The Past, Present and Future of Community Nursing
As Christmas approaches and NHS services face the usual winter pressures, we also find ourselves braced against the oncoming ‘tidal wave’ of Omicron cases. In the midst of the ongoing pandemic, Community Nursing teams – the ‘unsung heroes of the NHS’ – will continue to provide an invaluable service to all the vulnerable patients who are living in their own homes.
In celebration of their efforts, qualified district nurse and Malinko Benefits Realisation Lead Amanda Hobson takes a look at the past, present and future of community nursing.
Christmas past: what we have learned
Years ago, District Nurses worked closely with GPs. They were based in GP surgeries and worked alongside other healthcare professionals as part of a large, interdisciplinary team. There was a shared, joined-up vision to provide patients in the community with a holistic, responsive service. Communication between DNs and GPs was instant, regular, open and transparent, which facilitated decision-making and joined-up care.
The model of district nursing was very different, with most practitioners obtaining their DN specialist practice qualification. As a result, there were many more Sisters and Charge Nurses within DN teams. Each team had several senior staff members working alongside the junior workforce, which enabled junior DNs to observe senior practitioners and learn from their example as they took on more complex patients. They learned to work together with the multidisciplinary team, managing patients at home. Junior nurses were closely supervised and senior staff were able to spend time with them on a regular basis. It was nice to watch the junior workforce grow into autonomous practitioners. They were given the opportunity to improve their skills over time, slowly building their confidence until they were ready – and competent – to manage their own patients.
Patient caseloads were more manageable and cases were less complex. There was also less pressure on community teams in relation to patient flow. Discharge teams included District Nurses, so discharge plans for more complex patients were properly coordinated with community teams. District nurses would visit hospital wards to check for DN referrals, and DNs would regularly visit their patients in hospital and communicate with their families and the acute team to arrange a safe discharge home. District Nurses felt a strong sense of responsibility to their patients and provided continuity of care even when they were in hospital during an acute phase of illness.
DNs regularly managed long-term conditions and helped patients stay in their own homes longer. They had more time available to support their patients, because they did not have as many visits.
In the past, community nursing teams knew their communities and their patients. They completed their neighbourhood study, so understood what they needed. And more importantly, their communities and patients knew them.
Christmas present: a changing landscape
In the last decade, the number of District Nurses working for the NHS has almost halved. In addition to this dramatic reduction in staffing levels, the profile of community teams has also changed, with community nurses now less joined-up with GP surgeries. Community teams and DNs now operate on a much larger footprint because over the years, smaller teams have merged into larger teams. This has substantially reduced the skill mix, as Senior Nurses have been replaced with junior staff. As a result, there are now fewer Senior Sisters/Charge Nurses in community teams, leaving more junior staff to manage the care of patients with complex needs. The impact of this model is that experienced DNs now have less time to supervise and invest in junior staff. As a result, Junior Nurses are missing out on the opportunity to learn from the invaluable skills, knowledge and experience of more senior clinicians.
In recent years, caseloads have also grown dramatically, and patients often present with far more complex needs. Today, community teams are supporting patients with extremely complex needs who, in the past, would have required hospital or residential care. Home is where most patients want to be, and community teams want to support this. However, increasing complexity requires a skilled, responsive workforce and integrated working. Managing a caseload of 300-400 plus patients takes considerable time and coordination, 24 hours a day, 365 days a year.
Until now, technology has not evolved with the service, leaving community nursing teams struggling to coordinate multiple caseloads on spreadsheets or inadequate, proprietary systems. This lack of quantifiable data and poor transparency has forced community nursing teams to adopt a reactive, task-oriented approach: managing multiple, complex cases in the minimum possible time, with no data to support requests for additional staffing, or to assign practitioners to patients according to skills and experience.
Our community nursing teams do not want to work like this. They want to be given the time to care for patients, to adopt a holistic approach to healthcare and to proactively keep people in their own homes. But with the current demands on community teams, how can this be facilitated?
The ‘Today I Cried…’ video from Leeds Community Healthcare NHS Trust highlights the struggles teams face.
Future: what we can achieve
In the future, we can substantially improve patient outcomes as well as the working lives of community practitioners by returning to a multidisciplinary workforce, with DNs at the centre of neighbourhood teams, as the lynchpin of the community.
We need new, more focused training for DNs so that after they have completed their SPQ training, they can return to their community teams as advanced clinical practitioners: supporting junior staff, preventing hospital admissions, facilitating early discharges and managing patients living at home with long-term conditions.
We must devise a model to support the needs of our communities, with technology factored in. Too often, technology is forgotten, leaving teams unable to demonstrate their worth, and the value that they bring to patient care. Technology should play a key role in the future of community nursing teams. Not only can it help with workforce planning by accurately managing workforce capacity and patient demand, but it can also give community nursing teams the evidence they need to demonstrate their true value, support clinical decision making and ultimately, improve outcomes for patients.
By working together, planning, prioritising transparency and embracing technological advances, we can ensure that the future of community nursing is better than the past, with stronger outcomes for our patients and families.