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An Exploration of Embedding the Community Matron Role in Three Settings: Making the Invisible Visible? Randall, S

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An Exploration of Embedding the Community Matron Role in Three Settings: Making the Invisible Visible? Randall, S An exploration of embedding the community matron role in three settings: making the invisible visible? Randall, S. Submitted version deposited in CURVE October 2014 Original citation & hyperlink: Randall, S. (2014) An exploration of embedding the community matron role in three settings: making the invisible visible?. Unpublished PhD Thesis. Coventry: Coventry University. Copyright © and Moral Rights are retained by the author. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. Some materials have been removed from this thesis for third party copyright and data protection reasons. Pages where material has been removed are clearly marked in the electronic version. The unabridged version of the thesis can be viewed at the Lanchester Library, Coventry University. CURVE is the Institutional Repository for Coventry University http://curve.coventry.ac.uk/open An exploration of embedding the community matron role in three settings: making the invisible visible? Sue Randall A thesis submitted in partial fulfilment of the University’s requirements for the Degree of Doctor of Philosophy Coventry University Faculty of Health and Life Sciences Department of Nursing, Midwifery and Healthcare Practice March 2014 The candidate confirms that the work submitted is her own and that appropriate credit has been given where reference has been made to the work of others. This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement. Acknowledgements My thesis would not have made it to the submission date without help from so many people. One of the participants in my study talked about a ‘jigsaw of care’ made up of big and small contributions to the whole. I am applying the same analogy to describe achieving a ‘whole’ PhD. So, a lot of thanks are due to people who have helped me. A natural place to start would be with the participants, without whom, my study would not have got to where it is. You all gave so generously of your time and I appreciate that very much. My supervisory team: Gill Furze, Guy Daly, Colin Thunhurst and in the early days, Natalie Mills have been a ‘dream team’. You have supported me through the highs and lows and the advice I have received has been invaluable. Dave Guest, subject librarian and Tim Sparks, statistician also provided valuable help at timely moments. Also, Philip Scullion and Rosie Kneafsey for their thought provoking questions and suggestions at PRPs. My family have suffered, at times, through this process. As usual, even when I have been really out of sorts, you have been there. So, Mum, Dad, Steve, Isobel, Sarah, Lauren and especially Dunc, Matthew and Harry, I thank you for being there and putting up with me. Additionally, thanks are due to my friends, some of whom are, no doubt, feeling neglected. Tanya, Sarah, Andree and Nina deserve special mention for supporting me last year in particular. Finally, I thank my colleagues, especially those who allowed me to take a sabbatical and those who covered whilst I was away. The contribution made by each and every one of you, big or small, has helped me to complete my PhD. THANK YOU. i | Page Abstract Background The role of community matron (CM) was introduced to provide a single point of access to patients living with co-morbid long-term conditions who had, or were at risk of, frequent emergency admissions to hospital. CMs utilised case management as a means of managing this growing population of patients with fragile health. Since its inception, many changes in service delivery have impacted on the role. Aim The aim was to undertake a mixed methodology study of the factors that have affected embedding of the community matron role in 3 geographical areas. Methodology A pragmatic mixed methods approach (QUAL quan) was utilised. Settings and participants The studies were based in health services within 2 cities and a rural area in central England. Participants for the qualitative components of the study were purposefully sampled. The sample comprised professionals: community matrons (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). Quantitative data for 212 people with long-term conditions were derived from the anonymised Patients at Risk of Rehospitalisation database (PARR data) held by area 1. Methods Qualitative data were collected from participants using semi-structured interviews and audio diaries. For the quantitative component using PARR, some patient journeys within area 1 were explored. In addition, a sample of patients who were case managed by a CM (n=106) were matched with a set of patients who were not (n=106) and the data was examined. Findings Participants were largely positive about the role of CM. However, difficulties with role setup had led to numerous changes which affected how the role has embedded. Additionally, this impacted understanding of the role by health care professionals, and caused practical and emotional difficulties for some CMs as they perceived the role to be eroded. The quantitative findings showed that CMs did not make a significant difference to hospital bed days used by patients on their caseload. Evaluating the role and finding an effective means of showing the work undertaken by CMs, which is often invisible, proved difficult. Conclusion Embedding of the CM role has been affected by numerous changes in service delivery. Invisibility of community nursing rather than autonomy of the community matron role seems to be a key factor in the challenges of embedding the role. The significance of these findings is that using a mixed method approach and Liaschenko and Fisher’s adapted model may help CMs to improve the visibility of their role, and so helping the role to be less prone to the challenges of service redesign. ii | Page Original and Significant Contribution Original and significant contribution to research This study is the first to take use a mixed methodology to examine, across different sites and service contexts, the process of embedding of the role of community matron to undertake case management with people with long term conditions. The thesis has built on the work of a number of authors who have examined invisibility in nursing. Where it is unique is in considering these factors in community settings and in the work nurses do across the boundaries of the community setting and the hospital setting. While other studies of the work of community matrons have focused on outcome measures such as cost effectiveness and reduction in hospitalisation, this is the first study to apply the lens of invisibility in nursing to the work of community matrons. Using this lens may allow nurses to connect health policy and service designs to the needs of people to whom they deliver nursing. As such, my thesis adds a new perspective to a historical nursing argument of invisibility, as well as further highlighting that an autonomous nursing role is no more likely to be embedded. iii | Page Dissemination Aspects of this research have been presented at this conference: Randall, S. Managing Individuals with Co-morbid Long-term Conditions, using a Case Management Approach by Community Matrons in an English Inner City. Positioning Nursing for the Future: Advancing Nurses’ Roles in Community and Healthcare. National University of Singapore / National University Hospital International Conference 17-19, Nov 2011 (2nd prize: oral presentation) This research has informed the writing of the following peer reviewed publications and book chapter: Randall, S., Daly, G., Thunhurst, C., Mills, N., Guest, D. and Barker, A. (2014) Case management of individuals with long-term conditions by community matrons. Primary Health Care and Research 15, (01), 26-37 Randall, S. (2011) ‘Care Coordination’ in Long-term Conditions. A Guide for Nurses and Healthcare Professionals. Ed. Randall, S. and Ford, H. Chichester: Wiley Blackwell 221-262 Thunhurst C., and Randall S. (2010) Applied Research: building the evidence base for health sector development. International Journal of Therapy and Rehabilitation. 17 (8), 344-351 iv | Page Contents Acknowledgements i Abstract Ii Significant and original contribution iii Dissemination iv Contents v-xiii Tables and figures xiv-xv Glossary of terms and abbreviations xvi-xx 1-25 Chapter 1: Introduction 1.1 Background and context of my study 3-22 1.11 Changing Demographics, morbidity and mortality 3-5 1.12 Emerging means of managing individuals with LTCs 5-9 1.13 Context into which community matrons were placed 9-12 1.14 Current political issues in commissioning 12-5 1.15 New nursing roles: advanced nurse roles 15-9 1.16 Community matrons 19-22 1.2 Embedding new nursing roles 22-5 1.3 Chapter Summary 25 Chapter 2: Literature review 26-67 2.1 Introduction 26 2.2 Case management 26-51 2.21 Case management pre community matron (1996-2004) 30-1 2.22 Review of evidence on case management (1996-2004) 31-4 2.221 Hospital admissions 32 2.222 Emergency department visits 32-3 v | Page 2.223 Length of stay/hospital days 33 2.224 Functional status 33 2.225 Costs 33-4 2.23 Case management following implementation of 34-51 community matron 2.231
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