually chaired by the manager, who also drafts the agenda (Marrelli, 2017). In contrast, the CCNs wanted to host, design and lead their own meetings, with their network becoming fundamentally a vehicle for reducing isolation, championing clinical improvement, providing support and sharing ideas; this took Wenger's (2000) ideas of collaborative knowledge construction forward.
Although professional networking is necessary for all nurses, it is even more important for those working in a child's home, school or any area outside of an acute hospital, because care is being provided in a non-clinical environment, with none of the safeguards that are in place in the ‘controlled environment’ of a hospital (QNI, 2012). Additionally, many CCNs work geographically out of sight of colleagues or managers and can therefore feel isolated (Terry et al, 2015). This professional isolation is acutely felt when complex decisions need to be made (QNI, 2016). Yet, as Arnold pointed out:
‘The scope of practice … for contemporary nurses has become multidimensional, multirelational and highly complex … The strength of EBP [evidence-based practice] lies in the blending of extensive clinical experience with sound clinical research and professional judgment in real-time clinical situations.’
When faced with making real-time decisions within uncertain and complex environments, having opportunities to network with others who work in similar challenging roles, and to share evidence-based practice and experience, provides a system of shared support.
In the case of community nurses working in rural or remote areas, networking offers them the chance to have dialogues with peers and maintain an awareness of recent healthcare developments (Khanum et al, 2016). However, such opportunities did not exist prior to the formation of the community of practice clinical network described in this article.
Community children's nursing services in Wales
Recommendation 8 of the community nursing strategy (Welsh Assembly Government, 2009) was clear in stipulating the development of CCN services across Wales. However, despite the strategy, the seven health boards across Wales have taken different routes to developing community services for children and young people. This could be due to the fact that CCN services lack political kudos compared with district nursing and health visiting—the first has a designated workstream (http://www.1000livesplus.wales.nhs.uk/home), while the latter has an institution (http://ihv.org.uk). Despite this, all CCN services are undergoing substantial change to meet the delivery of care closer to home agenda (The King's Fund, 2014; Welsh NHS Confederation, 2015; Welsh Government, 2018b).
In hospitals, communities of practice networks can develop informally. Nurses have regular, timed handovers to discuss care, and the proximity of other staff reduces feelings of professional isolation. In contrast, not all nurses working in community and rural settings have regular team meetings, handovers or huddles (Hulme and Caulfield, 2017). As a result, decisions may not be shared, which means that nurses do not have the opportunity to articulate concerns throughout their working day. The need for communities of practice is consequently paramount.
A community of professional practice network was therefore set up with the collaboration of six of the health boards, with view to including the seventh in future to ensure the network represented the entirety of community children's services across Wales.
Aim of the community of practice network
The primary aim was to provide a forum to share ideas and knowledge, and to offer support to reduce feelings of isolation without having the constraints of a hierarchical meeting. However, the concept of hierarchy cannot be totally removed because humans tend to organise themselves in relative levels of status (Andersen, 2012). However, the CCNs wanted to distribute ‘power’ across members of the network, to work collaboratively without any single person being in charge.
Although it is recognised that the meetings are held in company time, the health board management does not dictate the content of the meetings, but board members can read the terms of reference and minutes. The terms of reference included that each health board's children's community nursing team would host a network meeting, decide upon its content, invite external speakers, if appropriate, and write and distribute the minutes of the meeting they had hosted.
Ongoing progress of the network
Although it is not the purpose of this article to measure the impact of the network, because qualitative and quantitative data have not been formally collected, the success and benefits of the networking meetings can be considered through a number of examples.
Enteral feeding
One team highlighted the frustration and controversy regarding nurses administering ‘blended diets’ for enterally fed children and young people. This provoked a constructive discussion that was continued into a subsequent meeting. The hosting team generated debate on the trialing of this method of feeding within the current evidence base. (For further information on blended foods for tube-fed children, see the review conducted by Coad et al (2017)). The level of interest in this topic was considerable and clearly clinically focused.
Wound care
The second meeting focused on wound care. To provide further insight, a representative from a company producing dressings demonstrated the use of negative pressure wound therapy (NPWT), as opposed to gauze or alginate dressings, for pilonidal sinuses, which can prove difficult to treat in adolescents. However, network members pointed out that, although NPWT has been used across the wound-care spectrum, they were aware of the paucity of evidence regarding its use with children (Rhee et al, 2014; Danne et al, 2017). Therefore, before recommending the use of NPWT with children the CCNs decided that each group would need to discuss the appropriateness of using the therapy with the tissue viability nurses within their health boards.
Handwashing
Another team focused the meeting they hosted on handwashing in community settings and brought to the meeting hand gel, soap and water. The nurses were able to try each approach and determine how effective each was by using a visual tool (Glo Germ); this uses ultraviolet light and a powder or liquid to simulate the spread of bacteria or viruses, and it used to support training in good handwashing technique. The challenges of effective handwashing in community settings was subsequently discussed.
Aspiration
At the next meeting, the CCNs conveyed a request from a parent whose child had died from aspiration. The parents wanted other families to be given more information about the risks of aspiration with children who are fed through a nasogastric tube. The nurses who had cared for the child had subsequently produced an information leaflet, and the meeting progressed with members editing the text by discussing the language, content and overall style.
Once the editing of the leaflet was subsequently completed as part of ongoing work, members of the other health boards requested that it be made available on an all-Wales basis following governance approval from the hosting health board.
Learning disabilities
Nurses at the next meeting invited a colleague from the Welsh Government to speak, who discussed a transforming care project for children and young people with learning disabilities, which was part of the Improving Lives Programme (Welsh Government, 2018c). The speaker was keen to hear the views and experiences of the nurses with regard to caring for such children.
In addition, two students who were consolidating their pre-registration education within this community team presented a flowchart they had designed after researching the use of suction machines in community settings. Their findings provoked a discussion not only about the cost of machines but, more importantly, about whether or not suctioning should be used as a first resort, which often appears to be the case.
Continence
The final meeting discussed the need for a paediatric continence service and some potential barriers to setting one up in rural Wales. Another session on wound care was also included. Finally, the members debated the training of healthcare support workers, especially with regards medication administration.
A space to share practice and knowledge
These six community of practice networking meetings provided a safe space for CCNs to gain and share knowledge, to challenge practice, to provoke discussion and to reduce professional isolation. It also became a forum for group clinical supervision, where peers commented on best practice and gave constructive guidance to each other from the perspective of shared experience. Clinical supervision is built into the revised NMC (2018) revalidation process. Nurses are required to reflect on their own practice and discuss their reflections with a registered peer or manager in order to maintain registration. Peer discussions at the forum were often reflective and brought both the challenges and rewards of their role home to members of the group.
Clinical supervision aims to improve practice and performance; it is a tool used for continuous professional development and to provide structured support (NMC, 2018). Evans and Marcroft (2015) discussed the advantages and disadvantages of group clinical supervision in their paper on the work of the First Community Health and Care Service in Surrey. They interviewed nurses in the field and found that facilitated group clinical supervision was particularly valued by staff. The views of the nurses taking part in the practice networking meetings in Wales echoed this. They stated that it was:
‘… good to share ideas about our practice, and to be with other nurses doing the same job.’
‘Our job can be lonely sometimes. This forum helps.’
Bifarin and Stonehouse (2017) described group clinical supervision as ‘professional socialisation’ founded on mutual trust, confidentiality and an agreed aim of purpose. This was clearly evident at the community practice networking meetings.
Towards the future
It is anticipated that this innovative and collaborative way of clinical networking will continue and develop further, for example by the inclusion of the seventh health board, and the inclusion of CCNs who had not previously attended. Hosting a meeting encourages leadership development and develops confidence in presenting, chairing and running meetings. For all nurses, reflecting on their role within the network would be useful when revalidating with the NMC.
The CCNs in Wales reported feeling energised and motivated after attending and delivering presentations in their networks, and are actively planning future events. For CCNs who are unable to attend regularly, it may be necessary to extend the community of practice into a virtual community of practice (VCoP) (for example the potential use of Skype has been discussed with the health board not currently involved) to enhance inclusion and reduce professional isolation (Long et al, 2014; McLoughlin et al, 2018).
Conclusion
There remain challenges for CCNs, who often work in under-resourced services, with ongoing inequity of care provision in developing services across Wales. Strategic, ringfenced funding for community children's nursing is yet to be achieved in many areas of the country.
In response to the perceived isolation and uncertainty within children's community nursing in Wales, a community of professional practice clinical network has been formed and continues to develop and thrive. The network is led by, and for, clinical nurses, and meets the requirements of the NMC that nurses share, feed back and support others to develop clinical nursing for the benefit of children and their families.
The benefits of developing a similar network is evident for all community nurses working within complexity and change.