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
- Read our report, Understanding quality in district nursing services
- Explore the quality framework for district nursing
- Our annual conference on 9 November includes a session on quality in district nursing