District nursing services have grown significantly and have adapted to the communities they serve, especially since the start of the COVID-19 pandemic in 2019. The service provides a lifeline for people who want to maintain and manage their independence and health conditions whether it be long-term, life-long or even acute. Additionally, the district nursing service aims to prevent or reduce hospital admissions by providing a person-centred approach to care (Maybin et al, 2018). Person-centred care is committed to empowering service users and ensuring their preferences, needs and values are included to enable collaborative support and treatment (Price, 2019). In 2018, in England there were approximately 4000 district nurses (DNs) (who hold the specialist qualification as opposed to community nurses) who were available to provide such care to approximately 55.8 million people (Queen's Nursing Institute (QNI), 2019a), a ratio of one DN for every 14 000 people, illustrating the demand in care. Concerningly, the QNI (2019a) also reported that the number of qualified DNs had reduced by 46% over the past decade, capturing the risk of a depleting service and task-focused care (Maybin et al, 2018).
The above mentioned figures from the QNI (2019a) provide evidence that due to advances in medicine and technology, people are living longer (NHS, 2019) despite an increase in the complexity of care of those living within their own home environments (QNI, 2019a).
The need for a DN to provide person-centred care can sometimes be in competition with the requirements of the service, such as the current demand in technology and digital devices. Price (2019) highlights that the service user's perceptions of care need, priority and service can cause conflict, therefore risking patient-centred care.
A renewed focus on supporting people in the community as highlighted in The Long-Term Plan (NHS England, 2019) has led to a great deal of change in how care and service provisions are provided.
The use of technology is now predominately used within healthcare as the NHS continues to transform its services. We already live in a world full of technology, particularly in light of the COVID-19 pandemic, and rely on its effectiveness to communicate daily. The use of mobile phones and computers for communication is an integral part of our daily routine and essential within our lives (QNI, 2018). The use of technology within healthcare can range from the storage of service user records, to communicating with the wider multi-disciplinary teams such as GPs and other specialties, making it easier to accurately monitor and refer when needed (Uprichard, 2019). It should be acknowledged that technical advances in healthcare is not a new concept; it has previously been highlighted within the Smart New World report by the QNI (2012). However, evidence has shown the demand for this has increased since the report. Other countries such as Denmark and Sweden have already yielded the benefits and have been pioneers in health technology such as accessing service user health records electronically (Danish Ministry of Health, 2018), but the healthcare systems in the UK continue to catch up. GPs have been using paperless systems for many years and more recently, hospitals have adopted similar practice with the use of handheld devices to record patient information such as observations (Uprichard, 2019). Community services, however, have been slow in adopting these new ways of working as shown in the ‘Nursing in the digital age’ report written by the QNI (2018). It states that community nurses are in agreement for a new digital era rather than paper use alone, but some nurses (29%) are still working with paper-based systems (QNI, 2018). However, with time, as the fast-paced digital era evolves we could see an increase in these figures.
DNs have predominantly used a paper format to undertake assessments, monitor and implement care plans. Any relevant information would be kept within the service user's homes, with a carbon copy being returned and kept securely at the DN's base. Paper documents such as the visiting diary, referrals, medicine authorisations and continuation sheets were also kept within the service users' homes and filled in on each visit. On returning to base, the DN would then input the data retrospectively using electronic systems such as Egton medical information systems (EMIS), but this would be limited information as comprehensive home notes would already have been made. Unfortunately, this did not provide accurate real-time information to other multi-disciplinary services such as tissue viability services, physiotherapy, and podiatry, as they could not gain access to the full information unless they were in the service user's home. Subsequently, a paper-lite system was introduced. Although this comes with many benefits, it also comes with challenges. Nurses have since tried to balance the new way of working and the fundamental practice of person-centred care, thus risking the therapeutic relationship needed for care (QNI, 2012).
The role of the district nurse in providing a person-centred care assessment
The role of a DN is described as highly complex and needing expert knowledge and skills that have been acquired from the completion of the specialist practitioner DN programme (QNI, 2015). Specialising in the assessment, management, and coordination of care, while working collaboratively with other multi-disciplinary teams enables DNs to have a more holistic point of view and provide care accordingly.
However, despite the voluntary standards (QNI, 2015) enhancing the existing Nursing and Midwifery Council (NMC) standards (NMC, 2018), there has been a drop in nurses holding the qualification (QNI, 2013). This could explain why community nurses have been seen taking on roles normally performed by DNs, such as completing initial assessments for service users with complex issues. However, this poses the risk of inexperienced nurses being task-focused and not addressing the holistic needs of the service user. Kennedy (2002) has previously suggested that an essential element of the district nursing role is the first assessment, and a thorough understanding of this is linked to making the best judgement and decisions at the time of the visit. However, there is still little evidence suggesting an increased service provision in the care and management of service users with a long-term condition (McHugh et al, 2009). This could be due to barriers in district nursing such as time, staffing and experience as the service demand rises, or because of a lack of awareness of the district nursing role. This is particularly true when it comes to understanding how pivotal the role can be, as described by the QNI (2009) in their 2020 Vision report. In light of this, the most recent statistics do indicate a small increase in the number of district nursing students starting the specialist course in recent years (QNI, 2020), which potentially indicates better role awareness. The NMC (2021) have recently outlined a proposal to modernise the public health nursing standards. These standards will reflect the reality of contemporary nursing, equipping the next generation of nurses to grow within a rapidly changing environment.
The district nurse and mobile working
DNs are used to working in a demanding, autonomous and fast paced role, so when mobile working with a paper-lite system came into place, it could be seen as the greatest opportunity of the 21st century (QNI, 2019a).
Now, at each visit, a digital device such as a laptop or tablet, are taken into the service user's home for documentation.
All the information needed for the visit such as care plans and any other consultations are visible on the computer. The DN then completes the full assessment in the service user's home environment by following the prompts and sections indicated within the EMIS mobile. This assessment is then saved and on returning to the DN base location it is synced and the information that was inputted during the visit is stored and saved onto the full EMIS system.
Technology is now an integral part of the delivery of care within the community setting, saving vital time for DNs. It is essential to allow DNs to remain in control of the complex care of a service user (QNI, 2019b). Davies (2019) suggests that digital health is here to stay; but despite providing the opportunity for enhanced person-centred care and the reduction of errors, there are some barriers.
Barriers faced with adapting to technology and person-centred care
Person-centred care
Despite the rapidly growing dynamic use of digital devices, person-centred care should be upheld throughout. DNs are bound by the NMC standards (2018), which state that each person should be treated with kindness and respect, while also considering the diversity and individual choice of that person. Maybin et al (2016) agree, recognising that good care is based on three characteristics—caring for the whole person, continuity, and the personal mannerisms of staff, all of which contribute to person-centred care. The benefits may not outweigh the risks of digital devices within service users' homes when nurses are unable to maintain eye contact and read body language. It risks person-centred care not being upheld at the most crucial times. Shipley (2010) corroborate in their report that if a nurse misses any verbal and/or non-verbal cues, especially with sensitive information such as end-of-life care, the likelihood of a meaningful, initial visit or assessment risks being lost. It can be very difficult to assess and remain person-centred, as previous research suggests. Kennedy (2002) reported that it can feel somewhat like an interrogation on the first initial assessment where nurses are expected to gain sensitive information and appear to delve deeper into a service user's personal life, but this is an essential attribute of the DN, taking great skill in building a rapport. Although barriers are still visible, the NHSx (2021) suggest prioritising people to feel empowered to actively participate in their care as part of the digital transformation. The NHS Constitution for England (2021) emphasised the importance of nursing principles and values, aspiring to the highest of standards, including respect, dignity and compassion with care being at the core. Similar to Maybin et al (2016), the NHS Constitution report (2021) advise that the fundamentals of person-centred care are all improved when staff feel empowered, supported and valued. Again, this also recognises that changes such as digital devices being used for assessments requires DNs to have the time to adjust, access to education and good leadership.
Communication
Communication is an integral part of nursing care (NMC, 2018). It is therefore paramount that DNs have the awareness of both verbal and non-verbal cues of communication: eye contact, body language, touch, and facial expressions are important for building a therapeutic and trusting relationship quickly, as indicated by the Kings Fund (2016). Furthermore, the use of emotional intelligence in nurses have better communication outcomes and caring behaviours (Kong et al, 2016). All the above play a pivotal role in the assessment process, but it could also question how non-verbal signs are not recognised when using digital devices to input data that is collected in real time. Therefore, the person-centred approach within the relationship becomes flawed.
There are strong concerns within the Digital Age Report (2018) which suggest that care has become too task focused and depersonalised instead of person-centred, leaving nurses disappointed in the care they provide. Additionally, staring at a screen to input data can be distracting for service users and nurses, thus taking away the fundamental aspects of nursing. Contrary to this, the Department of Health (2013a) concluded in their mobile health worker project report that confidence and service user engagement had risen since using mobile devices. This all questions if the disparity in communication is a confidence issue, as suggested by the QNI (2018), which might be due to the new concept in digital working, lack of training or resources to support knowledge and skills in completing assessments in general. This further questions if there was always a communication issue in providing person-centred care when assessing the service user and/or when entering a service user's home environment prior to the use of digital devices.
Connection issues
One of the most common problems regarding mobile working and the use of digital devices was the issue of connectivity when in a service user's home environment (Department of Health, 2013). This is a reoccurring issue as highlighted by Turner (2015) who advise that connective issues can be problematic as health professionals are not able to access the information needed. This has been seen in practice where the EMIS mobile app freezes, which not only creates problems in documentation where information is lost and then written in retrospect (which is time consuming), but also spending time in the service users' home in addressing it, again affecting communication and person-centred care in assessments. Turner (2015) acknowledges this, reporting that less contact due to having to complete work in awkward places such as the car can cause apprehension, but this is also seen in practice often quoted as the car being your office.
Reluctance to change
The QNI (2018) report that health professionals including DNs have struggled to embrace digital devices and technology—some of those who lack confidence in using the devices are more susceptible to resistance to change, compared with those who are more confident. Ambitions for digital nursing have been reported to be prioritised over nursing expertise (Par, 2014). Booth et al (2020) highlights that traditional ideals such as compassionate care and the risk of distraction with digital technologies such as laptops or tablets could explain nurses' reluctance to adapt to change and instead revert to paper form. They also reported that nurses need to be surrounded by good leaders who encourage and support a digital work culture, thus improving acceptance, rather than disruption. Consideration into the service users' opinion and experience should also be considered (Department of Health and Social Care, 2018). The NHS Long Term plan (NHS England, 2019) emphasises the importance of personalised care, recognising that everyone will have differing values and preferences, but feeling empowered and educated on the benefits of change can improve care outcomes. This relies on the relationship built through the district nursing service and usually based upon the first initial visit. Service users must also be accepting of change and understand that their care would not be any less person-centred.
Establishing therapeutic relationships
The Five Year Forward View report (NHS, 2014) had been instrumental in integrated transformations within community nursing which has continued and is now embedded within the NHS Long Term plan (NHS England, 2019). The ambitious commitments have started to become a reality, helping empower service users and in return, having better service user outcomes. Working in the community can be an isolating environment with pressures to make decisions promptly and frequently(QNI, 2019b). Digital technology is said to offer a lifeline in collaborative working with other health professionals, considering the accuracy and accessibility of service user records (NHS, 2019), but it could be argued that the support remains sparse, as it would without the devices. It questions the effectiveness of therapeutic relationships within district nursing. The philosophy of team working remains, and the multi-disciplinary services have always been contactable via telephone, email, and sometimes joint visits, which is the normal support system within the community. The use of digital devices does not yield benefits in this aspect, but has potential benefits for documentation, as other professionals can have access to patient records; however, this does restrict the service user. Paper copies of assessments, visits, and care plans are now not in their homes, and instead are saved within the electronic record (EMIS) for professional use only. This contradicts the NHS Long Term Plan (NHS England, 2019), even though this is an integral part of the assessment, collaboration, and the person-centred care of the service user (Doherty and Thompson, 2014). This could possibly create conflict and resistance from the service users if their care is not inclusive or person-centred. Therapeutic relationships are not just the integration of the wider multi-disciplinary teams, but include the service user and their relatives (Doherty and Thompson, 2014). Although restrictive at present, the NHS England (2019) highlight that it has not yet enabled the full transformation. Hence, therapeutic relationships and digital technology might be sustainable in the future.
Recommendations
The digital era and its innovations are now unavoidable and integrated into the community setting, meaning that engaging with them is paramount and part of the nurse's role (Brown and Hartley, 2021). Community nurses and DNs have a vital role to always practice in line with the best evidence-based care available, within their scope of practice (NMC, 2018). Therefore, the focus needs to be on strengthening the district nursing service through good leadership, clear direction, and perspective to enhance the nursing assessment, in line with policy and governance. Dedicated time, equipment, and resources to support the digital culture is needed, considering the usability when implementing the use of digital devices, rather than risking disruption, resistance, and person-centred care. In time, this should be evaluated accordingly through audits, but with support, increased knowledge, skill, and confidence, this should be echoed within the service user's assessment, outcomes, and feedback.
Conclusion
The transition into the digital era with the use of digital devices may seem challenging but this is because it is still relatively new. As we progress into a digital era, assessments—whether completed using the old paper format or the use of a digital device, should be completed meeting the highest standards, ensuring that service user safety and person-centred care is embedded throughout. This article affirms the challenges to nursing assessment with the use of digital devices; although accepting that this new concept is still relatively new, and nurses are still anxious about embracing the change. While challenging, DNs must advocate and empower service users and their colleagues to see the overall benefits of digital services that are greatly spoken about nationally.
It would be beneficial to see further research in this area as we accelerate into the future of digital nursing.
Key points
- A paper-lite culture in community nursing is the reduced dependence on paper for documentation, including assessment, planning and implementation
- Barriers in undertaking nursing assessments are apparent
- Collaboration between services, including digital services is key to ensuring person-centred care and therapeutic relationships between nurses, colleagues, service users and their relatives/carers
- Challenges between digital devices and community transformation is apparent–nurses therefore are key to the success of new or existing digital initiatives
- Investment into the community setting and future nurses specific to the paper–lite and digital culture is required
- Nurses and other professionals within the community setting need time to adapt
CPD reflective questions
- What digital tools and initiatives have you seen in your area?
- How do you feel about the use of digital devices such as laptops within your work area?
- Which one aspect of your day could be improved with the use of paper-lite and mobile working?