Nursing Leadership in Home and Community Care: An Introduction
When I was asked if I would contribute to an issue on nursing leadership in home and community care, it took me only a minute to say yes. In 2014–2015, I chaired an expert group on home and community care in Ontario that produced a report titled "Bringing Care Home" (www.health.gov.on.ca/en/public/programs/ccac/docs/hcc_report.pdf). The report pointed to the urgent need for system-wide change in home and community care to ensure that we have a transparent, equitable, accessible and accountable system that serves clients and their caregivers. The Minister of Health responded indicating he would implement our recommendations, and as a first step, announced the Patients' First Roadmap to Strengthen Home and Community Care (www.health.gov.on.ca/en/public/programs/ccac/roadmap.pdf), which included a 10-point plan to improve the care provided to clients and families receiving home care. Since the release of that report, I have been acting as an External Advisor to the Ontario Minister of Health and Long-Term Care to help advance the home and community care agenda.
Throughout this work, I have been increasingly concerned about the need for true reform in the way we deliver home and community care to citizens. I believe nurses could play a leadership role in this reform and have been frustrated at not seeing nurse leaders step up to the plate as much as I wish. This issue is a way to challenge all of us to use our understanding of the system, of our healthcare organizations and of the needs of our fellow citizens.
Why Leadership in Home and Community Care
Home and community care is not just a critical issue in Ontario. In the recent health accords with the provinces, the federal government has also targeted transfer payments to two critical issues – home and community care and mental health and addictions. I haven't heard anyone argue about the need for transformation in home and community care. In Ontario, and the picture is similar in other provinces, the numbers, complexities and demands for home care have been increasing dramatically. Caregivers (family, friends and neighbours) are bearing the heaviest burden of care – by most estimates about 70% of the care provided – and their needs also require urgent attention. And then there is integration; for all of our talk over the years about silos in healthcare, we haven't made much progress in eliminating them or at a minimum making transitions between them easier for families.
So, back to the reason I said yes to introducing this issue in Canadian Journal of Nursing Leadership (CJNL). In Ontario and across the country, we have seen examples of innovative, efficient and effective models of home care delivery. And most provinces are committed to making service delivery better, more transparent and easier to access and understand for families. But, although we have some terrific leadership in home and community care across the country, I have not heard the loud and sustained voice of nurse leaders in the discussion about transformation. Of course, there have been strong voices from individuals and from associations, but generally speaking, there is not enough consistency and strength to the arguments and they are not loud enough or broad enough.
As You Read This …
You may like to challenge this assertion, and I hope you will challenge the contributors' and my views; however, from where I sit, there is a tremendous opportunity for a partnership between nurses, clients and caregivers as we try to move patient-centred care forward in this country. In thinking about the need for this issue, I have wondered why has CJNL had to invite nurses to contribute rather than respond to an onslaught of articles and commentaries from nurses who want to see the issue receive attention in the journal? Where are the op-ed pieces in the newspapers? Why has no nurse written an article, a letter, a commentary for Canadian news magazines (Walrus, Macleans)? Where are the nursing scholars' voices in public policy journals?
I know that many of us have carefully considered why home and community care has not received the attention it deserves in public policy and the articles that follow identify some of those. But now that the provinces and the federal government have identified it as a focus for attention and funding, I hope that this issue will be only the first platform among many for nurse leaders to stand up and identify not just the challenges and barriers but also the opportunities that exist to make home and community care better for citizens. This is not only about what nurses can do about advocating for our role in the system; this is about what is needed and how we as a community and as a society can get from where we are to where we have to be. This issue is a beginning, but I encourage all of you to consider how you can lead in ensuring home and community care is better for patients and their families in the future than it is today.
Home Care as a Model for System Transformation
To encourage discussion and stimulate our collective wisdom, we asked Shirlee Sharkey and Nancy Lefebre to provide us with a paper that would challenge readers with their vision for nursing leadership in home and community care. And they have delivered (Sharkey and Lefebre 2017a). Using their work at Saint Elizabeth, they have described what home care can teach us about healthcare and about patient-centred care and asked us to bring the home care experience into the entire healthcare system. As they describe it, this transformation is about culture change and the place to learn about that is in the patient's/client's home. They encourage nurses to move from task to outcome, to look at different delivery models and to look at the home environment as a "living lab for how we need to approach and deliver care across the entire system." Their HOPE MODEL™ describes a system of empowered nursing-led home care teams that focus on patient care and wellness. They see nurse empowerment as a key driver in empowering people – patients, clients and families.
We commissioned two responses to the Sharkey and Lefebre article (2017a), one from Sally Thorne and Kelli Stajduhar at the University of British Columbia and University of Victoria, respectively, and the second from Tracy Kitch, President and CEO of IWK Health Centre in Halifax. Thorne and Stajduhar in their articulate and compelling commentary (Thorne and Stajduhar 2017), remind us that culture change is very difficult and caution us to be mindful of what they identify as "serious" barriers to nursing's capacity to lead that change. Among the most critical is what they identify as the weakening of nursing systems, the focus on program management that has contributed to silencing the nursing voice and the virtual eradication of the "middle management" layer that historically provided mentorship and professional guidance to front-line nurses. Another challenge they identify lies in the discourse related to evidence-based/-informed practice. "In our enthusiasm to integrate an evidence culture, we have forgotten that the patient is and always will be an 'n of one.'" They encourage us to use evidence to inform but to be wary of a slavish reliance on evidence to guide patient-centred practice. These barriers along with the conflict between a well-developed nursing discipline-specific system and a focus on interprofessional care systems are indeed areas for leaders to consider as they strive to develop a culture of patient-centred care in home and community care, or in any setting for that matter. Tracy Kitch responds to Sharkey and Lefebre (2017a) from a broader model, encouraging us to focus on person-centred care across the continuum, to champion integration and to partner across traditional boundaries, working in teams to develop collaborative care models (Kitch 2017). She sees nursing leaders as system leaders and says that our success will be measured by our ability to create a new system culture.
What Can We Learn about Leadership from Bundled Care?
This issue also provides a case study in nursing leadership and in system change. Wheatley, Doyle, Evans, Gosse and Smith (2017) describe a pilot in Ontario that changes the design of care delivery through a bundled care model that is patient-focused and in which nurses play a distinctive leadership role. They see nurses as a force for change in this model. Bundled care is the focus of considerable attention as a vehicle for system transformation; this case study describes what it is, why it contributes to patient-centred care and how it helps in system transformation. The role of nurses is central to the success of this collaborative interprofessional model of home care. It is an important example of how nurses can lead in system transformation and describes one way in which the culture or at least the expectations related to the "right" way to do things is challenged and the positive outcomes for patients, families and providers, especially nurses, can be realized.
We gave Sharkey and Lefebre the opportunity to rebut the challenges provided by the two commentaries and to comment on the Wheatley et al. (2017) paper. And they did! Their response (Sharkey and Lefebre 2017b) identifies the ways in which the commentaries and case study align with their view of the challenges facing nursing leadership, and they offer examples from their own experience as to how leading is also about "working with," of how knowing what to measure is important and how leadership is not only present in formal leaders but it is also a responsibility of all nurses – back to the "people empowerment" theme of their original article.
The final article in this issue (Udod and Lobchuk 2017) deals with a subject about which I am growing increasingly passionate – the role of caregivers in home and community care. The article is the result of work the authors are doing to study the communication needs of carers as partners with clinicians in meeting the needs of home care clients. The focus of the paper is on the role of nurse leaders as enablers to assist point of care staff to make transitions easier for carers and those they care for. The importance of making transitions easier for clients and families is well documented, and the authors remind us that integrating communication needs into hospital and community policies and programs can enhance the satisfaction of clients and families and lead to better outcomes for clients and for the system. This article is a call to action to nurse leaders and we need to hear them.
This issue on leadership in home and community care provides us all with more than enough food for thought. But as with most menus, we are sometimes left with questions about what is missing, what other food we might have eaten? And so, I'd like to ask our readers to think beyond what's written in this issue. What about the role of Advanced Practice Nurses (NPs, CNSs, etc.) in providing leadership in home and community care? Can we expand the discussion related to the conflict between leading interprofessional teams and enhancing the role of nurses and nursing expertise? What are other innovative models of delivering home care that nurse leaders could/should develop and promote? What should we expect from nursing leadership in home and community care?
I hope the work of these nurse authors will also challenge you to consider what defines nursing leadership, what nursing leadership looks like and what we need to do to truly transform the system to one that is centred on the needs and care of clients and families in home care and across the continuum.
I encourage you to respond to these papers and commentaries, challenge the assumptions, the opinions and the solutions offered and provide the nursing and broader healthcare community with other examples and views on how nursing leadership can be more engaged in creating the future healthcare system for all Canadians. We look forward to hearing from you.
About the Author
Gail Donner, RN, PhD, Professor Emerita,, Lawrence S. Bloomberg Faculty of Nursing,, University of Toronto, Toronto, ON
Correspondence may be directed to: Gail Donner; e-mail: firstname.lastname@example.org
Kitch, T. 2017. "A Leadership Perspective on a Shared Vision for Healthcare." Canadian Journal of Nursing Leadership 30(1): 30–32. doi:10.12927/cjnl.2017.25108.
Sharkey, S. and N. Lefebre. 2017a. "Bringing Nursing Back to the Future Through People-Powered Care." Canadian Journal of Nursing Leadership 30(1): 11–22. doi:10.12927/cjnl.2017.25110.
Sharkey, S. and N. Lefebre. 2017b. "Moving Forward: The Journey to People-Powered Care." Canadian Journal of Nursing Leadership 30(1): 43–46. doi:10.12927/cjnl.2017.25106.
Thorne, S. and K. Stajduhar. 2017. "Rebuilding the Roots of Patient-Centred Care." Canadian Journal of Nursing Leadership 30(1): 23–29. doi:10.12927/cjnl.2017.25109.
Udod, S. and M. Lobchuk. 2017. "The Role of Nurse Leaders in Advancing Carer Communication Needs across Transitions of Care: A Call to Action." Canadian Journal of Nursing Leadership 30(1): 47–55. doi:10.12927/cjnl.2017.25105.
Wheatley, L., W. Doyle, C. Evans, C. Gosse and K. Smith. 2017. "Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation." Canadian Journal of Nursing Leadership 30(1): 33–42. doi:10.12927/cjnl.2017.25107.
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