Section 4
Maximising nurses' contributions in community settings
The new service model described in the previous section is designed to deliver what individuals, carers, families and communities are asking for from nurses in the community. It also sets nursing in the community in the right direction to contribute significantly to meeting national health priorities as set out in Delivering for Health, including:
- providing safe and effective services closer to people's homes
- addressing the twin challenges of an ageing population and a diminishing potential health and social care workforce for the future
- enabling people with long-term conditions to live positively in the community
- improving people's health, providing anticipatory care and preventing illness
- developing individuals', carers', families' and communities' self-care skills
- supporting carers
- protecting children, young people and adults who are in vulnerable circumstances
- reducing health inequalities and widening access to services
- providing safe and effective unscheduled care services and reducing hospital admissions
- developing integrated services and positive teamworking.
It is essential that the future capability of the nursing workforce in the community be considered in relation to how, working within the new service model and practising the seven core elements of the nursing role in the community, it can deliver on the key policy aims of Delivering for Health.
The Review has considered this, and has drawn the following conclusions. Implementation of the model will need to incorporate processes, mechanisms and systems to support nurses to deliver in these areas.
Nurses must be supported to…
… support people as close to their own homes as possible, particularly those with long-term conditions
Many nurses working in the community spend most of their time with people who have, or are at risk of developing, long-term conditions. Nurses need evidence-based knowledge and skills to support these individuals and their carers and appropriate systems to facilitate direct access to specialist services when they feel it is necessary. They also need systems in place to allow them to access equipment required by individuals to support independent living.
Nurses have important roles as co-ordinators of different services involved in people's care. The Review endorses the need for nurses to use their co-ordination skills and knowledge of health and social care systems to act as care managers 2 for people with complex health needs and those whose long-term conditions impact on their lives.
… develop health promotion and health improvement strategies with individuals, carers, families and communities
Nurses are in a strong position to support individuals, carers, families and communities to adopt healthy lifestyles. Effective individualised health promotion strategies rely upon nurses adopting a career-long approach to developing and maintaining their knowledge and skills base for promoting individuals', families' and communities' health and safety. They should be supported in developing their knowledge and skills base through pre- and post-registration nursing programmes and in ongoing professional development activities.
… enable and develop individuals', families' and communities' self-care skills
Nurses have strong relationship and communication skills that can support people to self care. Measures to enhance nurses' capabilities in promoting people's self-care abilities in partnership with individuals and carers are being taken forward nationally as part of the Delivering Care, Enabling Health action plan.
Individuals who have experience of long-term conditions are an excellent resource from whom all can learn, and unpaid carers also have great experience of the satisfactions and challenges caring brings. Their experiences and knowledge can support people with long-term conditions, fellow carers and professionals to ensure that effective services are in place to facilitate supported self care.
… support unpaid and paid carers
Nurses should ensure they incorporate the health care needs of unpaid carers into care plans, utilise single shared assessment tools effectively and ensure carers have opportunities to access their statutory right to an assessment. A good practice framework should be developed to support service commissioners and providers to train and supervise paid personal care providers.
… identify and protect adults, young people and children from harm
As front-line clinical workers, nurses are often in a strong position to identify signs of abuse and neglect in patients, carers and families across the age spectrum and to trigger appropriate responses from services. As was identified within the description of the seven core elements of nursing in the community set out in Section 3, protection of children and young people has been identified as a national priority. This is an issue for all nurses, not just those who have specialised in the care of children and young people. Education and practical support is needed to enable nurses to recognise and respond effectively to the needs of people who are vulnerable through a variety of causes.
…contribute to a reduction in inequalities in health care and increase access to services
Nurses' core strengths - developing relationships, building trust, being accessible and approachable, working as equal partners with individuals, carers and communities, knowing about health and social care systems, carrying out holistic assessments, having public health knowledge and adopting culturally competent and flexible approaches - should be put at the disposal of communities who do not find services accessible. Nursing teams need to consider how they address health inequalities in the communities in which they work and develop and deliver appropriate action plans.
… maximise their contribution to managing unscheduled care services
Nurses are playing key roles in unscheduled and emergency care initiatives in a range of settings - community hospitals, health clinics, emergency response teams and NHS 24, to list a few. They are assessing, diagnosing, treating and referring or discharging patients suffering from minor illness and injuries in single care episodes. They are also helping to maintain individuals' and carers' health and supporting them to manage their own conditions to avoid the need for unscheduled care services.
Nurses now need to develop their contribution to unscheduled services further, building on their core strengths, taking opportunities for multi-disciplinary education and complying with relevant competency frameworks being developed by NHS Education for Scotland and Skills for Health.
… contribute to reducing length of patient hospital stays
Nurses working in the community need the knowledge and skills to support people with acute illness at home in partnership with individuals, carers, families and professional colleagues. A national best practice statement on caring for people who are acutely ill in their own homes should be developed to support this work.
Nurses in the community should remain involved in patients' care throughout the planning, admission and hospital inpatient stages and should support hospital discharge planning and implementation.
… contribute to anticipatory care
The overall aim of anticipatory care is to work with individuals to help them identify early any circumstances which may have a negative impact on their long-term conditions and support them to develop strategies to avoid them or reduce their effects. Nurses need the skills and knowledge to provide these kinds of services.
Nurses have a wealth of information available to them about the communities with whom they work. They should use this vital resource to prioritise their anticipatory care activity, making sure that people who are most at risk of ill health are identified and supported.
… work in effective teams
Nurses must work within multi-disciplinary, multi-agency teams to contribute effectively to meeting people's health and social care needs. NHS nursing teams in the community should be designed around population units, responding appropriately to the health needs of those populations.
It will be a matter for individual NHS Boards to determine whether group attached/aligned or geographically based services are selected for their areas.
Nurses must have knowledge and understanding of the services available to the populations with whom they work, what the services can offer and how they can be accessed by members of local communities. Team structures should support the development of strong professional working relationships among nurses, general practitioners and those working in local authorities and the independent sector and must have the capacity to include unpaid as well as paid carers. Further work will be undertaken to develop guidance on nurses working together across employment boundaries.
… use information technology effectively
Delivering for Health states that a common information and communications technology ( ICT) system is essential if NHSScotland is to deliver the integrated care services the Scottish Executive is calling for. Nurses in the community will have a big part to play in ensuring such systems, including the electronic health record ( EHR) and electronic joint assessment processes, operate effectively to deliver maximum benefits for individuals, carers, families and communities.
A review of the current nursing position in relation to IT use in community settings is now necessary. This would increase understanding of nurses' IT access, skills and utilisation of technology to support developments not only in record keeping and sharing, but also in the delivery of care.