Measuring and demonstrating district nursing's clinical effectiveness

Abstract

As district nurses, we are now experiencing extensive changes in the way community services are commissioned and run. Ideally, the result will be that patients living in the community will be better supported by having robust integrated services specifically designed to meet their needs. We are already seeing this with the emergence of ‘admission avoidance’ community teams specialising in supporting people through acute exacerbations of their health problems so that they do not have to go into hospital. Likewise, across the UK, specialist teams of community nurses are being commissioned locally to provide IV antibiotic therapy in people’s homes and community clinics. Supporting someone in achieving and maintaining their best health outcome involves having access to clinicians with the right skills, time and specialist clinical knowledge. What some groups of commissioners are finding is that their current district nursing services are not best able to address the needs of different patient groups. District nursing is constantly evolving to better meet patients’ health needs. The emergence of specialist community nursing teams supporting certain conditions should not be perceived as a threat to the role of the district nurse in enabling people to live independently at home. Community matrons and community chronic cardiac disease teams, for example, developed from district nursing to address previously unmet needs, and have made a demonstrable difference to vulnerable patients’ lives – often by working in partnership with GPs, district nursing teams and therapists. In these rapidly changing times, district nurses need to be mindful of what health care we are best placed to support at home. Sub-specialisations of community nursing have their place but, often, the vulnerable patients we support at home have multiple health and social problems, which affect their quality of life. People often want and need the generalist skills of district nurses who can identify their multifaceted problems, understand their whole situation, and coordinate services to meet their needs. This is an area in which district nurses excel. To ensure that district nursing services are commissioned to make the most of our strengths, we need to measure how we support outcomes for different types of patients, and advertise our value to commissioners. There may be some activities that we have historically undertaken, but for which district nurses are not best placed to deliver evidence-based care. Collating meaningful data helps inform practice and assists us in developing more effective ways of working. Wound management, diabetes care and supporting endof-life care commonly make up the bulk of district nursing workloads. Practitioners need to demonstrate their effectiveness and role within the multidisciplinary healthcare team in supporting health outcomes for these patients. As a first step, clinicians could record and demonstrate, for the patients under their care, the percentage of venous leg ulcer wounds that heal with 24 weeks of starting treatment, the percentage of people who die in their preferred place of care, and how many people have their haemoglobin A1c (HbA1c) controlled within agreed therapeutic ranges (Davies et al, 2011; Department of Health, 2011). This is the language of health outcome commissioning, and these are key measurements in ensuring we are providing high-quality care. These measurements do not quantify the complexity and diversity of the healthcare interventions, health advice and support that district nurses provide, but they are a starting point. Providing evidence is no easy task – particularly when some clinicians feel that they have done a good job up to now, without having to quantify their effectiveness. Information management skills, time and workload pressures can also inhibit data collection. However, information technology, such as mobile working, offers district nursing services an ideal tool for collecting quality data without making more work for practitioners (Queens Nursing Institute, 2012). Our challenge is to embrace and adapt these tools to ensure they measure and improve the quality of the care we provide, and not just quantify the visits we make. District nurses have an important role to play in supporting people’s health needs and independence at home. Our patients and colleagues often highly value our care and support. But equally, we need to ensure we are evidencing and advertising our role to the local healthcare commissioners. We also need to identify how our resources can best be used to support meaningful patient outcomes. On the ground, this means district nurses actively engaging with the commissioning process, presenting evidence, and influencing how we shape services to best meet patients’ needs. BJCN