2. HOW TO USE THIS PACK
Personas are a tool used to understand the
values, attitudes and behaviours of groups of
users. They are fictional characters but have
typical characteristics of the patient groups
they represent.
This pack is designed to introduce you to the
seven community nursing personas and offer
facilitation tips for how they can be used in
clinical settings and at system level to design
services that meet patient need while
delivering value for public services.
These tools are designed to encourage and
provoke discussion about service provision,
they are not a set of rules or specific
recommendations. The personas will support
teams to:
▪ identify opportunities for service
improvement
▪ articulate the economic value added by
community nursing
▪ consider service provision at a system level.
3. 3 |
CONTENTS
1 Introduction
• Aims of the project
• Methodology
2 Facilitation notes
• Step by step guide
• Assembling your team
• Ground rules
• Sample persona
• Facilitators ‘whiteboard’
3 Patient personas and prompt questions
• Patient segmentation
• Children
• Working Age Adults
• Older Adults
4 Appendix
• Meet the team
• Further work
4. AIMS OF THE PERSONA PROJECT
The National Community Nursing Fellows in partnership with NHS Horizons have
developed a series of patient personas with the aim of:
▪ Demonstrating the complexity of patient interactions with community
services
▪ Describing the wide-ranging benefits of community nurse teams in terms
of the patient, the health and care sector and wider society
▪ Testing community currencies against real world scenarios for better
resource planning
5. METHODOLOGY
Draft Initially the personas were drafted based on
staff stories from East of England community
nursing teams. We took characteristics of
typical patient interactions and anonymised
the clinical and personal identifiable data.
Clinical
input
The draft personas were introduced to
clinicians with relevant expertise in order to
further develop the patient stories and create
authentic health and care journeys. We drew
on clinical experience of patient interactions
to develop patient goals.
Test &
refine
Finally, the personas were introduced to a
wider group of clinical and patient advocates
to test the credibility and understand how
each persona demonstrates the complexity
and value of community nursing.
7. GUIDE TO A PERSONA WORKSHOP:
IN ADVANCE
• Select which personas you will work on in advance based on the needs of your
service or system
• Invite representatives from relevant teams and organisations – think quite broadly
and offer dates far enough into the future that attendees can make the time
• Share the persona in advance to give participants an opportunity to think ahead
of time
• Allow one hour for each persona broken down into three blocks of 20 minutes
• Prepare the space you are using with flip charts, pens and sticky notes for action
planning
• If you are running the workshop virtually, consider using a Jamboard or similar
online collaboration tool to support action planning.
8. GUIDE TO A PERSONA WORKSHOP:
DURING
Encourage participants to
introduce themselves,
acknowledging the range of
expertise in the room.
Open the discussion with
initial thoughts and reflections
from participants on the
persona they read in advance.
Use open prompt questions to
encourage deeper thinking
and curiosity.
Once the participants have had a
good quality, broad discussion about
the patient start to encourage them
to think about the specific services
within their locality and how they
meet the needs of the patients.
Refer back to the ground rules if you
need to encourage the conversation
to remain constructive and focused
on solutions. Ask “what do we need
to do to fix that?” if participants
identify problems.
Start to bring the group to a
consensus on actions,
acknowledging that there
may be existing work
happening.
The group should agree
collective responsibility even
for actions that are assigned
to a member or specific
team.
9. GUIDE TO A PERSONA WORKSHOP:
FOLLOW UP
• Thank all participants for their contributions
• Be clear on who has responsibility for the actions and the time frame for review
• Agree collectively how actions arising will be fed back to the group; who will be the core
members of the project team and who will be kept informed
• Decide when it suits your group to meet again for an update, this will depend upon the
agree actions
• Consider raising the profile of the work with an Executive sponsor for the project at
organisation or system level; is there an existing committee that could sponsor and
support the work?
10. ASSEMBLING
YOURTEAM
Health and care for patients
in the community is hugely
complex and requires a
multi-disciplinary, multi-
agency approach so any
persona workshop should
adopt the same philosophy.
The more perspectives the better!
11. GROUND RULES FOR
A GREAT SESSION
Create a safe and supportive space
Everyone has a voice
Contributions should always be constructive
Be curious and kind
Collectively take responsibility for the success of the
session
Focus on the future we want to create, rather than
today
Agree actions and ways in which you can follow up
with others after today.
Your team may already have a set of ground rules or
ways of working so feel free to use your own or adapt
these as it suits.
12. SAMPLE PERSONA
1. Health indicators – these show areas of concern, in
this example communication is the lowest score and
therefore the greatest concern
2. What matters to me statement in the patients voice
3. Health history – these descriptions are intentionally
brief to inspire deeper conversation about how our
services might meet the patients needs
4. My network – the most important people to the
patient, we wanted to spotlight that this is not always
family
5. My goals – not necessarily clinical
6. Perspective from someone important in their network
7. Scenario – summary of patient history including
impact on their life and network
8. Future – an opportunity to discuss in your workshop
what the future might be for the person and ask
questions about how we design services to meet their
future needs.
1
2 3
4 5 6
7 8
13. FACILITATORSWHITEBOARD
Each patient persona is accompanied by a
‘whiteboard’ and notes from the design team to
help you facilitate a discussion. It is important to
emphasise that the personas are not designed to
provide answers but rather encourage discussions
within clinical teams and systems about service
provision within their immediate locality.
You will notice a question mark on each whiteboard
to encourage curiosity from staff using the
personas.The questions posed in this pack are just
a guide and we would suggest adapting for your
services.
15. PATIENT SEGMENTATION
The patient personas we have developed
represent typical patient groups that have
been segmented on demographics, clinical
characteristics and psychographics.
By analysing psychographics we begin to
understand the patients values, attitudes and
behaviours; you will note that the patients
goals are not necessarily clinical outcomes,
they are lifestyle goals which can be achieved
through improved health.
Patients grouped by psychographics have
similar needs despite significant differences in
their demographics and clinical diagnosis, for
example carer crisis. You will see examples of
these groupings on the next page.
When discussing the personas in your
workshop it is important to acknowledge
clinical needs but these have been
intentionally designed to have gaps that
should provoke conversation in your team or
system.
18. Notes from the design team:
In Zachary’s story we
wanted to show the impact
on the whole family unit
with Mum not able to work
and big brother skipping
school; there is potential for
this story to have a very sad
ending if they are not
supported. If you have time,
consider the alternate
endings and the impact
that has on wider society,
for instance if Mum can
never work, Zachary is
taken into care or Archie
becomes involved in
criminality.
Zachary
What services
do we have in
our locality to
support Zachary
and his family?
Where are the
gaps in our
services that
mean Zachary
has unmet
needs?
What do we need to put in
place for Zachary and his
family to achieve their
goals? How are these
different to clinical
outcomes?
How well are we working as
a system to offer joined up
care and support? What
agencies are involved?
Where could these working
relationships be
strengthened?
Consider the future
for Zachary and his
family, what are the
short and long term
benefits to getting it
right for them?
?
19.
20. Notes from the design team:
In Preya's story we wanted to show
that there are mental health
challenges for Mum Anjali, her
full-time carer - with addition to
mental and physical challenges
for Preya that she will need to
be able to overcome with the right
support.
Preya will be supported with her
tracheostomy change by her
Teaching Assistant at school so
that she doesn't have to be taken
out of school for hospital
appointments. We want to ensure
Preya's needs are met throughout
her childhood and adolescence life
phases.
Preya
What support/
services could be
offered to Anjali to
ensure she is able
to manage her
wellbeing and
mental health well?
Being aware of
Preya's possible
body image
issues as she
gets older, will
need to be
considered
Preya is from an ethnic
minority and with her
condition she is in an
additional minority group –
how will health inequalities in
general society, impact Preya
negatively?
Preya's Health
Education Care Plan
will require routine
review to ensure that
she does not fall
behind in her
education and gets
the support she
needs.
Have cultural
barriers or
beliefs effected
Preya or her
family's ability to
cope with her
condition well?
Who has the responsibility to
ensure that community nursing
teams are scheduled to
provide the necessary transfer
of skills training to Preya's
Teaching Assistant in a timely
manner?
21.
22. Notes from the design team:
Jordan is a complex but not
uncommon situation where
a patient is “lost” during
adolescence. We want to
provoke conversation
around how services support
young people who might not
have parental support to
transition from children’s
to adult’s services. We have
intentionally been vague
about Jordan “letting off
steam” to suggest a
substance mis-use problem
for added complexity. Of all
our patients Jordan cares the
least about their health.
Jordan Consider Jordan’s quote
”the hospital aren’t worried
about me…I don’t meet
the threshold for specialist
care.” What message
does this send? Can
anything be done in our
locality to offer support to
vulnerable children
through transition?
What complexity
might be added
by Jordan
“letting off
steam”?
How joined up are the
teams caring for Jordan
in our locality? What
improvements could be
made particularly for
complex patients like
Jordan?
How would our system
ensure safeguarding
concerns are
communicated across
teams and services,
and followed up on?
Who holds
responsibility?
Consider the cost-benefit
of support a patient like
Jordan, what can be
done in the short term
that will prevent high
dependence on health
services in the future?
?
23.
24. Notes from the design team:
Steven and Mark’s
situation represents a group
of patients who were
previously healthy and now
find themselves in a new
set of circumstances
needing support to adjust.
While Steven’s clinical care
may have been exemplary to
date it is likely to be the
situation at home that leads
to carer crisis or a further
decline in his health.
Steven
What funding might
Steven be entitled to
and how does our
system support him in
applying for and
making use of the
funding?
Consider Mark’s
situation, what support
services can he access
in our locality to address
social isolation and to
enable him to be
economically active?
How might
Steven’s needs
evolve over time
and how would
our system
respond?
?
Consider the impact
on both Steven and
Mark, and the wider
social and economic
impact if they are not
supported
How joined up are the
services Steven needs in
our locality? How is
information shared
between the hospital and
the community teams?
What could improve this
system working?
25.
26. Notes from the design team:
We hoped to convey
Yolanda’s complex clinical
and personal circumstances
with sensitivity. The
safeguarding concerns over
her relationship with Gareth
and what will happen to
Kofi after her death should
provoke conversation. We
have intentionally not
clarified who has parental
rights over Kofi, again to
provoke discussion on how
this would be supported in
your locality.
Yolanda
How does our system
capture and escalate
safeguarding
concerns for patients
like Yolanda across
services and
specialties?
How do we
support
Yolanda to
make plans
for Kofi?
What provisions
could we put in place
to ensure Yolanda
has a dignified death
in a place of safety?
What additional
support might clinical
teams need in order
to achieve this?
What charity
services do we have
in our locality that
could support
Yolanda and who is
responsible for
linking her to them?
?
How joined up
are our services
to co-ordinate
Yolanda’s
mental health
and cancer
care?
27.
28. Notes from the design team:
Mary's situation is one of
physical frailty and mental
health concerns. Mary is
needing to move into
residential care due to her
mobility. Ensuring Mary
stays well during and post
her transition into residential
care is key.
Mary has Parkinson's
Disease and so
falls prevention is a priority.
MDT (Multi-Disciplinary
Teams) need to work in
tandem to give Mary the best
healthcare experience
Mary
With Mary's
declining health,
Have we
considered what
her future needs
will be?
Mary will need care
and medical support from
her GP, Pharmacist
and Specialist Nurse
in parallel. How will
we ensure that the multi-
agency process works
for Mary effectively?
Mary's emotional
state will need to
monitored closely,
with the fact that she
is leaving all that is
familiar to her and
having to deal with
change
Mary will need to
consider giving her
daughter lasting
power of attorney
to ensure
decisions can be
made on her
behalf
Start to gather
information for
her palliative
care plan
Mary has
Parkinson's Disease
and so we need to
consider the
possibility of
Dementia occurring
later down the line
29.
30. Notes from the design team:
Bob and Anne’s story is one
of ageing well at home. We
wanted to show that if
patients are supported
appropriately at home we
can avoid hospital
admissions and more
costly health interventions.
Anne is a carer in crisis but
may not recognise her
situation as such. We have
included Bob’s voice via his
advanced care plan and we
have implied that there may
have been a role reversal
between him and Anne due
to his dementia.
Bob
What charity or
voluntary services
do we have in our
locality to support
Anne as Bob’s
carer?
How closely do our
services communicate
regarding patients who
are also carers like
Anne?
How would an advanced care plan be
established and shared between
services for a patient like Bob? Is it
clear who has responsibility and how
this information is shared? At what point
after Bob’s diagnosis would we initiate
an advanced care plan?
How can we
avoid hospital
admission for
Bob in future?
?
What are the
opportunities for
population
health
management?
32. MEET THE TEAM
NHS Horizons
Claire Shields
Rupal Johal
Community Nursing Fellows
Charlotte Sumnall RN
Sifiso Mguni RN
sifiso.mguni@nhs.net
@sifiso_mguni
claire.shields3@nhs.net
@Claire_Shldsy
charlotte.sumnall1@nhs.net
@charlysumnall
rupal.johal@nhs.net
@JohalRupal
33. FURTHER WORK
While we have attempted to capture a cross section of community patient groups we
recognise there is scope for the personas to be adapted or extended to capture additional
complexities of the patient journey, for example:
Transition from children’s to adult’s services
Population health
Interaction with education, local authority, criminal justice and other public services
The role of virtual wards
The design team would be delighted to see future iterations of the personas incorporating
different aspects of the patient journey and would encourage teams to adapt the characters
to suit the specific circumstances in your locality.
