"It’s a lot more in-depth for us than it was before”: A multi-methods study of community nurses’ extended roles in palliative care

Problem

Community nurses have always worked very closely with patients and their families at the end of their life. Changes in ways of working, accelerated by the Covid-19 pandemic, have placed community nurses even more centrally than before within the complex patchwork of community palliative care provision. Our study aims were to explore UK-based community nurses’ views and experiences of their new or extended roles in palliative and end-of-life care since the pandemic, including what has been helpful or requires improvement.

Approach

We conducted a multi-methods e-survey and focus group study between February and April 2023, about a year after UK lockdowns ended. A social constructionist perspective underpinned the research.A detailed e-survey of 51 community nurses generated a descriptive overview of some specific areas of change in participants’ roles since the beginning of the pandemic. This was followed by focus groups; as well as serving to recruit focus group participants, the survey results provided a robust starting point for our subsequent in-depth qualitative exploration of 35 community nurses’ perceptions of their new or extended roles.E-survey responses were analysed descriptively. Qualitative data were analysed inductively using thematic analysis.

Findings

Participants identified two specific roles that were new to many of them: verifying death and prescribing. Many community nurses also talked about a broader, more fundamental expansion of their role; they described themselves as replacing general practitioners and palliative specialists in making important and often complex decisions with patients and families. Nurses expressed a mixture of positive and negative feelings about these extended roles. Most expressed pride in their new knowledge and skills, and satisfaction with the care they were providing. Yet many also expressed dissatisfactions, particularly concerning the quantity of work expected of them and the extent to which they had to take the lead in managing complex problems. They described heavy workloads impairing their capacity both to provide good clinical care and to train junior colleagues, and highlighted the importance of more general practitioners’ support with complex cases. However, accessing general practitioners’ input was difficult in some areas, and there was concern that many general practitioners lacked adequate expertise to provide effective back-up.

Consequences

These findings have two broad implications for policy-makers and commissioners seeking to recruit and retain more community nurses. First, they should recognise the importance of allowing experienced nurses enough time to facilitate their juniors’ experiential learning, alongside providing high-quality care for patients. Second, medical back-up for nurses managing complex end-of-life situations should be strengthened, in response to its perceived inadequacy in some areas. Addressing these two issues, we suggest, would reinforce community nurses’ already-strong commitment to fulfilling an expanding role in caring for the increasing number of people who die at home.