I work as a Clinical Governance lead and interim Neighbourhood nursing manager in the Adult Community service which is part of the Acute and Emergency Division in Lewisham and Greenwich NHS Trust. The Adult Community service is made of District Nursing Service, Admission Avoidance, Respiratory Service and Diabetic Service.
I would like to focus on the District Nursing Service for this report, District nursing service is for housebound patient or temporary housebound patient from the age of 19yrs old, we provide nursing care for people in their own home 365 days a year from 9am to 22.30pm, there are 4 neighbourhoods, each neighbourhood has 2 teams. My role involve working with staffs across the 4 neighbourhood as a Governance lead, which involve dealing with complaint management, patient safety incidents, auditing etc.. and also managing neighbourhood 3. The three stakeholder I would be analysing are: 1, the patients 2. Employees who are the internal stakeholder and the General Practitioner (GP) are the external stakeholderThe patients are our main stakeholder, without them there would be no service, we have to build a good relationship with them for the treatment or to be successful, however for there to be a service you need to have staff to run the service and all of this depend the GP who are our commissioners.
Benefits and ChallengesPatients in the community are getting more complex, we are seeing them getting home within hours after surgery or other treatments, like having intravenous injections, disconnection of chemo pump, monitoring of plurex drains, which they use to stay in hospital until they complete the treatment, this is a great benefits for community nursing service as we can continue to be commissioned to carryout these treatment and gives us job security but it also has it challenges. Most nurses use to work in the Acute setting when they qualify to gain more experience and learn more skills before going to he community like I did, but now nurses are going straight to the community from university with very little experience , with the vast amount of older nurses we sometimes don’t have a staff within the team that can do some of these tasks. Another major challenges is education, there is limited funding which has an impact on the number of staff that can be trained. Having a good skilled mix of employees is a great benefits, as it enables the manager to plan easily and effectively, which reduces complaints from patients and GPs. We value the relationship with as they are the first to seek help from instead of sending the patient to hospital which is beneficial to the patients as allows them to stay in their own home and reduce financial burden on the Trust for keeping the patient in hospital.
Attending MDT meeting with the GP is a build a good relationship, the patients are discussed and any issues can be addressed at that meeting, it also reassure the them the patients are receiving good care which reduces the complaint and conflicts. Most of these conflicts arise from poor communications and not able to meet the demand of the GPs or patients, as their expectations can be higher than what the service can offer. As a service we are commission to visit housebound patients but the GPs will send us a referral for a patient that is not housebound because their practice nurse is on holiday, this can of referrer has be refuse which cause a lot of conflict with the GP and the patient, all the patient wants is for him or her to get their treatment, which is not as simple they think. Visiting non housebound patient can sometimes cause a lot of issues for the nurses, there have been incidents that a non-housebound patient was on the caseload because the practice nurse hasn’t got the skills or training to do the treatment, nurses will visit the patient and they not home, our policy is to make sure know where your patient is if they are home, otherwise you have to call the police to break the door down and most times these patients have gone out shopping etc but did not inform the nurses. It is a wait of time for the nurses, the police and financial implication to fix a broken door, a patient has been found dead in his flat because everyone knows he is not housebound and he goes to visit his brother in hospital, when the nurse visit and there is no answer they will drop a card after 3 visits with no call back from the patient which he always does they call the police and he was found dead.
Preparation for stakeholder engagement and managementThe contractual frameworks been examined is contract and service levelAs mention in the report above the service starts at 09.00 to 22.30hrs and the largest amounts of patient treated in our service are diabetic patients and we the ageing population this number is increasing rapidly. The working pattern of the service is 09.00-17.00 day shift and 17.00-22.
30 is twilight service or as we call it out of hours service. Majority of the patients rely on carers to make their meals for them, their working hours are different to the DNs which is not beneficial for the patients’ for a diabetic patient to have correct blood sugar reading it should be done before meal. Due to the difference in working pattern of the nurses and carers most of the patients would have had their meals before the nurses visits which results in patients having a high blood sugar reading, this is detrimental for the patients because it leads to more complication, like poor eyesight, renal failure and many more. This has resulted in the senior management reviewing the working hours, for this to happen a lot has to be done as all the nurses have a contract.The Head of Nursing/ General manager call a meeting with the senior management team(SMT) which I am part of to discuss and review the service hours.List of things to be done ? Find out about what hours /work pattern other Trust are doing-my task? Meet with employees to find out what they think our changing the work pattern ? Ask the finance team to work the cost implication, will it cost more or can we save money which in turn we can use to get more staff? If we decide to change how many nurses will be needed at the peak hours of the day? Who will be affected – band of nursesThe other Trust were contacted and the different work pattern