District nursing – it’s not just an injection…

Guest blog

Our report, Understanding quality in district nursing services, sets out a framework that describes what ‘good care’ looks like in district nursing services. We invited Rebecca, a community staff nurse in London, to share her thoughts on the subject.

Walking up the drive I am already in assessment mode. I notice the curtains are still drawn.

During my last visit Bill* and I discussed his forthcoming appointment with the oncologist. He had expressed confusion about what was happening so we made a list of questions together and a plan to go through these with his GP. I’m conscious he will have an update.

As he comes to the door I see he’s lost weight, he’s more breathless on exertion and slightly unsteady on his feet. He smiles, ‘Welcome back, I’ve missed you’.

We had been visiting Bill for three months to administer daily injections related to his cancer treatment. During that time we’d listened to his hopes for treatment and, as things changed, his fears for the future.

Over the past month I’d taken longer than usual to do his injection as he opened up to me about worries for himself and his family.

While away, I was conscious of how he and Jane* would be ‘held’ by the system and we’d agreed I would liaise with other members of his multidisciplinary team to ensure a shared plan. I asked his GP and palliative care team to visit and briefed his clinical nurse specialist on our conversations. At a time of uncertainty and anxiety, continuity of care and team members was important to him.

This was all done using a fundamental tool for integrated care – the telephone.

As I give his injection he shared the consultation outcome. He says he has had a good life but worries about leaving Jane. As I leave we hug.

Later the electronic patient record system asks me to record time of the visit, and I select ‘injection’ from the mandatory drop-down list. So much of what goes on in a visit is not reflected in the activity data.

Recording the task in this way reinforces a reductionist approach and promotes task-orientated care. ‘Every system is perfectly designed to get the results it gets’.

What does good look like?

Reading the report on district nursing by The King’s Fund I’m interested in people’s definition of ‘good’ care and who prioritised what.

Caring for the whole person – I find myself thinking about handovers which, due to pressure of afternoon visits, sometimes aren’t long enough and are shortened to an update on tasks. Colleagues look at me as I relay name, age, diagnosis, current situation and plan – old habits die hard. As a junior staff nurse the ward sister would expect you to know what was happening with all the patients on the ward. I think it’s a good habit, one that keeps the whole person, not the task, at the forefront of our minds.

Predictability – People often ask for an exact visiting time and some struggle with our five-hour window. It is hard to predict though, as a 15-minute procedure can end up taking much longer, especially if we stay true to practising holistically.

Clinical competence and expertise – Patients understandably assume qualified means competent. Staff know that levels of clinical competence vary and have prioritised it as one of the characteristics of good-quality care. I wonder, having recently returned to practice, whether I am particularly sensitive to this issue? Why is it that the caring side of nursing seems to get privileged over the intellectual? A variation of Maslow’s hierarchy of needs? I want a caring AND competent nurse. Who wouldn’t?

When I think about ‘good’ in the context of a typical day I find myself frustrated by how much time is spent on administrative tasks, detracting from direct care. Too much of this requires manual data entry, often duplicated. As a former director I understand the importance of capturing activity and demand, yet I experience what Watlzowick refers to in his examination of problem formation when the solution to a problem becomes the problem in itself.

Playing our part in delivering the national strategy

Sitting with 86-year-old Fred* in his kitchen he is anxious we are discharging him because his wound is healed. Without wanting to say so, he is worrying that his wife has early signs of dementia and wonders how he’ll cope. We explore a network of support that will build new relationships so they can stay in their own home together and he feels reassured.

I do the referral and speak to colleagues but can’t help but feel anxious about how vulnerable they are. We work hard to keep people safe and well at home. In our day-to-day actions we deliver the national strategy set out in the NHS five year forward view by keeping people out of hospital and connecting them to the community network. But the downside is the risk that these people remain hidden, not just from the activity data but from the consciousness of society – out of sight is out of mind.

* Names have been changed

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#548188 Jill Gould
District Nurse and Lecturer
Association of District Nurse Educators

Nicely expressed blog, thank-you for sharing. Have been concerned about the approach to services since some areas started calling DN services "intervention teams" as though our patients can be seen a tasks. A good illustration of how it's so much more than tasks that District Nurses provide.

#548189 Anita Sharrad
Community Practice Teacher
Shropshire Community Health Trust

A perfect illustration is the holistic health care we deliver ... Delivering care in a very rural area much time can be spent driving to remote locations and holistic person centred care is vital when you reach these people. The purpose of the visit (the task) can account for a small part of the whole visit time but by 'unpicking' situations much preventative work and advanced care planning can be achieved in collaboration with that person. We are continually implementing national strategy by keeping people safe and managing risk with them in their own homes.

#548191 Ruth dymock

Concerns from a caring community nurse, expressed from the heart. Can't help thinking though that IT in this instance is a bit backward and not helping patient or nurses - duplication of documentation, time spent doing it later in the day, no place to put patient's real issues ... Updated IT, although still wanting in many areas, allows for documenting while being with the patient, and gives space (if not time!) to describe the real issues as seen by the patient, together with an action plan so these aren't forgotten. Am wondering if the pt-centred comment box should be mandatory ... Agree with Jill absolutely about division of Intervention Team and case management, a disaster which has opened up a further possibility of new DN teams run by staff nurses and populated by task-orientated HCSWs or new associate nurses.

#548193 Catherine Freeman
District Nurse

A shining example of what we do every day that goes unnoticed and unmeasurable, we are the invisible workforce . Although organisations say they strive for individualised care they are unfortunately still task related. I find it sad that as district nurses with all our knowledge and experience we are being turned into computer programmers and administrators now we are required to spend more and more time carrying out admin duties while still expected to know what's happening with our patient caseloads and staff. I enjoy the days when I can visit my patients and constantly feel guilty when I am required to spend time in the office.

#548198 Joanne Stinson
Specialist practitioner district nurse/tvn
Nottingham shire healthcare

So true, sadly the high skills of distrct nurses are not vauled. We are managed my non district nursing manages who think the role is tasks. District nursing is a passion and a calling, and the last remaining generalist nursing role which cares for the patient holisticallyand often the whole family Sadly within nursing, skill and experience counts for nothing there is always someone who can deliver care cheaper and quicker but less skilled, holistic and caring.

#548207 Beverley Marriott
Nurse Practitioner - Community Matron
Birmingham community healthcare foundation trust

District nursing provide core services for older people they do an amazing job providing the level of care for these many with complex long term conditions 'day in day out' - highly skilled and experienced, often walking into a situation that required decision making and risk- never knowing what they will walk into - amazing nurses doing amazing work touching the lives of many frail, vulnerable people. Great blog to read Thank you

#548212 John Toby
Retired GP

Congratulations on the blog. I should like to add to the supportive comments. It is difficult to remain credible as a retired practitioner (GP in my case) but I should like to echo the sentiments, the support for generalism and holistic care and confirm the very high regard for traditional district nursing for most of the history of general practice. Sadly, GPs are subject to the same constraints and pressures with a high probability that general practice as it has been known will shortly cease to exist. What a pity that those who will become frail and old (probably the majority in our brave new world) and need truly generalist care with continuity are not able to make common cause to defend the values and skills demonstrated here.

#548262 Mike Stone
Retired Non Clinical
None Private Individual

John Toby pointed out something very significant with his:

'What a pity that those who will become frail and old (probably the majority in our brave new world) and need truly generalist care with continuity are not able to make common cause to defend the values and skills demonstrated here.'

All too often 'systems' are designed [and I use the word generously] to suit the professional side of things, as opposed to the service-user side.

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