Problem

There are many health and social care services that have been facing an increase in demand, driven by multiple factors including: a growing and ageing population; advances in health science; and not enough funding to deal with performance and capacity issues and transform services.1 COVID-19 pandemic has exacerbated the situation for both patients and clinicians who are feeling the impact of an overpressurised system that is struggling to meet demand. The pandemic has also transformed use of remote monitoring (RM) in a matter of weeks, and with remote care having been the only option for most patients, health and social care are unlikely to be the same again.

In 2020, 95% of Integrated Care Systems (ICSs)across the country received funding to support or implement a technology-enabled RM or virtual ward solution, with an aim to save bed days, and avoid admissions.2 In 2021/2022, NHSX committed to: ensuring at least 300 000 people across the country receive technology supported care at home; continue to support the national innovation collaborative to maximise the benefits this model of care delivers for citizens and health and care staff; and rapidly sharing learning and evaluating the impact of the programme to compound the great work being done.

The Florence Nightingale leadership scholarship project being discussed here aimed to see whether the use of a community of practice (CoP) would enable possible healthcare benefits due to sharing and learning from peer practice.

Background

England has more than 15 million people with long-term conditions who also have the greatest healthcare needs of the population. This includes approximately 50% of appointments (GP); 70% bed days; and treatment and care that absorbs around 70% of acute and primary care budgets in England.3 In outpatient services, there is a drive to keep patients out of hospital by delivering more than 120 million appointments per year.4

Nursing staff have been key in managing the challenge of current models of dealing with long-term conditions that are not sustainable through increasing their delivering functions that were previously considered to be only in the remit of doctors.5 As demand continues to rise both patients and staff are feeling the impact of a system under significant pressure that is struggling to meet this demand.

The Royal College of Physicians5 highlighted that a key element of the outpatient redesign process was better utilisation of the technology already available, but there was some hesitancy to adopt these alternatives due to concerns with locally available IT infrastructure and support, data protection, loss of remuneration from clinical commissioning groups and discrimination against patients less comfortable with necessary technology.

There are several reports and research papers that highlight how the National Health Service (NHS) has struggled to adopt innovation due to various issues that include: leadership and cultures that are not supportive, a lack of improvement capability, evidence of effectiveness and understanding of the evidence.6 7

The Department of Health and Social Care,8 set out a vision for use of technology, data and digital within health and social care to meet the needs of all users. The NHS Long Term Plan9 included the commitment that digital first patient care will become an option for every patient by 2023–2024.

Research highlights how digital technology can transform care for the better through empowering patients, establishing more robust therapeutic relationships as well as supporting stronger teamworking across boundaries and enabling creation of communities and networks to support patients. It also shows the potential to create more responsive treatment models that better reflect the recurrent nature and the various forms of long-term conditions and the several issues they raise for patients.6

COVID-19 pandemic transformed the use of digital technology in a matter of weeks through necessity, with remote care now the only option for most patients, and the NHS is unlikely to be the same again. Hutchings10 agrees that the pandemic played a crucial role in accelerating change but argues that there are potential risks and downsides in clinical practice, impact on patients and the public and workforce especially when change happens at such a pace. It is important to recognise that staff are the most valuable resource in the health and care system, and digital technology needs to work for them and those receiving care.11

Agnew12 stated that nurses need to be at the heart of technological developments and implementation to make sure changes facilitate and enhance patient care and deliver on promises to free up clinician time and improve patient safety. Using nurse leaders like chief nursing information officers and digital champions is one useful way to engage nurses with digital technology as they are able to work collaboratively with system developers and speak the same language as their nursing colleagues who may be less confident in digital technology.13

One of the lessons from the pandemic is how collaboration and innovation enabled by digital technology can radically transform health and care services at pace when people are provided with the space and support to be innovative.10

Since the 1990s, CoPs have been endorsed as drivers of knowledge management within business sector that enable the sharing of tacit knowledge, innovation and learning, all of which creates social capital and adds organisational value.14 15 They later appeared in healthcare16 and were viewed as a strategy for improving organisational performance.17 CoPs are also viewed as a tool that enhances knowledge and improves practice.18 Wenger et al19 defined CoP as having three dimensions that include: a shared undertaking; common engagement; and a shared collection of resources.

It is problematic for researchers to examine the impact of CoP in the healthcare sector as they vary in form and purpose.20 Most of the case studies reviewed by Li et al 21 used qualitative approaches and had insufficient quantitative data to demonstrate specific impact of CoP on health outcomes in isolation from other interventions. However, other scholars19 22–26 argued paying attention to processes and outputs as viewed by the CoP members and ‘systematic anecdotal evidence’19 was as important as quantitative evidence of impact.

The social and cultural context within CoP operate are likely to influence their impact as they are used in healthcare to influence change in practice that requires a change in clinician behaviour.20 Behaviours espoused by a leader in each situation is fundamental to the effect it has on environment in which people they lead are working in.27 Making CoP environment supportive has potential to influence follower feelings of psychological safety where they can fully engage in a task.28 Florence Nightingale Foundation (FNF) through bespoke leadership programmes enabled the author to develop more awareness of self, team and networks; understand and use authority and influence; and express self to enable presence and have better impact on implementing this quality improvement project.

Measurement

Our data collections focused on using qualitative data to measure the value created by the community for members. Due to time and resource issues, we were not able to collate quantitative data to help corroborate how members were changing their practices and improving performance around uptake of tech-enabled RM solutions by patients as well as reduction in avoidable admissions, reduction in bed days and reduction in Accident and Emergency attendances. We only managed to track numbers of attendance to the network forum and the number of visits to the collaborative space as this would enable access to information. We had around 40 members attend on launch day, and we also gave them access to the collaborative space. We collected themes after every session of what the members were gaining from the sessions, and we conducted a 6-month review to gain some feedback to understand whether there was any value gained through CoP in personal knowledge and strength of relationships.

Design

Discussion with the NHSX Digital Health team on context of their regional scaling programme objectives highlighted that there were more similarities than differences to FNF leadership scholar project objectives, and it made sense to combine the projects because of these mutual benefits.

Desk research highlighted that a CoP approach was the best strategy for this project as it provided a space for knowledge to be shared across boundaries, generate and manage information resources for members to draw on, promote standardisation of practice and innovation,15 which were all part of the objectives we agreed in our discussion that led to development of a draft terms of reference (ToR).

A focus group with staff from NHS trusts that were part of the project teams within the NHSX Regional scaling programme was used to test if this was the right thing to do for the project groups. We had endorsement from the focus group as well as some additional information to strengthen the ToR.

The final ToR was also checked and signed off with key stakeholders before the launch. The implementation team met before and post sessions to review what went well and what could be improved, which helped to ensure there was value in the CoP activities for the members. Despite changes in the implementation team, the CoP activities were not impacted as the team had clear roles in how they supported the forum as defined in the ToR.

The most important single change in the NHS … would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. – Berwick Report29

This forum was designed to run with CoP principles that will make it more likely to be sustainable as it offers time, space and opportunities for members to innovate, share and learn from each other as well continue to develop cross boundary relationships with others who have a passion to see those issues tackled on behalf of the technology enabled Long-Term Conditions (LTC) and virtual wards (VWs) projects.

Membership to the forum was initially restricted to nurses working with LTC and VWs projects within the portfolio of the NHS Regional Scaling programme, but this extended to other clinicians (medical and allied healthcare professionals) as well as other project team members as multidisciplinary group was perceived as more beneficial. We also managed to connect with chief nursing information officer (CNIO) network, digital nurses’ network and community nursing digital network so the voice of the nurse was strong.

Strategy

Plan, Do, Study, Act (PDSA) cycle was used as a supporting mechanism for iterative development of the CoP strategy.30