Transforming nursing, midwifery and health professionals roles: district nursing roles

Annex 2: Fundamental features of the district nurse role

Assessment/review

• Provides a holistic health and social care assessment for all patients, regardless of where they live
• Provides all first assessments, assessments for new referrals, returning patients or deteriorating patients in the home, including assessment of the home environment, circumstances, support networks and impact on health and ability to meet outcomes
• Undertakes assessments with the patient and family that focus on outcomes important to the patient, including the need for specialist assessment and/or referral to additional specialist services where appropriate
• Reviews all assessments following any change to care needs and on a regular (six-monthly) basis
• Reviews patients with two or more inputs from social care and puts an anticipatory care plan in place that includes a self-management plan and guidance for care staff

Care delivery

• Provides relationship-based care
• Provides a single point of contact and co-ordination for patients, carers and families
• Delivers dynamic, flexible care centred on patient need and relationship-building, whether at home, in a clinic or the wider community environment
• Engages with patient safety and continuous quality-improvement initiatives aimed at improving care and reducing variation and harm
• Works with patients and their families to deliver interventions that prevent ill health and enable self-management
• Follows the patient in and out of hospital care to ensure continuity
• Uses early warning tools/indicators with deteriorating patients
• Is supported by full use of new technology, including electronic records, telemonitoring, telecare and telemedicine
• Discharges patients: where people are found to be frail, at risk or meet early warning criteria, they should remain part of the district nurse caseload and community profile
• Facilitates patients’ return home, enablement in the community, wrap-around care, teaching and supervision of care workers, anticipatory care planning, respite and carer support, and provides advice on housing/benefits

Leadership

• Acting as the lead nurse (and in partnership with others, such as community psychiatric nurses and general practice nurses where appropriate), should be responsible for commissioning additional interventions to be carried out by the wider community nursing team, social work, third or independent sector partners
• Oversees all community nursing needs, from enabling self-care and simple interventions (such as simple wound care and single immunisations) to management of patients with complex co-morbidity who are at high risk of hospital admission, mental health problems, addictions and frailty, and those at the end of life
• In partnership, acts to provide leadership, ensuring coordination of care for every adult, meeting predetermined criteria/level of need to lead on case and care management; this should be based on care needs and include any patient who requires clinical input or is at risk of deterioration, including young adults, those with complex care needs and frail older people
• Plays a key leadership role, acting as a conduit and ensuring continuity of care, care planning and appropriate communication within and across all partners and agencies
• Has a lead role with carers that includes setting standards, training, promoting understanding of anticipatory care planning, working together, and ensuring easy access to the district nurse service
• Receives report/feedback from any person involved in looking after a patient during a 24-hour period
• Maintains responsibility and considers care across the 24-hour period, involving all relevant partners

Referral and team-working

• All GP practices have an aligned district nurse or deputy
• Community profiling forms a recognised part of the district nurse role: definitions are redefined, based on GP practice populations; collective decisions by the district nurse, general practice nurse and social workers identify patients at risk or who would benefit from additional support
• Requests for one-off district nurse visits are via referrals that indicate key issues, risks and additional care needs; district nurses then undertake a holistic assessment as indicated and commission care
• The skills of the whole district nurse team, including healthcare support workers, are utilised to enhance service delivery and support the team’s capacity to provide a range of delegated interventions, such as ongoing/re-assessment for continence products
• Phlebotomy services are attached to clusters/localities, ensuring timely referral by GPs, district nurses and general practice nurses
• Long-term maintenance/administrations, such as eye drops, are administered by carers and/or healthcare support workers; district nurses undertake assessments over one week then refer/commission wider team members; healthcare support workers in locality teams require education, development and investment to undertake delegated activities as part of the plan of care, such as simple dressings, catheter and bowel care, eye drops and percutaneous endoscopic gastrostomy ( PEG) feeds