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Appendix 4
The new nursing team: potential links with existing community-based colleagues
Delivering for Health states:
'The emphasis on integrating care will require multi-disciplinary team working. It will require collaboration and co-ordination between professionals and across organisational boundaries.'
Delivering Care, Enabling Health reflects this idea when it says:
'Good team working is about harnessing what individual professionals do in common purpose. The contributions individual professionals make to the team are therefore central to teams' overall performance.'
All members of the new nursing teams will have a responsibility to work in multi-disciplinary, multi-agency teams. A number of questions and answers are set out below to illustrate how this principle will work in practice.
Working with general practitioners
'I am a general practitioner and it is important for me to have a close and trusting working relationship with the community nurse. Who will I be working with?'
The nursing colleagues you will be working with most commonly will be the Practice Nurse and Community Health Nurse. They will be jointly responsible for assessing nursing needs and planning nursing care for most of the people on your practice list. You will plan with them how you can best support people who are ill, those with long-term conditions and those who have terminal illness, and how public health activities such as immunisation programmes and anticipatory care activity can be taken forward. It will be possible, within local arrangements, for Community Health Nurses to make direct patient referrals to a specialist practitioner or other appropriate service. Further work will be undertaken on guidance for nurses working together across employment boundaries.
Working with community pharmacists
'I am a community pharmacist and am keen to develop my services by maximising the opportunities within the new Community Pharmacy Contract. Who should I contact in the nursing team to ensure our services are complementary?'
You will be in touch with all members of the nursing team, but the key link in relation to supporting patients in medicines management will be Community Health Nurses and Practice Nurses, and in relation to strategic development of services you will work with the Clinical Team Leader/Advanced Practitioner or Community Nurse Consultant. You will also be identified by members of the nursing team as a very helpful resource in augmenting and informing their prescribing practice, and are likely to be in contact with nurses across the team on this issue.
Working with allied health professionals
'I am an AHP in a supported discharge team. How can I ensure that the community nurse will reinforce rehabilitation programmes?'
The Community Health Nurse will be the main person with whom to discuss care planning and the maintenance of a treatment programme. He or she may delegate particular aspects of the care plan to other members of the nursing team.
Working with schools
'I am a head teacher. It is important for my staff and me to work closely with nurses to support children who are on medication and those who have physical and mental health needs, and to support health promotion activity and public health functions. Who will we be working with?'
Your main contact will be a Community Health Nurse from your local nursing team. The Community Health Nurse will work with you to identify how best to ensure that the health needs within your school community are met. You will be able to build an effective working relationship with the Community Health Nurse, who will be able to co-ordinate your access to a wide range of other resources in support of the community schools model.
Working with other nurses
'My daughter is 11 years old and is undergoing treatment for leukaemia. Some of her treatment can be provided at home, but I need the support of a nurse. Who will I getnursing support from?'
You will have contact with the Community Health Nurse who will support you and your daughter. The Community Health Nurse will ask her paediatric nursing colleague to join her when she visits and discuss with you how best to care for your daughter at home. Depending on what you feel is necessary, either the paediatric nurse or the Community Health Nurse will support you to provide her nursing care and co-ordinate any other care you and your family require.
Working with social workers
'I am a social worker. I have a number of older clients who have health needs. Who will I work with in identifying and meeting those needs, and what will he or she do?'
Your social work team will have close working relationships with the local nursing team. Community Health Nurses will be responsible for ensuring that single shared assessments are undertaken by nurses and that indications of social care needs are referred appropriately to you. In turn, single shared assessments carried out by you and your team which identify health needs will be referred to the Community Health Nurse. If the person has complex health needs, the Community Health Nurse will normally assume the care manager role, although some of the health interventions may be provided by other members of the nursing or health care team. If the Community Health Nurse finds the assessment identifies no indications for nursing interventions, she will organise any health care that is required and ask you to remain as the care manager for the person.
Working with community development workers
'I am a community development worker in a deprived community where there are many people with health problems. How can the nursing team help?'
The Clinical Team Leader/Advanced Practitioner and Community Nurse Consultant will work with you and health and social work colleagues to identify what health approaches the community would find most helpful. They will then work towards the development of accessible and appropriate local services. This may mean that nurses develop some open-access health care facilities to provide, for example, advice on how to improve health, parenting programmes, individual health checks, screening programmes and interventions such as wound care following surgery.
Working with child protection staff
'I am the Team Manager of the Children and Families Social Work Team for the local council. Who will my colleagues and I work with to ensure children at risk are identified and appropriate nursing services are provided?'
Protecting people is a responsibility for all health care workers. All those working in the nursing team will have an appropriate level of training to help identify people at risk and will have a particular responsibility to ensure that child protection plans are implemented. It is envisaged that specialist services will support all practitioners in areas such as child protection.
Working with care homes
'I am the manager of a care home. We employ registered nurses and care workers. What support can I expect from the local community nursing team?'
The local nursing team in the community will work closely with you to identify the type of support you require. It is envisaged that at least one of the registered nurses you employ will have the same level of knowledge and expertise as the Community Health Nurse and that your staff will be able to provide for your residents most of the nursing support that local nursing teams provide to the rest of the population, including screening and monitoring programmes. Your senior nurses will be able to access the expertise of Community Health Nurses and Community Nurse Consultants when necessary.
Working with nurses in the independent sector and occupational health nurses
'I am an occupational health nurse working within a large industry and the community I work with is also the community that nursing teams work with. Who will I be working with to ensure that the workforce benefits from the changes to community nursing teams?'
Nurses working within teams must integrate with other nurses providing important services within the community. The Scottish Executive will commission the development of a national framework to support the integration of nursing services across organisational boundaries within a public health context.
Working with specialist nurses
'I am a Macmillan nurse working with people who have cancer. Who will I contact to discuss the care needed for a particular individual?'
The Scottish Executive Health Department is developing a framework for specialist nurses in Scotland. The interface between new nursing teams and nurses working in specialist areas of practice will be informed by that work. The success of the new model is contingent upon nurses being able to access a network of specialists to support them when a presenting problem is outwith their knowledge and skills. Recognition of limitations and identifying when to refer individuals to a more appropriately qualified person is a key aspect of professional accountability.
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