01.21.07
Providing what you are told to
In the good old days, when I was first a district nurse, I had colleagues who took their patient’s washing home, did bits of shopping for them and even walked their dogs (the last one might only have happened once). The traditional view of district nursing was of a homely middle-aged person who was like a friend to the families they visited and who could also dress a wound or give an injection. Now I have never taken any ones washing home, after all doing my own washing and ironing is enough of a chore for me but I did perform a type of nursing where I had free reign to decide what care I thought I should provide, when and where. Once a patient had been referred by the GP or hospital, I was responsible for assessing them, and planning their care. If I thought the patient needed a particular dressing to be applied daily, then it was applied daily. If I thought I should visit each time then I did. There was little opportunity to challenge practice, and I especially didn’t tell my colleagues who had been district nurses for years that they were visiting patients unnecessarily in my opinion.
Things have changed, though I have a hunch that some people are still practicing in a hybrid way - evidence based family friend perhaps - I am not sure how long they will be able to do that though. Referrals to the service increasingly need to be made in a professional way, using such technology as a proper form, fax machine and certainly with a clear plan in mind. The days of a few words scribbled in a message book - Mrs Smith, 88, off her legs - are thankfully over. There are not enough qualified district nurses around to perform every assessment and reassessment, and so there is skill mix and whats more the junior nurses and health care assistants need to be competent to perform the duties they are asked to do. Evidence tells us how long it should take to complete a particular episode of care and a district nurse needs to be able to justify why things are not going to plan. Patients are often sicker, they come out of hospital more quickly, they are prevented from going in at all (our district nurses all know how much their employer is charged for a patient going into hospital and staying there). They need to be skilled up at giving IVs, cannulating, inserting suprapubic catheters, managing complex wounds, and prescribing care and medication for patients with long term conditions.
The relationship with GPs has also needed to change. The doctors who I worked with as a district nurse were sometimes heard to describe me as ‘their nurse’, proposed changes to the district nursing team structures locally led to cries from GPs that they would lose their personal service. But we are not their nurses, we are competent, experienced, knowledgeable, skillful individuals who are able to provide a range of care to sick people in their own homes. What is more, GPs are about to take on a new role, they are to become the commissioners of the District Nursing Service and when you are buying something you begin to look at exactly what is being bought. You need to know you are getting value for money, you need to know it going to be effective and you need to know exactly what you are getting for your money - after all any service provided by real people is very expensive.
I personally think it is a very exciting time for district nursing, it gives the opportunity to move out of the shadows of characters like Gladys Emmanuel and the like, and it gives an opportunity for working relationships with GP colleagues to develop in a much more professional, team like way. Trouble is, this is being done at a time of extreme PCT chaos, financial problems mean that when a district nurse leaves he or she isn’t replaced and any good will that existed to maintain the smooth running of the service is quickly evaporating. I just wonder exactly what the future holds!
Neil Wilkinson said,
January 21, 2007 at 8:43 pm
Not sure I’d use the word ‘exciting’ to describe District nursing at present ( obviously I can only speak for my PCT)
Uncertain. Dispirited are two words that are valid at the moment, although we have to be thankful that as frontline staff, we are al lot less vulnerable than managerial or admin staff. If staff sickness and turnover are barometers of morale, then things are not good locally.
More staff at a senior level are getting involved with Practice Based Commissioning. I’m not sure how this will benefit patients in practice, as theory and practice often turn out to be two different things. I can see it as another change which will cost a good deal of time and money.
As a Band 6 D/N, I still retain a reasonable amount of patient contact. Ultimately, this is our raison d’etre, one which is being eroded by increasing bureaucracy. Why is it necessary to spend 5 mins in a patients house on a simple one off procedure followed by 15 mins writing about it?
Fear of litigation is one reason, not giving one’s manager reason to criticise is another.
The technology exists to link our record keeping in with GP electronic record systems, so why the hell don’t we use it instead of being stuck in the Dark Ages?
Because IT is primarily geared to management, admin and finance. Front line staff are also rans, yet as I said before, service delivery is what we are about.
Neil Wilkinson said,
January 21, 2007 at 8:43 pm
oh ps well done Arsenal, beating Man U
Julie said,
January 22, 2007 at 7:09 am
Great result for Arsenal, Thanks!
Julie said,
January 22, 2007 at 5:47 pm
We have developed something called the prospectus of care which tells those buying the service what they get, why and how. We have been encouraging the district nurses therefore to take control in defining what is unique about what they do.
Kieran said,
January 22, 2007 at 10:10 pm
Not surprised about the hugging at the Emirates it was almost that bad at Reggie today with my Gooner mate from the SHA who sits in the office behind the library! Big smiles at the irony of Mr. I Need More Time Adding On Ferguson being hoisted by his own petard….
Meanwhile another timely post, I was at a Senior Managers Meeting today (never quite certain how I became one of them!) and we had a presentation from our provider arm who are steaming ahead towards at a minimum an arms length function with a view to ultimate autonomy. I can see where the Trust’s are coming from on the contestability stakes with the providers but can’t help but think that cutting the Commissioners from the Providers will not remind them why the PCT exists, which is to care for the population of Liverpool. Having done the whole HA thing before where we were cut off from those providing a service I’m not certain we were any better for it. People need to remember the NHS only exists to care for the population it serves.
Have to agree with Neil’s comment about the technology. I’ve just been doing some viral marketing to our AHPs as a measurable channel of communication and I’m fascinated by the amount of opening of the messages sent. It isn’t big and I can’t help but think it’s because there isn’t enough kit for the practitioners out there. Meanwhile in the library I gear my service to people with technology but also emphasise that strange instrument the telephone and weird system called post.
Ooops, that was meant to be a quick comment too!
Julie said,
January 22, 2007 at 10:20 pm
Also have to agree about the technology. When I was DN 10 years ago they talked about us inputting data using a hand held gismo. Here we are in the world of the cheap laptop and still they share a pc between about 10!
Neil Wilkinson said,
January 22, 2007 at 10:56 pm
As far as I can tell, we don’t need state of the art kit, just solid and reliable.
We are doing or perhaps have done, a District Nursing specification (a core spec, that can be expanded if anyone wishes to purchase our services) Dangerous territory methinks.
Meanwhile the new PCT ( 3 merged into 1) is slowly organising itself. Mammoth task for the managers, trying to create something new with many senior posts not yet filled, whilst still providing existing services. Bit like waking up after a serious night out and trying to remember what you have to do in order to get your body into work!
By the by, Julie, pro rata, the remains of the combined training depts is now smaller.