This case study provides an overview of the role of the district nurse (DN) in the care provision, care planning and coordination of care for individuals and carers with a range of needs. The role and responsibilities of the DN and accountability in nursing will be discussed using a case study from the community setting for illustrative purposes.
A DN is a registered nurse who has completed a specialist practice qualification in district nursing (Queen's Nursing Institute (QNI), 2014). This qualification provides DNs with higher technical skills, a wider knowledge base and broader experience, allowing them to have better decision-making ability (Barrett et al, 2007).
The role is unique in that it is considered a generalist role (Randall and Ford, 2011) which is multifaceted in nature. The uniqueness and indispensability of the district nursing role is highlighted by Bain (2015), who suggests that DNs have ‘unique knowing’ in practice and ‘tacit knowledge’, which are key elements in their role. Unique knowing and tacit knowledge are knowledge types that allow nurses to act on a hunch or intuition (Royal College of Nursing (RCN), 2004) and are gained through previous knowledge, experience and professional expertise (Kothari et al, 2012).
Accountability involves nurses being answerable for their own actions and omissions (Nursing and Midwifery Council, 2015), and it is fundamental to the protection of patients who are under their care (Griffith, 2015). DNs are also accountable for the quality of nursing care delivered in the community by the team they lead (Bain, 2015). This includes caseload admissions, discharges, care planning and delegation of tasks to capable staff members (Kane, 2015), as well as providing care.
The responsibilities of the district nursing team are expanding to include caring for acutely ill patients, those with long-term conditions and patients who require end-of-life care (Bliss and Dickson, 2016; Maybin et al, 2016), in addition to health promotion and patient education (Barrett et al, 2007). DNs also play a key role in risk assessment and clinical governance and, in some cases, are responsible for the leadership and management of a community care team (RCN, 2013). They must be able to collaborate with other members of multidisciplinary teams (MDTs) (QNI, 2014), who may be employed in the voluntary, statutory and private sectors.
DNs provide person-centred, preventive and coordinated care, which reduces unnecessary hospital admissions and enables patients who have a range of complex needs to remain at or return home (Barrett et al, 2007; QNI, 2014; Maybin et al, 2016). To achieve such outcomes, the DN must engage in a higher level of thinking and undertake complex, multidimensional health and social assessments, while developing therapeutic relationships with patients and their carers (Burke, 2014). They should possess a variety of skills including those in assessment, referral, coordination and crisis management (QNI, 2014). They should also be skilled in workload management, leadership and teaching/education, with advanced levels of knowledge, training and interpersonal skills (Barrett et al, 2007).
Case study
The case of Amanda Clarke (pseudonym) is used as a source of reference to further illustrate the role of the DN.
Ms Clark was 42 years old and a single mother of two children. She was involved in a road traffic accident in which she sustained a traumatic cervical spinal injury (TSCI). Following emergency care, Ms Clark was transferred for specialised rehabilitation, where she received intense physiotherapy and, after approximately 18 months of rehabilitation, was discharged home.
As a result of her TSCI, Ms Clark is quadriplegic and relies on individualised moving and handling techniques alongside a wheelchair for transferring and mobilising. She recently had a suprapubic catheter inserted for urinary elimination and relies on community nurses to assist with faecal elimination through digital rectal evacuation. Ms Clark receives a package of care twice daily to assist with personal hygiene needs and informal care from a family member, who assists with meals and helps care for her children. Because of the dynamic and varied nature of Ms Clark's condition, the DN plays a key role in many areas of her care.
Three key areas have been chosen to be focussed upon, with other topics being discussed throughout. These are:
Long-term condition management
A long-term condition is one that cannot be cured but which can be managed through medication and other therapies (Department of Health (DH), 2010; 2012), and it usually requires ongoing management and treatment over an extended period of time (Department of Health, Social Services and Public Safety (DHSSPS), 2012). Mendes (2014) estimated that more than 15 million people in the UK are living with a long-term condition, with spinal cord injury affecting more than 40 000 people (Royal College of Physicians, 2008).
TSCI can cause a variety of difficulties, including physical or motor problems, paralysis, fatigue, lethargy, incontinence and sexual difficulties (DH, 2005). Other long-term conditions associated with TSCI include depression and other psychological consequences, including effects on wellbeing, socialisation and family relationships (DHSSPS, 2012; Carrier, 2015).
The DN plays a pivotal role in caring for patients with long-term conditions (Carrier and Newbury, 2016), alongside care management and coordination (Randall and Ford, 2011). With primary care now focussed on the management of long-term conditions (DHSSPS, 2011a; 2012; 2017; DH, 2013), the DN is in a key position to contribute to health promotion and preventive and anticipatory care, encouraging patients to self-care and self-manage their long-term condition (DH, 2013; Carrier, 2015). The DHSSPS (2016) has outlined the importance of promoting self-care and self-management for individuals with long-term conditions.
The role of the DN is essential within the MDT as a lead for the delivery of care and an advocate for patients (Carrier, 2015) and to coordinate care and ensure its continuity (Randall and Ford, 2011).
The DN played a dual role as Ms Clark's case manager and key worker to lead and coordinate her care (DHSSPS, 2012). She had an in-depth knowledge and understanding of Ms Clark's condition, its effects on her everyday life, potential risks and her family dynamics. Ms Clark received care from the district nursing team on alternate days for bowel management, pressure area care, care of her suprapubic catheter site and other episodes of care for which the general practitioner had made a referral. Although care was delegated to staff nurses within the district nursing team, the DN visited Ms Clark at least once a week. This ensured the therapeutic relationship was maintained, allowed Ms Clark's needs to be assessed on an ongoing basis and supported the continuity of patient-centred care.
While the DN's role includes providing the care described above, she also assesses Ms Clark's situation on an ongoing basis, provides psychological support and promotes self-management strategies as identified by DHSSPS (2012; 2016). Ms Clark was regarded as an active partner in her care, with the DN keeping her up to date on all developments and involving her in all decisions made regarding her care (DHSSPS, 2012). Liaising with the MDT, including private care providers, ensured that all areas of Ms Clark's care were well coordinated and person centred and met her needs, that risk assessments were carried out and frameworks implemented. These skills and competencies are key to ensuring effective ongoing assessment and management of long-term conditions (Snoddon, 2010; DHSSPS, 2012). Supporting patients in this manner is fundamental to their independence, minimises risk, ensures safety and aids in the identification and management of potential risks (Snoddon, 2010).
Although the DN role is beneficial to the management of patients with long-term conditions, it is not without its difficulties (Cubby and Bowler, 2010). DNs can experience misunderstanding regarding their roles and a lack of support from GPs and secondary care services (Cubby and Bowler, 2010).
It is suggested that an overlapping in posts can sometimes lead to conflicts of roles and responsibilities (Cubby and Bowler, 2010; Randall and Ford, 2011). It is imperative that MDT members work together to ensure that people with long-term conditions are able to live independently at home and to achieve the best quality of life possible (DH, 2005; DHSSPS, 2012).
Holistic assessment
Assessment is a vital component of the DN role (QNI, 2014). Holistic assessment allows patients' past experiences, present situation and preferences, values and future wishes to be taken into account (DHSSPS, 2011b), while also setting the foundations upon which all other care is built (Barrett et al, 2007). Within the community care setting in Northern Ireland, the Northern Ireland Single Assessment Tool (NISAT) is used to guide the holistic assessment of patient needs (DHSSPS, 2011b; Doherty and Thompson, 2014).
A comprehensive, holistic assessment of Ms Clark's needs was carried out and documented using the NISAT. Assessment is a process, not a one-off event; patients' needs, views and circumstances can change at any time (DHSSPS, 2011b). By using the NISAT tool, the DN ensures Ms Clark's needs are assessed using a person-centred approach, which enables her voice and preferences to be heard (DHSSPS, 2011b).
The responsibility of the DN in carrying out the initial assessment of patients' needs was highlighted by Doherty and Thompson (2014), who suggested that it was the responsibility of the key person involved in the patient's care to carry out the initial assessment. In Ms Clark's case, this was the DN, but other members of the MDT also contributed as appropriate.
Although the NISAT is said to apply to all patients, DHSSPS (2011b) documentation refers continuously to the ‘older person’ as the patient for the NISAT. Despite this contradiction, the NISAT continues to be used for patients of all ages in the district nursing caseload.
The importance of person-centred care is demonstrated by its inclusion in Health and wellbeing 2026: delivering together (DHSSPS, 2017), a document that focusses on improving the health and wellbeing of Northern Ireland's population through a holistic approach. Person-centred care takes into account the views of service users, their families and the communities in which they live (World Health Organization, 2017), to enable an individualised approach to the delivery of care (Fredericks et al, 2015).
McCormack and McCance (2017) highlight that person-centred care is supported by respect for service users, which aims to empower them as individuals. They developed a framework to depict the essence of person-centred care, which places the person in the centre of care outcomes, highlighting that the aim is to ensure patients receive good care outcomes and are involved in their care and to encourage feelings of wellbeing. The framework states that working with service users and their beliefs, involving them in shared decision making and the provision of holistic care are central to achieving these outcomes (McCor mack and McCance, 2017).
Maintenance of the therapeutic relationship and effective communication skills are key components of the role of the DN. Having the ability to communicate effectively in appropriate ways with patients and carers allows the DN to gain a full understanding of their needs (Snoddon, 2010), develop the therapeutic relationship, deliver holistic care (Doherty and Thomson, 2014) and coordinate the care that the patient requires (Randall and Ford, 2011). Effective communication is described as an essential component of collaboration (Sprung and Harness, 2017; Francis, 2013) with timely, relevant, high-quality information being of utmost importance (Randall and Ford, 2011).
When completing Ms Clark's initial assessment, the DN ensured that she answered the questions she could to the best of her ability by ensuring effective communication was maintained throughout. If the DN felt she did not understand Ms Clark's response or opinions, she confirmed her understanding with her, which not only provided the patient with the opportunity to ensure her views and beliefs were understood but also gave her an opportunity to elaborate further. The assessment was carried out in Ms Clark's home when her children were at school. This ensured privacy and allowed Ms Clark to focus on the assessment.
Carrying out an assessment of patient needs in the home allows nurses to get to know their patient in their own environment, providing them with a better picture of how patients are responding or coping with their present situation (Burke, 2014). Putting Ms Clark at the centre of her assessment and enabling her to take the lead ensured that any subsequent care planning was person centred and focussed around her needs as she perceived them.
It is imperative that the needs and views of patients' families are considered, as this interplays with person-centred care (DHSSPS, 2012; Walton, 2014). Considering this, Ms Clark's care was organised around her family and their daily routine. Ms Clark's DN visits and bowel management were carried out in the morning once her children had gone to school. The days her children were not at school, the visit was carried out early in the morning, so it did not disturb the family's daily routines. As a young mother, Ms Clark was aware of the impact her TSCI and care needs had on her family and, as a result, she and the DN worked together to help reduce their impact. It is believed that therapeutic relationships and person- or family-centred care go hand in hand, with Corbett et al (2017) suggesting that the therapeutic relationship between the DN, patients and their families is essential to the delivery of effective nursing care.
Although Walton (2014) advocates the use of person- and family-centred care, they stress that it is not without its difficulties. Abusive patients and families as well as limited resources can affect person-centred care (Walton, 2014). McCance et al (2013) highlight many challenges to improving person-centred care, including staffing levels, confidence and competencies, communication and building therapeutic relationships.
Collaborative working and continuous care
To ensure that the findings from a holistic, person-centred assessment are reflected in the delivery of person-centred care, a multidisciplinary approach is required. Working in an MDT is a collaborative process among groups of individuals with different backgrounds who share common objectives (Hogston and Marjoram, 2007). It is suggested that this pooling of knowledge assists in the provision of high-quality care (Ndoro, 2014).
The importance of collaborative working in maintaining an individual's health and wellbeing, while supporting them in their own home, is highlighted by DHSSPS (2012) and Coulter et al (2013). These studies surmise that collaborative working should enable the delivery of coordinated and personalised treatment, care and services as required. It is suggested that the DN has six key roles in the MDT: advocate, supporter, coordinator, educator, team member and assessor (Carrier and Newbury, 2016). MDT working can also be referred to as ‘co-production’ (DHSSPS, 2016), and it has been stated that working in co-production involves a relationship where both professionals and patients work together to plan and support care that improves quality of life for service users.
Ms Clark's moving and handling care plan demonstrated person centredness and collaborative working. During her assessment, Ms Clark disclosed that she ‘hated’ using the hoist and full-body sling for transfers, and this was another visual reminder of her disability, for both for herself and her children, and she felt embarrassed when it was being used. Taking into account Ms Clark's wishes, the DN consulted with various members of the MDT and was initially met with resistance.
Because Ms Clark could not bear weight, it was assumed there would not be a safe alternative to assisting her with her transfers. The DN continued to support Ms Clark's choice by advocating on her behalf and contacting the BackCare coordinator to ask for advice. The coordinator suggested that if all disciplines and Ms Clark came together in a controlled environment, alternative moving and handling techniques could be trialled and an individualised moving and handling care plan agreed on. The DN discussed this with Ms Clark, who remained keen for an alternative transfer method to be trialled. The occupational therapist, BackCare coordinator, DN and care provider, along with Ms Clark, attended the BackCare facility and trialled various moving and handling techniques until a suitable, safe method of transfer without hoisting equipment was agreed upon. It was then arranged for all carers involved in Ms Clark's transfers to attend training to minimise all risk as far as possible and to ensure transfers could be completed safely.
This demonstrates how the district nursing role is imperative to supporting and advocating on patients' behalf and emphasises their role of coordinator and team member.
Following the completion of a collaborative risk assessment and individualised care plan, the DN continued to assist in the education of new staff members in the transfer techniques used by continuously assessing Ms Clark's circumstances and risk and ensured that the care plan remained relevant and safe. Taking Ms Clark's views on board and respecting her choice, while also enabling her to be involved in the care planning process, reflects the concepts laid out in the Bengoa report (DHSSPS, 2016).
The importance of DNs being able to work collaboratively is described as the foundation of case management (Snoddon, 2010), without which poorly coordinated and fragmented service delivery would result. This is further supported by Hartgerink et al (2014), who say that an MDT is a core component of effective care delivery. Although MDT working has many benefits, for both the professionals involved and service users, true collaborative working is difficult to achieve. Professional identity and poor role clarity have been identified as barriers to collaborative working (Cubby and Bowler, 2010; Randall and Ford, 2011). Dawson (2007) suggests that increased workload and time constraints can hinder collaborative working, in addition to issues surrounding goals and conflict among professions, including staff attitudes (Xyrichis and Lowton, 2008; Sprung and Harness, 2017). It is imperative that each profession recognises that the other has a valuable contribution to make (QNI, 2014). The philosophy of collaboration should be to ensure that the patient is at the centre of all discussions and their needs should far outweigh those of the MDT (QNI, 2014).
Parker and Glasby (2008) highlight that collaborative care continues to be inconsistent, duplicated and of poor quality. Nevertheless, as their study was published in 2008 and recent documents (DHSSPS, 2012; 2016) stress the importance of MDT approaches to care, it could be assumed that collaborative working is improving.
Conclusion
Throughout this case study, the multidimensional role of the DN has been explored and discussed. The DN plays a vital part in the care of patients in the community nursing team's caseload. Having a higher level of thinking, advanced communication skills and collaborative working skills, knowing how to apply knowledge and understanding of complex conditions, and advocating on behalf of the patient, the DN has an indispensable skill set in relation to the provision of safe, effective, patient-centred care, particularly for those with complex needs.
Through their care manager role, the DN is accountable for the overall coordination of care that patients receive, achieving this through MDT working, holistic assessment, person- and family-centred care planning, effective communication and the maintenance of therapeutic relationships. With the emphasis of care delivery now on the community setting (DHSSPS, 2011b; 2012; 2016; 2017; DH, 2013), the role of the DN is of utmost importance.
District nurses value the uniqueness of individual patients and understand the complexity of the care they require (DH, 2013), while patients value the single point of contact the DN gives them in accessing appropriate information and providing advice regarding their conditions and services they can access (DH, 2005).
Although this paper demonstrates the invaluable role of the DN while recognising that the role is not without its challenges, it remains that the true value of nursing is difficult to quantify (Barrett et al 2007).