COMMENT
The district nursing service: a national treasure Crystal Oldman
T
he district nursing service is key to meeting many of the challenges currently facing our NHS. The agenda is huge. We are faced with a growing older population that will only increase in future years: medical advances and technology are supporting longer lifespans and the long-term conditions that develop, accumulate and multiply in complexity with age. The impact of dementia and other long-term conditions is becoming increasingly well understood and there exists an army of informal carers (frequently close relatives) upon whom the mix of burden, obligation and privilege rests when caring for a loved one. Hospitals frequently have patients who might otherwise be cared for at home but cannot be discharged in a timely way because the services are unavailable to be put in place in the home. However, there is a way in which many of these issues can be addressed: it is time the district nurse was placed back in centre stage, recognising the skills they have in leading, managing and coordinating teams to deliver the most appropriate, person-centred care in people’s homes.
Changing the focus It is unclear when or how it was forgotten that the district nursing service is a national treasure, a cadre of expert community nurses developed to deliver vital patient care. District nurses themselves are as highly valued and respected as ever by the communities they serve. The focus
Abstract
District nurses are a national treasure. They are the key professionals who will enable the agenda of patients being cared for at home to be realised. They are highly trusted and valued by communities who lead and manage teams of nurses and nursing assistants expertly to deliver high-quality care in the patient’s own home. In an era where the focus is now turning to the community for more care, more actions are required to increase our district nursing workforce. This article discusses the above issues in relation to recent reports on the current status of community nursing.
KEY WORDS
District nursing Workforce numbers Specialist practitioner qualification
394
email: [email protected]
in recent years has been on the general hospital as a service hub that will provide an unending conveyor belt of services to meet every health-care need as and when it arises with no longer than 18 weeks’ waiting time after referral. Health-care funding is perversely weighted in favour of admission to hospital rather than care and self-care in the community, even when the latter would be more appropriate for the patient concerned. The ‘block contract’ for community nursing services is an enormous constraint for providers in terms of developing services. This means that an increase in referrals to the district nursing service is not matched with consequential funding, whereas each admission of a patient to a hospital will attract extra funding. Financially, the system is set up to encourage the admission of patients to hospital, not the promotion of nursing care delivered at home.
Discharge planning When patients are ready for discharge, but will require nursing and care support at home, an assessment of their needs is required to enable the services to be put in place to coordinate seamlessly with their arrival back at home. This requires a nursing assessment that takes into consideration the patient’s own specific living conditions. This can be a challenge for hospital-based nurses, but a simple call to the district nursing service can often be the solution. If a patient is older or has a long-term condition, they will often be known to the district nursing service already, and the provision of care in the home and any equipment needed can be swiftly put in place or recommenced in advance of the discharge. However, the Queen’s Nursing Institute’s (QNI’s) new survey of district nurses, 2020 Vision 5 Years On: Reassessing the Future of District Nursing (QNI, 2014a) provides a plethora of stories about the poor quality of discharge planning undermining what should have been a coordinated, smooth transfer of care for patients and their families. This is a typical example from a district nurse:
‘The people in the acute side do not always think how the patient is going to manage in their own home. Discharge planners should have or be given community experience in orientation so that they understand the problems that arise with a bad discharge. For example, no medication, no prescrip-
© 2014 MA Healthcare Ltd
Chief Executive, Queen’s Nursing Institute, London
British Journal of Community Nursing August 2014 Vol 19, No 8
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 26, 2015. For personal use only. No other uses without permission. . All rights re
COMMENT tions for medication and no easy access to a GP to have medication written up in community home notes at weekends and bank holidays. The same stands for dressings and equipment if the patient is not assessed properly.’ District nurses also have a vital role to play with endof-life care in the community. With a growing demand for patients to be cared for in the home at the end of their lives, we have a duty to ensure that the district nursing service is properly developed and supported to meet this need. In the same way that we have midwives to care for the start of life, we need more appropriately trained nurses to care for people with expert skills to ensure a comfortable, secure and supported end of life. It is a key measure and proof of how we value the elders in our society.
Workforce numbers However, there are grave concerns about the number of district nurses who have been prepared for the leadership role in the last decade, with the number of district nurses falling from 7851 in September 2009 to 5816 in December 2013 (Health and Social Care Information Centre, 2014). The recent reports into community nursing from both the QNI (2014a) and the Royal College of Nursing (Ball et al, 2014) provide clear evidence of the impact the shortage of district nurses is having on the existing workforce, where the teams (by definition) work without the limits of a defined number of hospital beds and where referrals to the service are seemingly limitless. In many instances district nurses are unable to turn away referrals, some of which may be inappropriate, whether they have the capacity to deal with them or not. This makes no logical sense in terms of supporting the stated political agenda of moving care closer to the home. In the home nursing context, the leadership, supervision and support of staff nurses and nursing assistants is critical to the quality of the service provided. The QNI has become increasingly concerned that the number of new district nurses being trained is nowhere near the ‘replacement level’ required to sustain existing services. In the light of this concern, in 2013 the QNI undertook a survey of all universities approved by the Nursing and Midwifery Council (NMC) to provide the district nurse specialist practitioner programme. The low figures were alarming and the report has served as a catalyst for much activity and focus on the district nursing service over the last year (QNI, 2013).
© 2014 MA Healthcare Ltd
Increase in student district nurse numbers The QNI has repeated the survey again this year (this time including Scottish universities in the research). The figures show an overall upward trend. In England, Wales and Northern Ireland there has been an overall increase of 38% in the number of district nurses due to qualify this summer in comparison to this time last year (QNI, 2014b).
British Journal of Community Nursing August 2014 Vol 19, No 8
However, the numbers are simply not sufficient to meet the increasing demand for the service and to match the replacement of those who are due to retire in the next 12 months. More nurses need to be developed by undertaking what is one of the best practice-based leadership and management programmes available to nurses in the UK—the NMC-approved District Nurse Specialist Practitioner programme. Another recent QNI survey demonstrated how patients and their families value the district nurse service and the ‘brand’ of district nurse—a name associated with highly trusted and skilled professionals (QNI, 2012). It is time for a greater focus on the development of this specialist area of the community nursing profession.
Standards for district nursing A considerable time has passed since the NMC standards for specialist practice in district nursing were last reviewed (the most recent published standards date to 2001). While the programmes offered have adapted according to changes in technology and the needs of the patients, their families and carers, this practice is not reflected explicitly in the current standards. For example, many district nurses are now independent prescribers; make full use of remote consultations and telehealth; they provide chemotherapy in the home and routinely care for patients who are ventilated and those at the end of their lives. The service has changed beyond recognition in the last 20 years. For this reason, the QNI is partnering with its sister charity, the Queen’s Nursing Institute Scotland (QNIS), to develop joint QNI/QNIS standards for district nurse education and practice. These standards will serve to enhance and update the existing NMC standards and will demonstrate explicitly the expectations of and the preparation required for this central role in the community. The work is expected to take a year and will commence in September 2014. There will be a wide consultation—the views of patients, their carers and families, in addition to nurses and others working in the community and primary care settings, will be considered. The non-negotiable element in all of this, however, is the observation that the district nursing service is an indispensable national treasure that cannot be allowed to atrophy any further. It will remain a key asset to health services in the UK for as long as we need people to be expertly cared for in their own homes. BJCN Ball J, Philippou J, Pike G, Sethi J (2014) Survey of District and Community Nurses in 2013. http://tinyurl.com/pqzxcn2 (accessed 28 July 2014) Health and Social Care Information Centre (2014) NHS workforce statistics: December 2013—provisional statistics. http://tinyurl.com/mvb399l (accessed 25 July 2014) Queen’s Nursing Institute (2012) Nursing People at Home: The Issues, the Stories, the Actions. http://tinyurl.com/kh4vayn (accessed 28 July 2014) Queen’s Nursing Institute (2013) Report on District Nurse Education in England, Wales and Northern Ireland 2012–13. http://tinyurl.com/q9sjhqd (accessed 28 July 2014) Queen’s Nursing Institute (2014a) 2020 Vision: 5 Years On—Reassessing the Future of District Nursing. http://tinyurl.com/mf58vm3 (accessed 28 July 2014) Queen’s Nursing Institute (2014b) Report on District Nurse Education in the United Kingdom. http://tinyurl.com/k5xohkk (accessed 28 July 2014)
395
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 26, 2015. For personal use only. No other uses without permission. . All rights re
The district nursing service: a national treasure Crystal Oldman
T
he district nursing service is key to meeting many of the challenges currently facing our NHS. The agenda is huge. We are faced with a growing older population that will only increase in future years: medical advances and technology are supporting longer lifespans and the long-term conditions that develop, accumulate and multiply in complexity with age. The impact of dementia and other long-term conditions is becoming increasingly well understood and there exists an army of informal carers (frequently close relatives) upon whom the mix of burden, obligation and privilege rests when caring for a loved one. Hospitals frequently have patients who might otherwise be cared for at home but cannot be discharged in a timely way because the services are unavailable to be put in place in the home. However, there is a way in which many of these issues can be addressed: it is time the district nurse was placed back in centre stage, recognising the skills they have in leading, managing and coordinating teams to deliver the most appropriate, person-centred care in people’s homes.
Changing the focus It is unclear when or how it was forgotten that the district nursing service is a national treasure, a cadre of expert community nurses developed to deliver vital patient care. District nurses themselves are as highly valued and respected as ever by the communities they serve. The focus
Abstract
District nurses are a national treasure. They are the key professionals who will enable the agenda of patients being cared for at home to be realised. They are highly trusted and valued by communities who lead and manage teams of nurses and nursing assistants expertly to deliver high-quality care in the patient’s own home. In an era where the focus is now turning to the community for more care, more actions are required to increase our district nursing workforce. This article discusses the above issues in relation to recent reports on the current status of community nursing.
KEY WORDS
District nursing Workforce numbers Specialist practitioner qualification
394
email: [email protected]
in recent years has been on the general hospital as a service hub that will provide an unending conveyor belt of services to meet every health-care need as and when it arises with no longer than 18 weeks’ waiting time after referral. Health-care funding is perversely weighted in favour of admission to hospital rather than care and self-care in the community, even when the latter would be more appropriate for the patient concerned. The ‘block contract’ for community nursing services is an enormous constraint for providers in terms of developing services. This means that an increase in referrals to the district nursing service is not matched with consequential funding, whereas each admission of a patient to a hospital will attract extra funding. Financially, the system is set up to encourage the admission of patients to hospital, not the promotion of nursing care delivered at home.
Discharge planning When patients are ready for discharge, but will require nursing and care support at home, an assessment of their needs is required to enable the services to be put in place to coordinate seamlessly with their arrival back at home. This requires a nursing assessment that takes into consideration the patient’s own specific living conditions. This can be a challenge for hospital-based nurses, but a simple call to the district nursing service can often be the solution. If a patient is older or has a long-term condition, they will often be known to the district nursing service already, and the provision of care in the home and any equipment needed can be swiftly put in place or recommenced in advance of the discharge. However, the Queen’s Nursing Institute’s (QNI’s) new survey of district nurses, 2020 Vision 5 Years On: Reassessing the Future of District Nursing (QNI, 2014a) provides a plethora of stories about the poor quality of discharge planning undermining what should have been a coordinated, smooth transfer of care for patients and their families. This is a typical example from a district nurse:
‘The people in the acute side do not always think how the patient is going to manage in their own home. Discharge planners should have or be given community experience in orientation so that they understand the problems that arise with a bad discharge. For example, no medication, no prescrip-
© 2014 MA Healthcare Ltd
Chief Executive, Queen’s Nursing Institute, London
British Journal of Community Nursing August 2014 Vol 19, No 8
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 26, 2015. For personal use only. No other uses without permission. . All rights re
COMMENT tions for medication and no easy access to a GP to have medication written up in community home notes at weekends and bank holidays. The same stands for dressings and equipment if the patient is not assessed properly.’ District nurses also have a vital role to play with endof-life care in the community. With a growing demand for patients to be cared for in the home at the end of their lives, we have a duty to ensure that the district nursing service is properly developed and supported to meet this need. In the same way that we have midwives to care for the start of life, we need more appropriately trained nurses to care for people with expert skills to ensure a comfortable, secure and supported end of life. It is a key measure and proof of how we value the elders in our society.
Workforce numbers However, there are grave concerns about the number of district nurses who have been prepared for the leadership role in the last decade, with the number of district nurses falling from 7851 in September 2009 to 5816 in December 2013 (Health and Social Care Information Centre, 2014). The recent reports into community nursing from both the QNI (2014a) and the Royal College of Nursing (Ball et al, 2014) provide clear evidence of the impact the shortage of district nurses is having on the existing workforce, where the teams (by definition) work without the limits of a defined number of hospital beds and where referrals to the service are seemingly limitless. In many instances district nurses are unable to turn away referrals, some of which may be inappropriate, whether they have the capacity to deal with them or not. This makes no logical sense in terms of supporting the stated political agenda of moving care closer to the home. In the home nursing context, the leadership, supervision and support of staff nurses and nursing assistants is critical to the quality of the service provided. The QNI has become increasingly concerned that the number of new district nurses being trained is nowhere near the ‘replacement level’ required to sustain existing services. In the light of this concern, in 2013 the QNI undertook a survey of all universities approved by the Nursing and Midwifery Council (NMC) to provide the district nurse specialist practitioner programme. The low figures were alarming and the report has served as a catalyst for much activity and focus on the district nursing service over the last year (QNI, 2013).
© 2014 MA Healthcare Ltd
Increase in student district nurse numbers The QNI has repeated the survey again this year (this time including Scottish universities in the research). The figures show an overall upward trend. In England, Wales and Northern Ireland there has been an overall increase of 38% in the number of district nurses due to qualify this summer in comparison to this time last year (QNI, 2014b).
British Journal of Community Nursing August 2014 Vol 19, No 8
However, the numbers are simply not sufficient to meet the increasing demand for the service and to match the replacement of those who are due to retire in the next 12 months. More nurses need to be developed by undertaking what is one of the best practice-based leadership and management programmes available to nurses in the UK—the NMC-approved District Nurse Specialist Practitioner programme. Another recent QNI survey demonstrated how patients and their families value the district nurse service and the ‘brand’ of district nurse—a name associated with highly trusted and skilled professionals (QNI, 2012). It is time for a greater focus on the development of this specialist area of the community nursing profession.
Standards for district nursing A considerable time has passed since the NMC standards for specialist practice in district nursing were last reviewed (the most recent published standards date to 2001). While the programmes offered have adapted according to changes in technology and the needs of the patients, their families and carers, this practice is not reflected explicitly in the current standards. For example, many district nurses are now independent prescribers; make full use of remote consultations and telehealth; they provide chemotherapy in the home and routinely care for patients who are ventilated and those at the end of their lives. The service has changed beyond recognition in the last 20 years. For this reason, the QNI is partnering with its sister charity, the Queen’s Nursing Institute Scotland (QNIS), to develop joint QNI/QNIS standards for district nurse education and practice. These standards will serve to enhance and update the existing NMC standards and will demonstrate explicitly the expectations of and the preparation required for this central role in the community. The work is expected to take a year and will commence in September 2014. There will be a wide consultation—the views of patients, their carers and families, in addition to nurses and others working in the community and primary care settings, will be considered. The non-negotiable element in all of this, however, is the observation that the district nursing service is an indispensable national treasure that cannot be allowed to atrophy any further. It will remain a key asset to health services in the UK for as long as we need people to be expertly cared for in their own homes. BJCN Ball J, Philippou J, Pike G, Sethi J (2014) Survey of District and Community Nurses in 2013. http://tinyurl.com/pqzxcn2 (accessed 28 July 2014) Health and Social Care Information Centre (2014) NHS workforce statistics: December 2013—provisional statistics. http://tinyurl.com/mvb399l (accessed 25 July 2014) Queen’s Nursing Institute (2012) Nursing People at Home: The Issues, the Stories, the Actions. http://tinyurl.com/kh4vayn (accessed 28 July 2014) Queen’s Nursing Institute (2013) Report on District Nurse Education in England, Wales and Northern Ireland 2012–13. http://tinyurl.com/q9sjhqd (accessed 28 July 2014) Queen’s Nursing Institute (2014a) 2020 Vision: 5 Years On—Reassessing the Future of District Nursing. http://tinyurl.com/mf58vm3 (accessed 28 July 2014) Queen’s Nursing Institute (2014b) Report on District Nurse Education in the United Kingdom. http://tinyurl.com/k5xohkk (accessed 28 July 2014)
395
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 26, 2015. For personal use only. No other uses without permission. . All rights re
