Despite evidence that district nursing is valued by the population it services and that the policy agenda supports healthcare at home (Scottish Government, 2017), it is well recognised that the district nursing service in some areas is in crisis (Maybin et al, 2016). It is also acknowledged that the practices of the district nurse vary considerably across the UK. The northeast of Scotland led the way in district nursing in 2013, by moving education and service delivery beyond the traditional district nurse model to supporting education at Master's level and integrating advanced clinical skills in learning. However, this move was not without its challenges for some. With district nurses being lone workers and existing district nurses not practising advanced skills, student district nurses faced considerable challenges in consolidating their skills. At this point, the education was more advanced than the practice experience available.
Concurrently with this being recognised, NHS Grampian employed two advanced practice nurse consultants, one for primary care and the other for acute care. These appointments resulted in a practice development project, in which the transforming nursing roles were incorporated in the development of an advanced care academy concept to support robust initial preparation of advanced skills for all health professionals under the supervision of skilled and experienced mentors. In this collaboration between Robert Gordon University and NHS Grampian, medical colleagues supported key components of competency development in advanced practice.
As part of this workstream, the district nurses in the region of Grampian were targeted to support the consolidation of their advanced skills, including high-level decision making, clinical examination and history taking, interpreting the significance of findings, developing a differential diagnosis and treatment plan and building prescribing competence. Fortnightly, these district nurses participated in a clinic, initially supported by a nurse consultant and district nurse practice teacher with advanced practice skills, including prescribing. Over time, they have developed their competence and confidence.
This model has now been replicated throughout NHS Grampian. In addition to the two nurse consultants, experienced advanced nurse practitioners are employed as fellows within the academy to support the agenda. They work closely with district nurses who do not yet have consolidated advanced skills and student district nurses, to support clinical competence and enhance care in the community setting. This approach has not been without its challenges, especially around gaining access to protected learning time for the district nurses, mainly due to workload/workforce planning, despite recognition that it is essential to maintain this high level of supervision and development in practice. However, it is recognised that once advanced clinical skills are embedded within the community nursing practice, the approach will become routine.
This type of a blended learning approach, along with the consolidation in practice, has produced significant outcomes for patients and access to services. The partnership has received positive feed-back from both service users and medical colleagues. Traditional boundaries have been crossed, and person-centred care by the right person in the right place at the right time has been embraced. Interestingly, a paper published by the Chief Nursing Officer of Scotland (Scottish Government, 2017) confirms the requirement for district nurses in Scotland to embrace and develop in this way to meet the needs of the population. This advanced care academy model is one way to support learning in practice as district nurse roles advance with developments in service needs.