|
Cynulliad Cenedlaethol Cymru |
National Assembly for Wales |
|
Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon |
Health, Social Care and Sport Committee |
|
Ymchwiliad I wasanaethau Nyrsio Cymunedol a Nyrsio Adal |
Inquiry into Community and District Nursing services |
|
HSCS(5) CDN04 |
|
|
Ymateb gan Goleg Nyrsio Brenhinol Cymru |
Evidence from Royal College of Nursing Wales |
Executive Summary
– Most Registered Nurses work in the community in a variety of roles and settings including public health. Adults and children with complex conditions receive care in the community as do those recovering from treatment or operations.
– The Welsh Government should set out a renewed vision for primary, community and social care including the role and value of community nursing.
– The Welsh Government should invest in supportive technology for Community Nursing. RCN Wales believes the use of hand-held devices with instant access to patient information should be standard across Wales.
– The Welsh Government, HEIW and NHS Wales should work together to increase the number of District Nurses in Wales
– The Welsh Government should extend the Nurse Staffing Levels (Wales) Act 2016 to community nursing services.
– The Welsh Government, HEIW and NHS Wales should work together to increase the number of Children’s Nurses in community nursing Introduction to Nursing in the Community
Introduction to Nursing in the Community
– Most Registered Nurses work in the community in a variety of roles and settings including public health. Adults and children with complex conditions receive care in the community as do those recovering from treatment or operations.
1. Contrary to the common and popular image of the nurse on the hospital ward most nurses work actually outside a hospital. Two thirds of the RCN’s membership work in the community.
NHS Nurses working in the community could be District Nurses, learning disability nurses, community psychiatric nurses, specialist nurses, school nurses or a Health Visitor (Specialist Community Public Health Nurse). Practice Nurses and health care support workers working in GP surgeries form part of this collective nursing workforce in the community.
A third of RCN membership (half of those working in the community) work in the independent sector in the community e.g. for a hospice or a care home. These nurses and the care workers who are part of a nursing team also are part of this collective nursing workforce in the community.
2. Adults and children with complex conditions receive care in the community as do those recovering from treatment or operations. Some of our most vulnerable older people are supported 365 days of the year by community nursing delivering complex care and treatment packages at home.
Community nurses act as a valuable link between acute services, primary care and promote independent living. Nurses in the community specialise in many areas for example dementia, stroke, palliative care and Parkinson’s disease and some have obtained additional qualifications to prescribe medications which ensure that older people receive a quality nursing service. Community nurses also signpost older people to appropriate third sector organisations for support befriending and advice.
Community Nurses have a holistic philosophy of care. Rather than focusing on a task –based approach (e.g. changing a dressing) it is about a range of caring activities that assess and respond to the whole spectrum of needs of people being cared for in their homes and communities. This fits perfectly with the aspirations of A Healthier Wales. Research clearly demonstrates the detrimental impact of care delivered without nursing input[1].
In other words, DNs are the present and future solution to community- based health and social care.
A nursing presence in residential care for older people is essential for:
– Continuous monitoring and assessment of residents’ health and wellbeing; recognising cues to problems, anticipating problems; acting to prevent problems developing; preventing deterioration
– Managing acute illness and emergencies; preventing crisis situations; preventing unnecessary hospitalisation.
Nurses promote residents’ independence through safeguarding, proactive, rehabilitative care; promote residents’ health and flourishing; deliver high quality palliative care and end of life care for individuals; play a key role in advocacy for residents and families. With the increasing complex care needs of people in nursing homes there is a need for greater communication, sharing of professional knowledge and support between Health Boards and independent care providers.
The role of and vision for Community Nursing
– The Welsh Government should set out a renewed vision for primary, community and social care including the role and value of community nursing.
3. Recent years have seen a transformation of NHS healthcare and population need. Our population is living longer and living longer with chronic and complex conditions. For the last decade in Wales Health Boards have been reconfiguring acute hospital services, reducing bed numbers, encouraging shorter patients stays and enabling more complex treatments and care to be delivered at home. There is a renewed emphasis in Welsh Government policy on prevention and public health and an integration between health and social care.
The Royal College of Nursing is a strong supporter of these policy goals which, if implemented, will improve the experience of care for people and the efficiency of the healthcare system.
4. One of the unintended consequences of this policy shift however has been that ‘social care’ and ‘primary care’ are now the term most often used by decision-makers to describe care received outside a hospital. ‘Primary care’, is grouped and delivered through 64 clusters across Wales. ‘Social care’ is often used to mean any care delivered outside a hospital. There is a real danger that the contributions of nurses such as community and district nurses, but also groups such as occupational health nurses, school nurses and health visitors are becoming invisible to policy makers and undervalued.
5. The last Welsh Government Community Nursing Strategy was published in 2009 and rapidly superseded by the developments and cluster model of the Primary Care Strategy.
6. The CNO’s guidance on District Nurses recommends that community nursing teams in Wales are structured on a cluster basis. However it is not clear if this is always the case in practice. There also is tremendous variation in how included community nursing teams are in cluster discussion, and vision. RCN Wales would like to see greater support from the Welsh Government for the development of non-medical leadership in clusters to broaden their vision.
7. The role of the Executive Nurse Director is community service design is limited and varied across Wales. Aligned community health services (e.g. continence, respiratory, diabetes, tissue viability, lymphedema, palliative and cancer services) are therefore run very differently across Wales. All of these affect the way district nursing teams work in each area and affects their caseload.
8. Regional Partnership Boards (RPBs) have been given a central role in progressing the integration agenda in Wales; ‘A Healthier Wales’ describes them as having a ‘strong oversight and coordinating role’ in delivering change. Given this central role, the RCN would like to see far greater transparency and scrutiny around the work of RPBs. Nursing input into service design is needed and it needs to be clear how and why projects are funded. If projects are successful there should be a mainstreaming process.
9. A plethora of funding initiatives have resulted in a myriad of different specialist nursing teams based in the community. In many areas there will be teams that are integrated with local authority or not integrated, have rapid response within the DN teams or have separated service such as rapid response, Community resource teams, ACAT or frailty. Some teams have specialist chronic conditions leads, some lack any and some teams have access to community based specialists for chronic conditions and work in partnership with them.
10. Many of these new initiatives are excellent in outcomes when their work is viewed in isolation but the wider strategic picture across Wales is unexamined leading to the following problems:
– The new is prized over the successful: Initiatives are usually funded via a bidding process. This bidding process is in itself capacity-consuming. In addition many of our community nursing members tell us that they can no longer received funding for proven successful mainstream work but only for unproven new schemes or ‘rebadging’ the old as new.
– Lack of evaluation and mainstreaming: It a particular model of working is successful then it should be sustainably funded.
– Lack of succession planning- when a specialist nurse leaves, too often the post cannot be filled or the post is removed resulting in a loss of service and a loss of any improved efficiency.
– Deskilling of community nursing: Staff can be pulled from community nursing teams into a ‘new’ team such as frailty. If the new team requires skills such as IV medications this shift of people and/or ways of working can denude the community nursing team of the ability and confidence to deliver these skills. Community Nursing teams then can become dependent on referrals to specialist teams undermining their ability to work flexibly at the level commensurate with need.
11. The current assessment system for Continuing Health care is placing a large burden on the most senior members of the community nursing team. Our members report up to a third of their time is occupied by repeated assessment to distinguish between health and social care needs and confirm this. The patient often gets caught up in this delay as the teams are overwhelmed with assessments that are time consuming.
12. RCN Wales is also calling for a national strategy to encourage student nurse placements in care homes, with practice nurses and in community teams to encourage the pursuit of community based nursing careers. However nurse mentors in community are finding that poor staffing levels and increased workload mean they are concerned about the education and placement experience that they ae providing for nursing students in community.
13. Over all the RCN is receiving a picture from its members of a significant loss of resources and a constant devaluing of the skills and benefits received from a functioning community nursing service. The Royal College of Nursing believes the Welsh Government should set out a renewed vision for primary, community and social care including the role and value of community nursing. HEIW will launch a workforce strategy at the end of this year and the vision for the future of the service needs to be clear.
ICT Infrastructure, Documentation & Technology
– The Welsh Government should invest in supportive technology for Community Nursing. RCN Wales believes the use of hand-held devices with instant access to patient information should be standard across Wales.
14. The core role of the community nurse is to act as an intermediary between secondary, primary health care and also social services. It is particularly invidious therefore that community nursing has long-been at the back of the queue for investment in modern communications technology that can support and make their work more efficient.
Our members still report carrying large amounts of paperwork around and having to spend many hours updating records at the end of the day. A plethora of different recording methods are in use including handwritten, ipad, pc, phone. Written documentation is usually left in the patient’s home but this can be problematic if the patient mislays it. RCN Wales believes the use of hand-held devices with instant access to patient information should be standard across Wales.
15. In a world where the knowledge base is expanding and changing so rapidly, ICT and access to the right technology can give nurses access to a world of knowledge and resources; not only patient records, but also current protocols, guidelines and the latest research findings. This is particularly valuable when delivering care within people’s homes and in the community.
16. Welsh Government must show a concerted and expeditious commitment to investing in the use of technology in care delivery in Wales. Whilst any public spending on eHealth and new ICT systems will always require a high level of scrutiny, the NHS in Wales spends less than 2% of its funding on ICT – significantly less that the recommended figure of 4%. It is also essential that nurses are involved in the design of digital records and software systems to ensure their practicality in use.
17.
There are many examples of good work happening in Wales in the
field of eHealth and harnessing the latest technology. For
instance, VR (virtual reality) and digital media (tablets,
internet, etc.) are being used successfully with care home
residents in a variety of ways. Digital Communities Wales has
several
examples of best practice on their website,
including a case study on Woffington House Care Home in Tredegar.
Here, the use of iPads combined with VR glasses, has allowed
residents to revisit Aberystwyth in 1965 and experience roller
coaster rides. The home has seen a 100% reduction in the use of
anti-psychotic medications on an “as required” basis,
as well as a reduction in falls and ambulance call outs.
The Community Nursing Workforce
–
The RCN believes that the Welsh Government should improve
nationally held activity and outcome information on nursing care in
NHS community settings to improve workforce and service
planning.
18. The graph above (fig.1) shows the increase in the number of registered nurses and nursing staff working in the community over the last 5 years. The RCN believes this increase needs to continue and more information required before need can be properly assessed.
– We know that there is a growing number of older people and other vulnerable groups needing nursing at home.
– We know there is the rise in the number of people with long-term conditions requiring complex care and support at home.
– We know that Health Boards have reduced the number of acute beds available believing that care in the community will replace this.
19. However the number of people receiving (or requiring) care and the level of their needs is not collated or published at a national level so it is very difficult to judge the level of nursing need required at a national level[2]. How HEIW will address this is a matter of some concern for the RCN.
It should also be pointed out that we do not have outcome data on the patients receiving care so it is difficult to judge which models of care are most optimum form a patient perspective and from the perspective of efficiency with public money.
The RCN believes that the Welsh Government should improve nationally held activity and outcome information on nursing care in NHS community settings to improve workforce and service planning.
– The Welsh Government, HEIW and NHS Wales should work together to increase the number of District Nurses in Wales
20. The District Nurse is a title given to those with a Specialist Practitioner Qualification (SPQ). An SPQ is separately recordable on the Nursing and Midwifery Council register. It recognises a level of knowledge and practice that is highly skilled. It is a specialism in general community nursing. These nurses are the experienced pinnacle of a community nursing team providing clinical supervision and leadership to the registered nurses and health care support workers in the team.
21. The position of the Royal College of Nursing is that ultimately the purpose of a qualification is to inform the public and employer of the standard of knowledge, practice and competence care they can expect to receive.
22. As well as the District Nurse qualification Registered Nurses can also undertake a post-registration (i.e. postgraduate) degree in community nursing. The RCN is calling for this to be a recognised and registered qualification. The Royal College of Nursing would expect a national framework to set out clearly the standard of knowledge, practice and competence and qualifications required for a senior leadership position in community nursing in Wales. An extension of the Advance Practice Framework for Nursing, Midwifery and Allied Health Professionals in the community may also be helpful.
23. A recent welcome development has been the publication by the Chief Nursing Officer of the “District Nurse Guiding Staffing Principles”. This makes a recommendation that all community nursing teams in Wales should be led (and deputised) by a District Nurse or by a nurse possessing a postregistration community nursing degree “aiming towards” supernummary status (i.e. allowing time to be spent on supervision or case management). The guidance also suggests least 15 hours administrative support for the team.
24. The Royal College of Nursing would welcome regularly published information on whether this standard has been achieved. We are aware from our members that this is not always the case. We are also aware of teams with no administrative support. In addition it is our view that each registered nurse working in the community should have completed the core module of community fundamentals but again this is often not the case. There can be no dilution of the quality of care for patients.
25. The graph (fig. 2) below shows the decline in the numbers of District Nurses in Wales. This is alarming and should be of concern to the Welsh Government.
The information in fig.2 is published by Statistics Wales. Statistics Wales is supplied with this Information by Health Boards.
The graph shows an apparent increase in District Nursing numbers from 2016. The RCN has used a dotted line for this increase as unfortunately this information is not reliable. Some Health Boards have incorrectly coded all nurses working in the community as District Nurses. While there has always been an element of accidental miscoding in the data the scale of the problem has become serious enough to destabilise this quality of this series as a whole.
Statistics Wales are aware of the problem and RCN Wales has been informed they will use additional information from the NMC register to correct these figures in March 2019.
26. Education places for District Nursing are commissioned by the Welsh Government. Modules allow a flexible approach to learning. It can be seen from the graph above that the Welsh Government increased the number of education places commissioned in 2013 but this number has stabilised in recent years. Given the age profile of District Nurses and the increasing numbers of people being cared for in the community with complex conditions the Royal College of Nursing would argue there is a serious case to be made for increasing this provision.
– The Welsh Government, HEIW and NHS Wales should work together to increase the number of Children’s Nurses in community nursing
27. Traditionally Children’s Nurses were relatively few in number and hospital based. These days’ children with complex health needs can receive far more care at home. This means many more Children’s Nurses are needed in the community. Wound care & management, ventilation, BP monitoring, IV medication/ line management, enteral feeding support and palliative care are some of the services Childrens Nurses provide, along with vital education for other healthcare professionals and for carers and school staff. Learning Disability Nurses are also in very short supply and are needed to support children and young people with challenging needs.
28. In 2017 and 2018 the Welsh Government increased the number of commissioned student places for Children’s Nursing but these figures remained static this year. As well as needing Children’s Nurses in the community here is also a sharp demand for Children’s Nurses in neonatal services– this means that the rise is by no means yet sufficient to meet need.
29. The RCN is calling for the Welsh Government to publish up to date figures showing the number of Childrens Nurses in the Community. HEIW should demonstrate how it is planning the workforce to meet need.
Extending the Nurse Staffing Levels (Wales) Act 2016 to the community
– The Welsh Government should extend the Nurse Staffing Levels (Wales) Act 2016 to community nursing services.
30. During the passage of the Nurse Staffing Levels (Wales) Act 2016 one of the areas much discussed in the Assembly Health, Social Care and Sport Committee was why the Act could not be extended to the cover nursing in community settings.
31. The Welsh Government has committed to extending the Act to more care settings by the end of this assembly term and has taken steps forward in this field. The work stream looking at extension to the community has only recently been supported by the appointment of 2 year administrative support and a project lead. The Nursing Group established to oversee this work is currently looking at developing the Welsh Levels of Care Tool for use in the community. This would allow a consistent assessment of acuity and dependency in patients to allow for the consistent calculation of staffing need. There should be greater investment of support and a clear timeline of progress on this work.
32. It is the Royal College of Nursing belief that this work should be progress by the Welsh Government with a view to extending the Act by the end of this assembly term.
Annex A – RCN Nurse of the Year Community and District Nursing Winners
2018 Community Nursing Award Winner, and overall Nurse of the Year
Winner: Eve Lightfoot, Community
Infection Prevention Nurse, Hywel Dda University Health Board
Eve became concerned that there was no teaching about sepsis or the early recognition of the deteriorating patient in the community, as these were perceived as ‘secondary care’ issues, so she started to raise awareness of the issue, and then commenced a research internship and undertook a research project. As a result a Community Situation, Background, Assessment, Recommendation template is being implemented; and National Early Warning Score, vital signs and SBAR are being incorporated into community nursing documentation and GP admission criteria. In addition a new out-of hospital Rapid Response to Acute Illness Learning Set group has been set up in HDUHB and there has been a standardisation of monitoring equipment and an increase in education provided to care homes and managers on sepsis recognition. Eve is passionate about this work,
never taking no for an answer and goes above and beyond what anyone would realistically expect, achieving significant change across care sectors and driving to improve patient safety and empower nurses.
2017 Community Nursing Award Winner:
Paul Crank, Senior Nurse, District Nursing, Cwm Taf University
Health Board
Paul has worked with his colleagues and teams to challenge ways of traditional thinking that have empowered and enabled teams to problem-solve in innovative ways. Paul has led the All Wales work in development of the acuity tool and testing of the principles on behalf of colleagues in Wales. His use of IT solutions to deliver care at home has been transformational and the work has been recognised as an exemplar for others. Through the creative utilisation of modern technology, he has engaged the nursing workforce to deliver responsive, outcome-focused care. Paul has demonstrated leadership, even in times of adversity, implementing learning and taking forward changes in practice on a wider scale, outside his own team and across the other healthcare organisations.
2016 Community Nursing Award Winner: Jacqueline Jones, School Nurse,
Hywel Dda University Health Board
Jacqueline developed a simple, yet
unique way of engaging children in talking and opening up to
professional help and advice in relation to their health and
wellbeing by using items that they are familiar with as visual
prompts to start conversations. The work is based on sound evidence
and has been evaluated and reported on at a national level. Due to
its simplicity, it could be effectively transferred across a range
of settings and health and social care situations.
Jacqueline’s passionate, highly motivated approach to her job
and team was inspirational. Because of her developmental approach
she has been thinking about ways to engage future generations and
colleagues in healthcare and how to promote her idea across Wales
and beyond.
2015 Community Nursing Award Winners: Ann Bamsey & Susan Grounds, Health Visitors, Powys Teaching Health Board
Ann and Susan recognised a need to
support parent and infant relationships within their community.
Together they facilitated ‘Little Dippers’ Aqua Tots
group, a parent and baby swimming course which was an innovative
project believed to help reduce postnatal anxiety and feelings of
isolation for new mothers. The project went from
strength-tostrength. Ann and Susan accessed grant monies which
helped them to make the necessary changes to an unused area within
their local community. They are now able to use this area to
facilitate a form of gymnastic play. The peer support and friends
gained from attendance has also encouraged parents to become
involved in further health enhancing activities. Despite the
pressures of austerity, Ann and Susan have sought out and secured
funding which has enabled the sustainability of the core project.
As well as this they have created a bilingual nursery rhyme book
which accompanies and reinforces the songs that are sung throughout
the water play. Ann and Susan have demonstrated the rich potential
of the health visiting role in a project that combines family
focused care, parent support and community development.