# Identifying the Top Ten Unanswered Questions in Community Nursing: A James Lind Alliance Priority Setting Partnership in Community Nursing

Authors: Catherine Henshall; Louise Jones; Claire Armitage; Lee Tomlinson
Journal: Advances in Public Health
 (2022)

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## Abstract

Community nurses deliver comprehensive nursing care to patients living outside of hospital settings and play a crucial role in meeting individual and public health needs. Research is essential in providing evidence-based care for patients; however, most community nurses are not research active, with few relevant studies and little funding for community nursing research. To address this, four National Institute for Health Research senior nurse researchers in England conducted a James Lind Alliance priority setting partnership in community nursing with the aim of raising the international profile of community nursing research through the identification of meaningful research priorities that matter to this community. Community nurses, patients, and carers were integral to the process, which aimed to identify the top ten unanswered questions to inform community nursing practice. The Priority Setting Partnership process utilised a coproduction, mixed-methods approach. It involved consultation meetings with stakeholder partners and nested quantitative surveys. The study ran from March 2020 until September 2021, and numerous unanswered evidence uncertainties were identified. The top ten priority questions included nursing and patient focussed issues, which reflect the complexity of care delivered to patients and the workforce pressures community nurses face. Findings reflect the views of community nurses, patients, and carers and highlight areas that need attention to ensure research is embedded within community nursing settings. Identification of the top ten priorities has provided an international platform for community nursing research. This must be sustained through engagement, collaboration, funding, and innovation and has widespread implications for developing the community nursing workforce and optimising the safety and quality of patient care.


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## Body

## 1. Introduction

Internationally, engagement in evidence-based practice within community nursing settings is sub-optimal, with few research studies addressing challenges or issues that are relevant to community nursing settings [1]. This has potentially devastating consequences for the future of the community nursing profession and its ability to keep up with changes across healthcare systems, with resulting implications for the retention and recruitment of staff and the quality and safety of patient care.Community nurses deliver comprehensive nursing care to patients living in their own homes and in other out-of-hospital settings by working collaboratively with neighbouring health and social care organisations and by playing a key role in meeting individual and public health needs [2–5]. They employ multi-faceted skillsets to ensure that the needs of people living in the community are carefully assessed, monitored, met, and sustained [2]. In recent years, the role of community nurses has become more complex due to increasing pressures for patients to be cared for in community care settings rather than hospital-based environments [6]. This has required the utilisation of advanced nursing skills and often entails managing the health and social care needs of patients living with multi-morbid conditions that are associated with an ageing patient population [7, 8]. In addition, community nurses are an integral part of integrated care systems, constantly communicating with primary, secondary, and social care services to ensure that the holistic care needs of their patients are met [9, 10].The complex and highly skilled roles of community nurses are set against a backdrop of staff shortages, recruitment and retention issues, growing patient caseloads, autonomous working practices, a lack of training and development opportunities, and limited career progression pathways [7, 11]. These challenges have been exacerbated during the COVID-19 pandemic, with many of the changes imposed by COVID-19 resulting in increased work-related stress, exhaustion, and burnout [12], further increasing the gap between capacity and demand in community nursing services [13]. A recent Queens Nursing Institute (QNI) survey involving almost 3,000 UK district nurses found that 46% of respondents were planning to leave community nursing within the next six years. In addition, 75% of respondents identified vacancies within their nursing teams, with 22% of respondents stating they worked a day or more of unpaid overtime each week to meet the demands placed on them [14]. As a result, the QNI has encouraged newly qualified nurses to begin their nursing careers in the community rather than starting in secondary care before moving to community settings [15]. However, more support is needed to ensure that the best nursing staff are attracted to the profession and that optimal patient care outcomes are delivered.The national health service (NHS) in England’s National Community Nursing Programme (NCNP) [4] recognises the complex and comprehensive care that community nurses deliver and the integral role they play within and across the health and social care systems, whilst also identifying the ever-increasing demands on their time. The NCNP aims to build and support the community nursing workforce to enable the delivery of safe, high-quality patient care and intends to advance research and innovation across community nursing settings in England [4]. Research is essential in providing nurse-led evidence-based care for patients at a global level [16]; however, despite initiatives implemented by the international collaboration for community health nursing research (ICCHNR) to provide support for community nurses through building an international network of nurse researchers, hosting conferences, and funding scholarship awards [17], most community nurses are not research active. Much of nurses’ day-to-day practice has been shown to be based on experiential knowledge, clinical assessment, obtaining information from colleagues, and following routine guidelines rather than seeking out original research [18–20]. This has resulted in a lack of research studies focussed on community nursing and a lack of research funding opportunities [5]. Research-active healthcare organisations are known to have better patient outcomes [21]. However, due to barriers and challenges—such as time constraints, lack of managerial support, poor dissemination of and access to research findings, and cost implications [22]—that make it difficult for nurses to access research career pathways, few play a key role in supporting, delivering, and leading research [5]. These issues need to be addressed and resolved to allow for a more uniform spread of visible research roles in community nursing research roles and an increase in research activity within community nursing settings.NHS England’s Chief Nursing Officer’s Strategic Nursing Plan: making research matter [5] outlines the need for a culture where nurses are leading, using, supporting, and participating in research on a daily basis [5] and identifies James Lind Alliance Priority Setting Partnerships (JLA PSP) as a means of identifying evidence uncertainties within nursing settings. Past priority-setting partnerships have been referred to as trusted sources of guidance for funders and researchers [23]. To address the lack of evidence within the community nursing setting, four national institute for health research (NIHR) 70@70 Senior Nurse Research Leaders [24] collaborated on a JLA PSP in Community Nursing with the aim of raising the profile of community nursing research at a national and international level. Community nurses, patients, and carers were integral to this process, which set out to identify the top ten unanswered priority questions for community nursing [25]. Thus, this paper reports on the JLA PSP in Community Nursing process and its findings.


## 2. Materials and Methods

### 2.1. Study Design

The JLA PSP process utilised a coproduction, mixed-methods approach as a way of engaging a range of stakeholders in the prioritisation process [26]. It involved a series of consultation meetings with stakeholder partners and nested quantitative surveys. The JLA PSP process is mapped out in Table 1.Table 1
An outline of the steps involved in the James Lind alliance priority setting process.
The priority setting partnership process(1)Create a steering group with equal representation of patients, carers, and clinicians and strong links to relevant partner organisations; and raise awareness of the project in order to maximise support and participation(2)Gather evidence for uncertainties by asking patients, carers, and clinicians to respond to a survey asking what questions they have for research and by searching existing literature to identify gaps(3)Refining questions and uncertainties—the steering groups work with a JLA information specialist to create a long-list of summary questions from the survey responses(4)Evidence checking—the long list of summary questions is checked against the existing research evidence to ensure that they have not previously been answered by research studies(5)Interim prioritisation—through consensus, the steering group prioritises the identified uncertainties by asking patients, carers, and clinicians to complete a second survey to rank the research questions(6)Final prioritisation—this is generally a one-day workshop facilitated by the JLA with input from the steering group; up to 30 patients, carers, and clinicians will participate in discussion and ranking to determine the top 10 questions for research studies(7)Publish and promote the top 10 research priorities—the top 10 are announced and published and a publication, and promotion plan is implemented to disseminate the results and influence researchersJames Lind Alliance [27] JLA Guidebook available at: https://www.jla.nihr.ac.uk/jla-guidebook/Accessed 20.07.21.


### 2.2. Setting

The study was led by four national institute for health research (NIHR) 70@70 senior nurse and midwife research leaders (SNMRLs) who were based at four geographically diverse NHS Trusts across England. One was in the northeast, one in the East Midlands and two were in the southeast region of the country. Each of the SNMRLs worked in a community or community and mental health NHS Trust. Funding for the study was obtained from the NIHR applied research collaboration (ARC) (reference: NIHR200172), and the study ran from March 2020 until September 2021. Ethical approvals were not required due to the JLA PSP being classified as a consultation exercise.


### 2.3. Stakeholder Group Formation

The SNMRLs accessed study stakeholders and participants using their combined community nursing networks. Each SNMRL contacted the Chief Nurse in their NHS Trust to inform them about the PSP, invite them to take part, and ask their permission to invite other community nurses in their organisation to participate in the stakeholder group. In addition, the SNMRLs contacted community nursing organisations and charities at a local, regional, and national level to promote the upcoming PSP and ask for participation; many agreed to collaborate. Patient and carer representatives were identified through liaising with the patient and public involvement (PPI) lead at one of the NHS organisations in South England and asking them to access their PPI contacts to ask if they would be interested in being part of the stakeholder group process. Four patients and their carers expressed an interest in taking part and were interviewed by the PPI lead and two of the SNMRLs. Four PPI representatives were appointed to the steering group: one was based in South England, another in North England, and the other two in the Midlands. In total, 13 community nurses (including two chief nurses) and four patient and carer representatives were appointed to the steering group, along with the four SNMRLs, a project coordinator, a JLA advisor, and an information specialist.The first stakeholder meeting was held in March 2020. All meetings took place virtually via Microsoft Teams and Zoom platforms due to COVID-19 restrictions. At the first meeting, the group’s terms of reference were reviewed and the project protocol was agreed; this included finalising the JLA PSP process and its aims and scope [27] (Table 2).Table 2
Aims, objectives, and scope of the JLA PSP in community nursing.
Aims, objectives and scope of JLA PSPAim: to identify unanswered questions about community nursing from patient, carer and clinical perspectives and prioritise those that patients, carers, and clinicians agree are most important for research to addressObjectives(i) work with patients, carers and clinicians to identify uncertainties about community nursing in England, in relation to the provision of nursing care to adults in their own homes, in community nurse led clinics, or residential homes(ii) to agree by consensus a prioritised list of those uncertainties, for research(iii) to publicise and disseminate the results of the PSP(iv) to take the results to research commissioning bodies to be considered for funding(v) to enable community nurses to expand and enhance their involvement in research(vi) to change community nurses’ practice through increased engagement with evidence-base(vii) to increase national collaboration and impact through partnerships with funders, community nursing organisations, and healthcare providers(viii) to extend and enhance patient and public involvementThe scope of the community nursing PSP was defined as(i) including uncertainties around community nursing in England that relate to the care of adults being cared for in their homes, in community clinics or in residential homes by NHS community nurses(ii) perspectives reflective of practice-based roles of community nurses, including district nurses(iii) physical and mental health and areas of overlap between them(iv) perspectives of patients and carers who access community services in relation to the service provided, information, assessments, interventions, and service outcomes(v) questions relating to Covid-19 and its impact on community nursing careThe PSP excluded from its scope questions about(i) community nursing outside England(ii) community nursing practice based outside the NHS(iii) people accessing community nursing services who are under the age of 18(iv) specific government policies across England for health and social care(v) preand postregistration education of community nursing(vi) training, education and professional development of community nurses(vii) services with a commercial interest(viii) noncommunity nurses, school nurses, health visitors, practice nurses, and community nurses working in children’s nursing, mental health and learning disabilities(ix) patients cared for in secondary care and nursing homesIt was confirmed that steering Group meetings would take place online every month for the duration of the PSP. Appendix1 provides a summary of the key points discussed at each JLA PSP steering group meeting.


### 2.4. Surveys

Two community nursing JLA PSP surveys were developed using a collaborative, coproduction approach with members of the stakeholder group. The surveys were available online via the SNAP online platform as well as in paper-based formats. Responses were anonymous unless individuals added their details for an invitation to the final workshop.


### 2.5. Survey One

The aim of the first survey [28] was to capture the views of community nurses, patients, and carers across England in relation to their priorities for community nursing research. JLA PSPs routinely focus on disease, and this community nursing PSP was only the second to consider a professional, rather than disease, group. This meant that the questions developed for patients and carers were intentionally broad so as to generate wide-ranging topic areas for discussion in relation to community nursing. The survey one questions were discussed, debated, and agreed upon during the stakeholder meetings (Table 3).Table 3
Survey one questions for community nursing JLA PSP.
Community nurse questions(i) what questions do you want research to address about community nursing?(ii) is there anything else you would like to tell us?Patient and carer questions(i) what did the community nurse/nursing team do that worked well?(ii) what could the community nurse/nursing team have done differently/better to improve the care experience?(iii) is there anything else you would like to tell us about when you, or someone you care for had care, support or advice from a community nurse/nursing team?


### 2.6. Recruitment and Data Collection

The SNMRLs worked with the communications lead at the NIHR ARC to design and create a bespoke web page that promoted the Community Nursing JLA PSP [29]. The purpose of this was to create a virtual platform from which to promote and recruit for the PSP and to host the online surveys. The communications lead also developed promotional materials and branded the webpages to ensure consistent messaging about the study was communicated at all levels throughout the PSP. These included prewritten Tweets and press release materials, which were embargoed until the survey’s launch date in November 2020. Key organisations were contacted by the SNMRL project team and asked to share the promotional materials and survey links on social media. These included the four NHS organisations that the 70@70 SNMRLs were based at, national community nursing bodies such as the Queens Nursing Institute and the National District Nursing Network, charities, PPI networks, and the NIHR. A full list of organisations contacted is listed in Appendix 2.Paper copies of the survey were printed, and the core team distributed these where possible with patients and carers who were not able to access the online survey; this was at times difficult due to the ongoing pandemic [30]. The completion and return of the survey implied consent to participate, and information was provided about its aim and scope to ensure all participants were well informed of the purpose of the consultation exercise. The survey was open to all community nurses or healthcare staff working alongside community nurses, as well as patients and carers who had received community nursing care in England. The first survey was open for 11 weeks, between November 2020 and February 2021. The second survey was launched in May 2021 and was open for seven weeks.


### 2.7. Data Analysis

Free text data from the first survey was extracted from the online SNAP platform before being reviewed by the Information Specialist from the JLA PSP team. The Information Specialist excluded any research questions that fell outside of the Community Nursing JLA PSP scope (Table2). These included any questions relating to the training and development of community nurses and questions that related to best clinical practice, for example, wound dressing techniques or catheter care procedures. Following this, the Information Specialist shared the out-of-scope questions with the stakeholder group to check that they agreed that they should be excluded. Any questions that, on reflection, were felt to be in scope were moved back into the “in scope” folder. Following this, the Information Specialist conducted a scoping review to identify if any systematic reviews had been conducted, which answered some of the questions within the scope (Table 4). Key search terms used included: “community; district; nurse; nursing; systematic review.” Databases searched included Cochrane and PubMed. In addition, NICE guidance, King’s Fund reports, and Google were searched for relevant reviews on this topic that had been published between 2016 and 2021. Over 1300 papers were identified, but no relevant systematic reviews were found. Individual research papers were not subsequently searched for due to the time constraints involved in conducting the PSP.Table 4
Top 18 unanswered questions prioritised in the community nursing JLA PSP.
Top 10 evidence uncertainties(1) How can community nurse teams better meet the complex needs of patients with multiple health conditions?(2) How can community nurses promote shared care/self-care amongst patients and support carers to provide some aspects of care (e.g., changing dressings)?(3) How can community nurse teams best contribute to the management of acutely ill patients at home? What difference does this make to hospital admissions?(4) What are the best ways for community nurses to involve unpaid carers/relatives/friends in decisions about their loved one’s treatment and care?(5) How can community nurse teams work effectively with social services and care services to improve the quality of patient care?(6) How has community nursing changed in response to COVID-19? Are any of the changes (e.g., timed visits, new skills, and working from home) worth keeping?(7) Does seeing the same community nurse(s) over time make a difference to the quality of patient care?(8) How can community nurses work effectively with other health professionals in hospitals and specialist community services to improve patient care?(9) What are the stresses on community nurses, and what impact does this have on their health and well-being? How can this be improved?(10) How can nurses be encouraged to become community nurses and stay in the profession?Evidence uncertainties 11–18(11) What is the optimum ratio of patients to staff in a community nurse team to ensure safe and effective care, and what is the ideal skill mix within the team?(12) How can community nurses best contribute to end-of-life care?(13) Can better tools be developed to assess whether community nurse teams have sufficient capacity to meet local demand?(14) How can a community nursing service best meet the health care needs of frail patients?(15) Do community nurses with specialist qualifications make a difference to the quality of patient care?(16) What are the best ways for community nurse teams to work with GP practices? How can the partnership between community and practice nurses be improved?(17) How can community nurses encourage and promote optimum health amongst their patients, e.g., to help people care for their skin and avoid ulcers?(18) What is the best way to organise the working day to ensure community nurses can meet patients’ needs and have a manageable workload?The “in scope” questions were then grouped by the Information Specialist into broad cluster groups, and an overarching question for each cluster was developed. At the next Stakeholder Group meeting, attendees were asked to review the cluster questions for clarity and check that the grouped questions were represented by the overarching cluster question. This led to changes to the wording of the cluster questions until a consensus was formed that the questions were representative of the grouped questions sitting under them. Any cluster questions that were deemed to be out of scope were removed at this stage. The remaining cluster questions were incorporated into the second survey.


### 2.8. Survey Two

#### 2.8.1. Recruitment and Data Collection

The second survey [28] aimed to prioritise the cluster questions that had been developed from the survey one findings. In total, 40 questions were included in the survey, which was open from May to July 2021. Survey two was promoted and disseminated through the same links and networks that were utilised for the first survey. Paper copies of the online survey were also printed, and the core team shared these where possible with patients and carers who were not able to access the online survey. The completion and return of the survey implied consent to participate, and information was provided about the aim and scope of the PSP survey to ensure all participants were informed of the purpose of the consultation exercise. The survey was open to all community nurses or healthcare staff working alongside community nurses, as well as patients and carers who had received community nursing care in England. Survey respondents were asked to prioritise their top ten questions (with rank one being the most important) from the forty questions listed.


#### 2.8.2. Data Analysis

Data from online and paper-based surveys was collated and listed by a member of the project team. Questions were thematically grouped under drafted summary questions and categories [31]. The goal of each summary question was to provide an accurate and transparent summary of the responses given. Following this, the different questions were ranked in order of priority. As well as the questions being listed in overall priority order, the priorities were subdivided into different groups to check whether there were any major differences between the overall priority list and the priority list according to certain subgroups of respondents. These subgroups included responses from patients and carers, responses from community nurses and other healthcare workers (Figure 1), responses from ethnic minority groups, and responses from male healthcare professionals. Overall, differences between the priority list and the subgroup priority lists were minimal; however, five questions were found to have been ranked significantly more important by specific subgroups, and adjustments were made to reflect this and make sure that the priorities of each subgroup were represented.Figure 1
Healthcare workers’ responses to the survey.


#### 2.8.3. The Final PSP Workshop

The top 18 priorities that had been listed as a result of the responses from the second survey were collated and taken to the final online JLA PSP workshop, which was held in September 2021. The workshop was held over two days, and its aim was to identify, through discussion and debate with stakeholders, the top ten unanswered questions in community nursing. In total, 40 people attended the final workshop. Meeting representatives included three of the SNMRLs, a project coordinator, five JLA advisors, seven community nurses, two other members of the multidisciplinary healthcare team, 11 patients and carer representatives (of which four were Steering Group members), and five hybrid healthcare professionals/carers. In addition, five observers were invited to the final workshop, representing national organisations and bodies with a sustained interest in the legacy of the PSP, such as the NHS and the NIHR. Observers were not allowed to actively participate in discussions or debate but were able to observe the PSP and how decisions and agreements were reached; this aided transparency and enhanced credibility in the process [32].Workshop members were split into five working groups, each facilitated by a JLA advisor. Within these groups, the 18 priorities were discussed, reordered, and ranked according to the insights offered by working group members as to which questions should take higher priority than others, which should be included within the top ten, and which should not. At the end of the first day, the ranked lists from each of the five groups were merged to form a reprioritised top 18 list. At the start of day two, workshop attendees were split into new working groups and provided with the updated list. Discussions continued, and the top 18 list was reordered again, with a key focus being to make sure that the correct priorities were included within the top ten list. Following this, the five revised lists from each working group were merged again, and the top ten unanswered questions in community nursing were confirmed.


## 2.1. Study Design

The JLA PSP process utilised a coproduction, mixed-methods approach as a way of engaging a range of stakeholders in the prioritisation process [26]. It involved a series of consultation meetings with stakeholder partners and nested quantitative surveys. The JLA PSP process is mapped out in Table 1.Table 1
An outline of the steps involved in the James Lind alliance priority setting process.
The priority setting partnership process(1)Create a steering group with equal representation of patients, carers, and clinicians and strong links to relevant partner organisations; and raise awareness of the project in order to maximise support and participation(2)Gather evidence for uncertainties by asking patients, carers, and clinicians to respond to a survey asking what questions they have for research and by searching existing literature to identify gaps(3)Refining questions and uncertainties—the steering groups work with a JLA information specialist to create a long-list of summary questions from the survey responses(4)Evidence checking—the long list of summary questions is checked against the existing research evidence to ensure that they have not previously been answered by research studies(5)Interim prioritisation—through consensus, the steering group prioritises the identified uncertainties by asking patients, carers, and clinicians to complete a second survey to rank the research questions(6)Final prioritisation—this is generally a one-day workshop facilitated by the JLA with input from the steering group; up to 30 patients, carers, and clinicians will participate in discussion and ranking to determine the top 10 questions for research studies(7)Publish and promote the top 10 research priorities—the top 10 are announced and published and a publication, and promotion plan is implemented to disseminate the results and influence researchersJames Lind Alliance [27] JLA Guidebook available at: https://www.jla.nihr.ac.uk/jla-guidebook/Accessed 20.07.21.


## 2.2. Setting

The study was led by four national institute for health research (NIHR) 70@70 senior nurse and midwife research leaders (SNMRLs) who were based at four geographically diverse NHS Trusts across England. One was in the northeast, one in the East Midlands and two were in the southeast region of the country. Each of the SNMRLs worked in a community or community and mental health NHS Trust. Funding for the study was obtained from the NIHR applied research collaboration (ARC) (reference: NIHR200172), and the study ran from March 2020 until September 2021. Ethical approvals were not required due to the JLA PSP being classified as a consultation exercise.


## 2.3. Stakeholder Group Formation

The SNMRLs accessed study stakeholders and participants using their combined community nursing networks. Each SNMRL contacted the Chief Nurse in their NHS Trust to inform them about the PSP, invite them to take part, and ask their permission to invite other community nurses in their organisation to participate in the stakeholder group. In addition, the SNMRLs contacted community nursing organisations and charities at a local, regional, and national level to promote the upcoming PSP and ask for participation; many agreed to collaborate. Patient and carer representatives were identified through liaising with the patient and public involvement (PPI) lead at one of the NHS organisations in South England and asking them to access their PPI contacts to ask if they would be interested in being part of the stakeholder group process. Four patients and their carers expressed an interest in taking part and were interviewed by the PPI lead and two of the SNMRLs. Four PPI representatives were appointed to the steering group: one was based in South England, another in North England, and the other two in the Midlands. In total, 13 community nurses (including two chief nurses) and four patient and carer representatives were appointed to the steering group, along with the four SNMRLs, a project coordinator, a JLA advisor, and an information specialist.The first stakeholder meeting was held in March 2020. All meetings took place virtually via Microsoft Teams and Zoom platforms due to COVID-19 restrictions. At the first meeting, the group’s terms of reference were reviewed and the project protocol was agreed; this included finalising the JLA PSP process and its aims and scope [27] (Table 2).Table 2
Aims, objectives, and scope of the JLA PSP in community nursing.
Aims, objectives and scope of JLA PSPAim: to identify unanswered questions about community nursing from patient, carer and clinical perspectives and prioritise those that patients, carers, and clinicians agree are most important for research to addressObjectives(i) work with patients, carers and clinicians to identify uncertainties about community nursing in England, in relation to the provision of nursing care to adults in their own homes, in community nurse led clinics, or residential homes(ii) to agree by consensus a prioritised list of those uncertainties, for research(iii) to publicise and disseminate the results of the PSP(iv) to take the results to research commissioning bodies to be considered for funding(v) to enable community nurses to expand and enhance their involvement in research(vi) to change community nurses’ practice through increased engagement with evidence-base(vii) to increase national collaboration and impact through partnerships with funders, community nursing organisations, and healthcare providers(viii) to extend and enhance patient and public involvementThe scope of the community nursing PSP was defined as(i) including uncertainties around community nursing in England that relate to the care of adults being cared for in their homes, in community clinics or in residential homes by NHS community nurses(ii) perspectives reflective of practice-based roles of community nurses, including district nurses(iii) physical and mental health and areas of overlap between them(iv) perspectives of patients and carers who access community services in relation to the service provided, information, assessments, interventions, and service outcomes(v) questions relating to Covid-19 and its impact on community nursing careThe PSP excluded from its scope questions about(i) community nursing outside England(ii) community nursing practice based outside the NHS(iii) people accessing community nursing services who are under the age of 18(iv) specific government policies across England for health and social care(v) preand postregistration education of community nursing(vi) training, education and professional development of community nurses(vii) services with a commercial interest(viii) noncommunity nurses, school nurses, health visitors, practice nurses, and community nurses working in children’s nursing, mental health and learning disabilities(ix) patients cared for in secondary care and nursing homesIt was confirmed that steering Group meetings would take place online every month for the duration of the PSP. Appendix1 provides a summary of the key points discussed at each JLA PSP steering group meeting.


## 2.4. Surveys

Two community nursing JLA PSP surveys were developed using a collaborative, coproduction approach with members of the stakeholder group. The surveys were available online via the SNAP online platform as well as in paper-based formats. Responses were anonymous unless individuals added their details for an invitation to the final workshop.


## 2.5. Survey One

The aim of the first survey [28] was to capture the views of community nurses, patients, and carers across England in relation to their priorities for community nursing research. JLA PSPs routinely focus on disease, and this community nursing PSP was only the second to consider a professional, rather than disease, group. This meant that the questions developed for patients and carers were intentionally broad so as to generate wide-ranging topic areas for discussion in relation to community nursing. The survey one questions were discussed, debated, and agreed upon during the stakeholder meetings (Table 3).Table 3
Survey one questions for community nursing JLA PSP.
Community nurse questions(i) what questions do you want research to address about community nursing?(ii) is there anything else you would like to tell us?Patient and carer questions(i) what did the community nurse/nursing team do that worked well?(ii) what could the community nurse/nursing team have done differently/better to improve the care experience?(iii) is there anything else you would like to tell us about when you, or someone you care for had care, support or advice from a community nurse/nursing team?


## 2.6. Recruitment and Data Collection

The SNMRLs worked with the communications lead at the NIHR ARC to design and create a bespoke web page that promoted the Community Nursing JLA PSP [29]. The purpose of this was to create a virtual platform from which to promote and recruit for the PSP and to host the online surveys. The communications lead also developed promotional materials and branded the webpages to ensure consistent messaging about the study was communicated at all levels throughout the PSP. These included prewritten Tweets and press release materials, which were embargoed until the survey’s launch date in November 2020. Key organisations were contacted by the SNMRL project team and asked to share the promotional materials and survey links on social media. These included the four NHS organisations that the 70@70 SNMRLs were based at, national community nursing bodies such as the Queens Nursing Institute and the National District Nursing Network, charities, PPI networks, and the NIHR. A full list of organisations contacted is listed in Appendix 2.Paper copies of the survey were printed, and the core team distributed these where possible with patients and carers who were not able to access the online survey; this was at times difficult due to the ongoing pandemic [30]. The completion and return of the survey implied consent to participate, and information was provided about its aim and scope to ensure all participants were well informed of the purpose of the consultation exercise. The survey was open to all community nurses or healthcare staff working alongside community nurses, as well as patients and carers who had received community nursing care in England. The first survey was open for 11 weeks, between November 2020 and February 2021. The second survey was launched in May 2021 and was open for seven weeks.


## 2.7. Data Analysis

Free text data from the first survey was extracted from the online SNAP platform before being reviewed by the Information Specialist from the JLA PSP team. The Information Specialist excluded any research questions that fell outside of the Community Nursing JLA PSP scope (Table2). These included any questions relating to the training and development of community nurses and questions that related to best clinical practice, for example, wound dressing techniques or catheter care procedures. Following this, the Information Specialist shared the out-of-scope questions with the stakeholder group to check that they agreed that they should be excluded. Any questions that, on reflection, were felt to be in scope were moved back into the “in scope” folder. Following this, the Information Specialist conducted a scoping review to identify if any systematic reviews had been conducted, which answered some of the questions within the scope (Table 4). Key search terms used included: “community; district; nurse; nursing; systematic review.” Databases searched included Cochrane and PubMed. In addition, NICE guidance, King’s Fund reports, and Google were searched for relevant reviews on this topic that had been published between 2016 and 2021. Over 1300 papers were identified, but no relevant systematic reviews were found. Individual research papers were not subsequently searched for due to the time constraints involved in conducting the PSP.Table 4
Top 18 unanswered questions prioritised in the community nursing JLA PSP.
Top 10 evidence uncertainties(1) How can community nurse teams better meet the complex needs of patients with multiple health conditions?(2) How can community nurses promote shared care/self-care amongst patients and support carers to provide some aspects of care (e.g., changing dressings)?(3) How can community nurse teams best contribute to the management of acutely ill patients at home? What difference does this make to hospital admissions?(4) What are the best ways for community nurses to involve unpaid carers/relatives/friends in decisions about their loved one’s treatment and care?(5) How can community nurse teams work effectively with social services and care services to improve the quality of patient care?(6) How has community nursing changed in response to COVID-19? Are any of the changes (e.g., timed visits, new skills, and working from home) worth keeping?(7) Does seeing the same community nurse(s) over time make a difference to the quality of patient care?(8) How can community nurses work effectively with other health professionals in hospitals and specialist community services to improve patient care?(9) What are the stresses on community nurses, and what impact does this have on their health and well-being? How can this be improved?(10) How can nurses be encouraged to become community nurses and stay in the profession?Evidence uncertainties 11–18(11) What is the optimum ratio of patients to staff in a community nurse team to ensure safe and effective care, and what is the ideal skill mix within the team?(12) How can community nurses best contribute to end-of-life care?(13) Can better tools be developed to assess whether community nurse teams have sufficient capacity to meet local demand?(14) How can a community nursing service best meet the health care needs of frail patients?(15) Do community nurses with specialist qualifications make a difference to the quality of patient care?(16) What are the best ways for community nurse teams to work with GP practices? How can the partnership between community and practice nurses be improved?(17) How can community nurses encourage and promote optimum health amongst their patients, e.g., to help people care for their skin and avoid ulcers?(18) What is the best way to organise the working day to ensure community nurses can meet patients’ needs and have a manageable workload?The “in scope” questions were then grouped by the Information Specialist into broad cluster groups, and an overarching question for each cluster was developed. At the next Stakeholder Group meeting, attendees were asked to review the cluster questions for clarity and check that the grouped questions were represented by the overarching cluster question. This led to changes to the wording of the cluster questions until a consensus was formed that the questions were representative of the grouped questions sitting under them. Any cluster questions that were deemed to be out of scope were removed at this stage. The remaining cluster questions were incorporated into the second survey.


## 2.8. Survey Two

### 2.8.1. Recruitment and Data Collection

The second survey [28] aimed to prioritise the cluster questions that had been developed from the survey one findings. In total, 40 questions were included in the survey, which was open from May to July 2021. Survey two was promoted and disseminated through the same links and networks that were utilised for the first survey. Paper copies of the online survey were also printed, and the core team shared these where possible with patients and carers who were not able to access the online survey. The completion and return of the survey implied consent to participate, and information was provided about the aim and scope of the PSP survey to ensure all participants were informed of the purpose of the consultation exercise. The survey was open to all community nurses or healthcare staff working alongside community nurses, as well as patients and carers who had received community nursing care in England. Survey respondents were asked to prioritise their top ten questions (with rank one being the most important) from the forty questions listed.


### 2.8.2. Data Analysis

Data from online and paper-based surveys was collated and listed by a member of the project team. Questions were thematically grouped under drafted summary questions and categories [31]. The goal of each summary question was to provide an accurate and transparent summary of the responses given. Following this, the different questions were ranked in order of priority. As well as the questions being listed in overall priority order, the priorities were subdivided into different groups to check whether there were any major differences between the overall priority list and the priority list according to certain subgroups of respondents. These subgroups included responses from patients and carers, responses from community nurses and other healthcare workers (Figure 1), responses from ethnic minority groups, and responses from male healthcare professionals. Overall, differences between the priority list and the subgroup priority lists were minimal; however, five questions were found to have been ranked significantly more important by specific subgroups, and adjustments were made to reflect this and make sure that the priorities of each subgroup were represented.Figure 1
Healthcare workers’ responses to the survey.


### 2.8.3. The Final PSP Workshop

The top 18 priorities that had been listed as a result of the responses from the second survey were collated and taken to the final online JLA PSP workshop, which was held in September 2021. The workshop was held over two days, and its aim was to identify, through discussion and debate with stakeholders, the top ten unanswered questions in community nursing. In total, 40 people attended the final workshop. Meeting representatives included three of the SNMRLs, a project coordinator, five JLA advisors, seven community nurses, two other members of the multidisciplinary healthcare team, 11 patients and carer representatives (of which four were Steering Group members), and five hybrid healthcare professionals/carers. In addition, five observers were invited to the final workshop, representing national organisations and bodies with a sustained interest in the legacy of the PSP, such as the NHS and the NIHR. Observers were not allowed to actively participate in discussions or debate but were able to observe the PSP and how decisions and agreements were reached; this aided transparency and enhanced credibility in the process [32].Workshop members were split into five working groups, each facilitated by a JLA advisor. Within these groups, the 18 priorities were discussed, reordered, and ranked according to the insights offered by working group members as to which questions should take higher priority than others, which should be included within the top ten, and which should not. At the end of the first day, the ranked lists from each of the five groups were merged to form a reprioritised top 18 list. At the start of day two, workshop attendees were split into new working groups and provided with the updated list. Discussions continued, and the top 18 list was reordered again, with a key focus being to make sure that the correct priorities were included within the top ten list. Following this, the five revised lists from each working group were merged again, and the top ten unanswered questions in community nursing were confirmed.


## 2.8.1. Recruitment and Data Collection

The second survey [28] aimed to prioritise the cluster questions that had been developed from the survey one findings. In total, 40 questions were included in the survey, which was open from May to July 2021. Survey two was promoted and disseminated through the same links and networks that were utilised for the first survey. Paper copies of the online survey were also printed, and the core team shared these where possible with patients and carers who were not able to access the online survey. The completion and return of the survey implied consent to participate, and information was provided about the aim and scope of the PSP survey to ensure all participants were informed of the purpose of the consultation exercise. The survey was open to all community nurses or healthcare staff working alongside community nurses, as well as patients and carers who had received community nursing care in England. Survey respondents were asked to prioritise their top ten questions (with rank one being the most important) from the forty questions listed.


## 2.8.2. Data Analysis

Data from online and paper-based surveys was collated and listed by a member of the project team. Questions were thematically grouped under drafted summary questions and categories [31]. The goal of each summary question was to provide an accurate and transparent summary of the responses given. Following this, the different questions were ranked in order of priority. As well as the questions being listed in overall priority order, the priorities were subdivided into different groups to check whether there were any major differences between the overall priority list and the priority list according to certain subgroups of respondents. These subgroups included responses from patients and carers, responses from community nurses and other healthcare workers (Figure 1), responses from ethnic minority groups, and responses from male healthcare professionals. Overall, differences between the priority list and the subgroup priority lists were minimal; however, five questions were found to have been ranked significantly more important by specific subgroups, and adjustments were made to reflect this and make sure that the priorities of each subgroup were represented.Figure 1
Healthcare workers’ responses to the survey.


## 2.8.3. The Final PSP Workshop

The top 18 priorities that had been listed as a result of the responses from the second survey were collated and taken to the final online JLA PSP workshop, which was held in September 2021. The workshop was held over two days, and its aim was to identify, through discussion and debate with stakeholders, the top ten unanswered questions in community nursing. In total, 40 people attended the final workshop. Meeting representatives included three of the SNMRLs, a project coordinator, five JLA advisors, seven community nurses, two other members of the multidisciplinary healthcare team, 11 patients and carer representatives (of which four were Steering Group members), and five hybrid healthcare professionals/carers. In addition, five observers were invited to the final workshop, representing national organisations and bodies with a sustained interest in the legacy of the PSP, such as the NHS and the NIHR. Observers were not allowed to actively participate in discussions or debate but were able to observe the PSP and how decisions and agreements were reached; this aided transparency and enhanced credibility in the process [32].Workshop members were split into five working groups, each facilitated by a JLA advisor. Within these groups, the 18 priorities were discussed, reordered, and ranked according to the insights offered by working group members as to which questions should take higher priority than others, which should be included within the top ten, and which should not. At the end of the first day, the ranked lists from each of the five groups were merged to form a reprioritised top 18 list. At the start of day two, workshop attendees were split into new working groups and provided with the updated list. Discussions continued, and the top 18 list was reordered again, with a key focus being to make sure that the correct priorities were included within the top ten list. Following this, the five revised lists from each working group were merged again, and the top ten unanswered questions in community nursing were confirmed.


## 3. Results

The first survey received 333 responses, of which 23 were incomplete. Respondents included 232 nurses and clinical colleagues and 101 patients and carers. The responses submitted by clinical staff generated 592 questions, of which 177 were out of scope, leaving 415 questions in scope. Patients’ and carers’ responses generated 317 questions; of these, 207 were out of scope, leaving 110 in scope. In total, 525 questions were in scope. The combined characteristics of respondents from both surveys are shown in Table5.Table 5
Respondent characteristics from surveys 1&2.
JLA PSP survey respondent characteristics (n = 758)Number of respondents =n (%)ParticipantsProfessional596 (77)Patient79 (10)Carer/family member75 (10)Not stated8 (1)GenderFemale642 (83)Male99 (13)Prefer not to say2 (<1)No answer11 (1)Age18–24 yrs5 (<1)25–34 yrs62 (8)35–44 yrs84 (11)45–54 yrs144 (19)55–64 yrs128 (17)65–74 yrs47 (6)75–84 yrs33 (4)85+ yrs8 (1)Prefer not to say10 (1)No answer6 (<1)EthnicityWhite701 (94)Black/African/Caribbean/black British14 (2)Other ethnic group4 (1)Prefer not to say13 (2)Asian/Asian British11 (1)Mixed/multiple ethnic groups6 (1)GeographySouth East of England139 (18)South West of England57 (7)North East England229 (30)North West England122 (16)East of England24 (3)Yorkshire and Humber22 (3)West Midlands47 (6)East Midlands42 (5)London15 (2)Other6 (1)No answer55 (7)The JLA PSP process resulted in 18 unanswered questions in community nursing being prioritised, with a focus on the top ten unanswered questions. The list of the top 18 priorities is presented in Table4.


## 4. Discussion

The JLA PSP in community nursing led to a wide array of unanswered evidence uncertainties in community nursing being prioritised for the first time, using an inclusive, coproduction approach [26]. The value of this approach is confirmed through findings from other JLA PSPs focusing on professional groups (social workers and occupational therapists), which showed that the priorities identified through the priority setting partnership were rarely the same as those identified by researchers who were not involved in the process but were issues of the utmost importance to people accessing and delivering services [23, 33]. The top ten community nursing questions reflect the needs, views, and priorities of community nurses, patients, and carers of different ages across England, across geographical regions, and take account of any differences in perspectives according to gender and ethnicity. This widespread representation is important and allows the top ten findings to be considered transferable to a wide range of community settings across the country and internationally [32]. The top ten questions include a mixture of both patient and nursing focussed questions, highlighting the equal merit that stakeholders placed on these two areas. This mix also reflects how closely questions relating to improving nursing workforce issues are related to the provision of quality patient care [34, 35]. Whilst patients are at the heart of nursing and healthcare practice, the JLA PSP has highlighted that it is not possible to provide excellence in patient care delivery without paying attention to the needs and priorities of the nursing workforce who are delivering that care. Many of the nursing focused questions relate to retention, recruitment, and wellbeing issues. It is crucial that care and attention be paid to these very real and fundamental community nursing workforce challenges [36] if long term, sustainable changes to patient care are to be made.The number one JLA PSP priority question focused on the need for community nursing teams to better meet the needs of people living with multiple long-term health conditions; this was a key priority for nurses, patients, and carers alike. The challenges of providing comprehensive nursing care to patients living with multi-morbidities has been highlighted as complex and is becoming an increasing challenge in community nursing practice [7, 8]. Research into ways to better understand the needs of these patients and to design interventions to improve care in this area is essential to improving patient care outcomes and avoiding unwanted admissions to secondary care hospital settings [37]. Question six identified the need to review some of the changes that have occurred in community nursing practice as a result of COVID-19. This is particularly pertinent due to the multitude of changes that have occurred within healthcare practice since the onset of the pandemic [38]. It is crucial that some of the changes that have resulted in positive implications for practice and patient care are captured and evaluated so that these changes can be shared with other practice settings and embedded within them. In this way, some of the learnings from COVID-19 can be harnessed as a means of increasing service efficiency and addressing workforce issues and patient care challenges.The JLA PSP top ten priorities have highlighted key areas that need to be focused on by national and international funding bodies to ensure that research is embedded within community nursing settings for the benefit of patients, carers, and relatives. There is a need for more funding both within the healthcare setting and also within social care settings [39]; the integration and dynamic relationship between health and social care settings is reflected in the results of the JLA PSP, with the fifth priority question exploring ways that community nurses could work more effectively with social care services to improve patient care outcomes. This demonstrates the need for greater emphasis to be placed on research that focuses on both health and social care settings. At a national level, the NIHR has responded to this need, with a strategic focus and priority being to expand and increase research funding in social care; this reflects the growing priority for research funders in this area [40]. The newly established integrated care systems also strengthen the case for more research into social care, as they are reliant on dynamic and flexible working practices across health and social care settings [9, 10].The published JLA PSP top ten questions have the potential to positively contribute to increased engagement in research by community nurses. As the priorities identified have been generated, in part, by nurses working at all levels across the community nursing landscape, they are likely to resonate with many community nurses working in a range of care settings. Despite the challenges many community nurses face in engaging with research and evidence-based practice [2, 22], the top ten priorities can help to motivate, influence, and inspire community nurses to undertake small- or larger-scale research that has direct implications for their own area of practice. The published priorities will also raise awareness of the importance of using the evidence base to directly inform community nursing practice. As such, the priorities can help all community nurses support, deliver, or lead research that can impact clinical care outcomes. In time, this means that community nursing can become an environment that nurses are attracted to work in due to the opening up of structured research career pathways. This commitment to developing future nurse research leaders has been demonstrated by NHS England’s Chief Nursing Officer’s Research Strategy, which presents a clear commitment to embedding research within all areas of nursing practice [5]. Furthermore, the NIHR’s 70@70 SNMRL Programme [24] and its increased focus on the community and social care sectors [40] are clear indicators that community nursing research is a growing priority at a national policy level. This, combined with the NCNP [4] and the NIHR’s Primary Care Strategy [41], provides a robust platform for nurses to engage with and learn more about research. It is anticipated that the JLA PSP’s top ten questions in community nursing will underpin this work at a national and international level.Community nurses make a significant contribution to patient care outcomes in a challenging environment that is becoming progressively more complex as care moves out of hospitals and into community settings, with the resulting increasing demands on community care services [2, 7]. An increasing gap in capacity and demand, together with the impact of Brexit [42] and, more recently, the COVID-19 pandemic, have added to overall workforce pressures; together, these risks have the potential to compromise the quality of care being delivered by community nursing teams [3, 14, 15]. Due to the pressures outlined, the JLA PSP SNMRL leadership team was required to demonstrate flexibility when undertaking the project, as previous JLA PSPs had been delivered face-to-face and had included more traditional methods of engagement and dissemination; none of this was possible due to the COVID-19 pandemic. The four SNMRLs adopted an inclusive leadership style and used the collaborative nature of the JLA PSP to drive forward and coproduce any necessary changes in a positive manner, being careful to include all stakeholders in decision-making processes [30]. The four SNMRLs were based across different regions of England, had different professional nursing backgrounds, and a variety of networks and contacts at local, regional, and national levels that could be harnessed for the benefit of the project [30]. As a result of this inclusivity and innovation, the project was the first JLA PSP project in the UK to be launched and conducted purely online via., video conferencing. The methods and mechanisms used to undertake the JLA PSP online while maintaining a sense of community can be replicated by future teams wishing to undertake JLA PSPs in other areas, paving the way for a new model of working in the future.


## 5. Conclusion

The top ten research priorities for community nursing were determined through a rigorous JLA PSP process that was robust and inclusive and involved representation from hard-to-reach groups. A strength in the process for a profession-based priority setting exercise was the equal contribution of nurses who delivered the service alongside patients and carers who were in receipt of it. The final top ten uncertainties list demonstrates this collaboration with a mix of profession and patient focused topics, both of which were validated and championed by all stakeholders involved in the process.The final list identifies areas of need for research within community nursing settings and provides a framework from which community nurses, other healthcare professionals, managers, and policymakers can all base their priorities for practice. The published evidence uncertainties have provided an international platform for community nursing research; this must now be sustained through engagement, collaboration, funding, and innovation to ensure that the legacy of the JLA PSP in community nursing reaches far and wide, with widespread implications for developing the community nursing workforce and for optimising the safety and quality of patient care.



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