COMMENT

District nursing: the hidden giant of the NHS? Vanessa Heaslip

Vanessa Heaslip is Senior Lecturer in Adult Nursing, School of Health and Social Care, Bournemouth University  Email: [email protected]

T

he recent 65th birthday of the NHS is a timely reminder of the ‘cradle to grave’ service principles upon which the NHS was founded. This commitment was reaffirmed in the NHS Constitution (Department of Health (DH), 2009), which noted that the service should be available to everyone and should put patients at the heart of everything it does. Yet, almost daily, health care and nursing in particular are bombarded with publications reporting people’s negative experiences of care (DH, 2008; Francis, 2010; Parliamentary and Health Service Ombudsman, 2011). This has led to a plethora of debates and questions being raised as to whether nursing has lost its caring focus, and whether the NHS can live up to the principles it sets out in the constitution. A response to these criticisms and challenges by the Chief Nurse (Cummings and Bennett, 2012) has been to develop the 6Cs of care (care, compassion, competence, commitment, communication and courage). It could be argued that many of these values (care, commitment, competence, compassion and communication) have always been at the heart of good nursing care. Yet courage is an area in which nurses need to develop in order to have the strength of conviction not only to question and challenge individual care practice, but also to question the culture of the care organisation and the existing structures in which care is provided. This article focuses on each of the six core values in turn, examining their relevance to district nursing today and in the future.

Care District nursing has a long history in providing high-quality, complex care to people in the community. The demand for

Abstract

The recent 65th birthday of the NHS is a reminder of the purpose of the NHS: to provide a service that puts people that need it at the heart of care. However, recent negative reports have questioned nurses’ ability to provide this care, which led to the development of the 6Cs. This article examines each of these values from the viewpoint of the district nursing service, in particular from a district nurse’s perspective, as well as providing a critical commentary regarding the future of the service.

KEY WORDS

w District nurse w community nursing w care w compassion w 6Cs of nursing

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district nursing services is increasing for many reasons, such as w An ageing population and other vulnerable groups requiring care at home w An increasing population living with complex chronic illness w A structural move away from acute hospital care towards providing more services within the community setting w A need for shortened length of stay for people in hospital w The increased recognition and commitment to enabling people to die at home where possible. In addition to the factors identified above, it is also important to recognise that many people wish to be cared for in their own home, surrounded by their own belongings and people that they love. Yet the nature of care within the community setting is changing due to cultural and structural factors that focus increasingly upon outputs and efficiency drives. This focus upon outputs, often medically based, reduces opportunities for district nurses to develop proactive initiatives that prevent people becoming ill, the outputs of which are harder to capture and quantify. As such, the service needs to develop ways of articulating why this aspect of the role is fundamental to meeting national policy directives.

Compassion The nature of the relationship between community nurses and patients is vastly different to the nature of a relationship between the patient and a hospital nurse. In the community setting, the nurse enters the patient’s domain and remains a visitor in their home. This shift in power is clearly evident, as patients are much more confident in their own homes and are less likely to comply than in a hospital setting, in which the patient enters the nurse’s domain. Caring for a patient in their own home environment surrounded by their personal belongings, family and reminders of their lives reinforces the concept of ‘treating the person instead of the disease’, and this supports the delivery of compassionate, person-centred care. There have been no equivalents to the major hospital enquiries within the community district nursing sphere. Instead, it remains a service that is highly valued by patients. A review by the Picker Institute (2010) of one district nursing service identified that the service was highly rated by patients and was recognised to provide a vital service. Extracts from patients’ comments regarding the service are provided in Box 1.

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COMMENT Thus, to many patients, the district nurse is a lifeline they could not do without. Patients talk of the relationships that they develop with their nurses and the high level of support and advice that they and their families receive, which is crucial to enabling them to remain living at home. For some patients, their relationship with the district nurse may be a lengthy one, particularly those with complex, chronic illnesses. This enables the nurse to gain a depth of understanding of patients’ needs and the way in which they respond to their illness, meaning that they are ideally placed to recognise pending signs of crisis and to take appropriate action to prevent unnecessary hospital admissions.

Communication Since many of the clients now cared for in the community, have very complex conditions, the district nurse plays an important role as case manager, liaising with other members of the interprofessional team. Key to this is the ability of the nurse to communicate widely across both statutory and voluntary sectors, as well as with the patient, their family and major networks, enabling their voices to be heard. District nurses also have a key role in offering support and guidance to informal carers, acting as a lynchpin, enabling them to continue their caring role. Yet this facet of the role is hidden and difficult to quantify. As such, nurses need to learn to communicate this vital aspect of the role. It is interesting to note that the role of the district nurse more generally is a hidden one. It is not seen to be as glamorous as other nursing roles and does not receive the same media attention. Therefore, unless the public or their family have required the services of a district nurse, they may not even be aware that such a service exists. The reality is that the district nursing service is as hidden as the population it serves. The implications of this are huge, as the public can be instrumental in protecting services (as evidenced by public campaigning against hospital closures), yet campaigns to strengthen the district nursing service have received very little public attention.

Competence Nursing people in their own homes requires a particular skill set that is significantly different from caring for people in a hospital setting or another clinical setting in the community. District nurses are specifically qualified to do this. The Queen’s Nursing Institute’s 2020 Vision Focusing on the Future of District Nursing (2009) identified that the skills required as a nurse in primary care include: w Ability to develop networks of contacts through effective working relationships w High-quality interpersonal skills, building relationships with patients, their families and networks w Confidence in making decisions as a lone worker w A creative and problem-solving approach w Ability to reflect and learn from experiences.

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Box 1. Patient perceptions of the district nursing service w ’A credit to the NHS’ w ‘The service I received was excellent: I felt happier with their treatment than I did at the hospital’ w ‘Vital service to the community’ w ‘They look at the broader picture’ w ‘District nurses are my main point of contact with the NHS’ w ‘My nurse is very caring and I have great trust in her’ w ‘Gives peace of mind’ w ‘They take a personal interest in my treatment’ w ‘Sensitive to my needs and always ready to listen’ w ‘Over the years we have developed a family friendship’ Source: Picker Institute (2010)

While undergraduate nursing programmes should enable nurses to work directly in the community or hospital setting, the degree to which this is being achieved could be questioned when examining the skills required as noted above. Working in the community as a newly qualified band  5 nurse requires considerable support, as community nurses work autonomously and do not have the luxury of an emergency call bell to ring if they are concerned. While traditionally the majority of nurses have worked in a hospital setting, this has shifted and now the majority of nursing occurs in the community (Luthy et al, 2013), yet the numbers of qualified district nurses in the workforce is falling (Queen’s Nursing Institute, 2013). Instead, there are many more health-care support workers and community staff nurses who work under the care of the district nurse. The Royal College of Nursing (2013) has concerns that this current skill mix is insufficient to meet the expectations of the service. Historically, district nurses were allocated to GP practices and typically covered one or two practices (depending upon the size of the GP practice). Yet now many district nurses cover extended teams responsible for four or five GP practices while retaining 24-hour responsibility for the caseload, and their role has become managerial rather than clinically focused. This has clinical implications, since it means that people who are critically ill and who have complex social circumstances are being cared for by staff that may not have the specialist expertise to meet these complex needs. The Queen’s Nursing Institute (2013) has identified a reduction in the numbers of nurses training to become district nurses. According to Dickson et al (2011), this is due in part to the reorganisation by the Nursing and Midwifery Council when they identified a third part of the register for specialist community public health nurses (health visitors, school nurses and occupational health nurses), which resulted in downgrading district nursing to

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COMMENT Box 2. Measuring impact: outcomes and indicators District nursing’s contribution to health needs: Public Health Outcome Framework

w Improving the wider determinates of health w Health improvement w Health protection w Public health and preventing premature mortality District nurses leading care and contributing to healthy communities: NHS Outcome Framework

w Preventing people from dying prematurely w Enhancing quality of life for people with long-term conditions w Helping people to recover from episodes of ill health or following injury w Ensuring that people have a positive experience of care w Treating and caring for people in a safe environment and protecting them

from avoidable harm

Source: Department of Health (2013)

a recordable rather than a registered qualification. This has resulted in many nurses not recognising and valuing the career opportunities offered by becoming a district nurse. However, despite these falling numbers nationally, district nursing has fallen under the spotlight, and a recent review of care in local communities by the DH (2013) recognised three facets of the role, which were: w Population and caseload management w Supporting and caring for patients who are unwell, recovering at home and at the end of life w Facilitating independence. In meeting these core aspects, the service contributes fundamentally to the NHS and Public Health Frameworks (Box 2).

Commitment It is evident that the role of the district nurse is fundamental to meeting national policy drives by contributing to health indicators. Many district nurses are totally committed to providing high-quality care to patients, and their shift does not end at an allocated time; it finishes when all patients on the caseload have been seen. This has resulted in many district nurses working over their contractual employment hours. The Royal College of Nursing (2013) identified that 87% of the district nurses that they surveyed regularly worked overtime and, of those, 47% on average worked more than four hours per week overtime. In the long term this is unsustainable, as prolonged workload stress can lead to burnout, which would further reduce the skill base of the service. As such, the district nursing service requires commitment by commissioners to invest in the service (Queen’s Nursing Institute, 2013), otherwise it will be ill-equipped to meet the Care in Local Communities strategy (DH, 2013)

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Courage It is encouraging that district nursing is under the national spotlight and is finally being recognised for the excellent services it delivers. Yet times are changing and, as such, district nurses need courage to weather the storm and to stand together to articulate the exceptional work they do for patients and local communities, giving the service and the people they serve a voice in local commissioning arrangements. Nurses need to be shouting from the rooftops about how district nursing enables the NHS to meet the core responsibilities set out in the NHS Constitution and the care strategy proposed by the Chief Nurse. District nurses also need to advocate their profession as a career choice for colleagues, highlighting that it is an exciting and dynamic career pathway (Bennett and Nicholson, 2013).

Conclusion It is evident that the role of the district nurse is fundamental to the NHS in the future, and the excellent work that district nurses do is highly valued by patients and their families. However, there is a need to invest in the service by having more qualified district nurses providing highly skilled expertise to patients as well as developing and leading the service for the future if the ambitious targets set out for the service are to be met. District nurses can play a role in this by promoting and advocating the excellent work they do, and having the courage to take a stand and argue that their service is fundamental to the NHS and to people living in the community in general. BJCN Bennett V, Nicholson W (2013) Care in local communities: a vision and service model for district nursing. Br J Community Nurs 18(2): 74–6 Cummings J, Bennett V (2012) Compassion in Practice Nursing, Midwifery and Care Staff: Our Vision for Practice. Department of Health, London Department of Health (2008) Confidence in Caring: A Framework for Best Practice. Department of Health, London Department of Health (2009) The NHS Constitution. Department of Health, London Department of Health (2013) Care in Local Communities: A New Vision and Model for District Nursing. Department of Health, London Dickson C, Gough H, Bain H (2011) Meeting the policy agenda, part 2: is a ‘Cinderella service’ sufficient? Br J Community Nurs 16(11): 540–5 Francis R (2010) Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. Stationary Office, London. Luthy K, Beckstrand R, Callister L (2013) Improving the community nursing experiences of nursing students. J Nurs Edu Practice 3(4):12–20 Parliamentary and Health Service Ombudsman (2011) Care and Compassion? Report of the Health Service Ombudsman on Ten Investigations into NHS Care of Older People. http://tinyurl.com/ clmnu32 (accessed 27 July 2012) Picker Institute (2010) NHS Cumbria District Nursing Survey Winter 2010. Picker Institute, Oxford Queens Nursing Institute (2009) 2020 Vision: Focusing on the Future of District Nursing. Queens Nursing Institute, London Queens Nursing Institute (2013) Report on District Nurse Education in England, Wales and Northern Ireland 2012/13. Queens Nursing Institute, London Royal College of Nursing (2013) District Nursing: Harnessing the Potential: The RCN’s Position on District Nursing. RCN, London

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District nursing: the hidden giant of the NHS?

The recent 65th birthday of the NHS is a reminder of the purpose of the NHS: to provide a service that puts people that need it at the heart of care. ...
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