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Section 3
The new service model and core elements of practice
The new service model for nursing in the community
The Review recommends that the disciplines of District Nursing, Public Health Nursing (Health Visiting and School Nursing) and Family Health Nursing be absorbed into a new, single Community Health Nursing discipline. The elements common to each of these disciplines will be assumed by the Community Health Nursing discipline.
The new Community Health Nursing discipline will build on the strengths of nursing in the community to:
- adopt a strong partnership approach with individuals, carers, families and communities
- work as part of nursing and multi-disciplinary, multi-agency teams
- practise according to the seven elements of nursing in the community (see below)
- focus on providing services that meet local needs and complement and reflect national priorities as set out in Delivering for Health ( see Section 4).
It is envisaged that the new nursing team central to the service model will sit within a wider multi-disciplinary, multi-agency context. It will incorporate strong professional leadership provided through the introduction of Community Nurse Consultant posts and through enhanced co-ordination of care (particularly for people with complex care needs) by Clinical Team Leaders/Advanced Practitioners. The Community Health Nurse will be the visible access point for people to the nursing service, providing care through a team of appropriately trained nurses backed by Health Care Support Workers and administrative support. Examples of how the new nursing team might work with existing community-based colleagues are given in Appendix 4.
Practice Nurses have a crucial role in the delivery of care to communities and will be important partners of those working within the new service model. It has not been possible to identify Practice Nurses in the model due to the particular nature of their employment circumstances; it is recommended, however, that local systems embrace their skills and expertise and include them in team approaches to meeting the health needs of local communities.
The team will seek support as required from individuals, teams and communities holding specialist expertise, knowledge and skills, and will have strong interfaces as part of delivering scheduled and unscheduled care with the following key services:
- primary health care teams
- community pharmacy services
- mental health services
- learning disability services
- children's and young people's services
- local authority teams
- community hospitals
- the acute sector
- maternity services
- the independent sector.
The new service model is represented diagrammatically in Figure 3.1.
Figure 3.1 New service model for nursing in the community
The overriding aim of the new service model is to ensure that nursing services in the community are fit for purpose to meet the demands of 21st century Scotland. It brings clarity to the nursing role in the community to create greatest benefits for individuals, carers, families and communities. The model builds on the best elements of nursing practice in the community to provide a means to support nurses to deliver a modern, flexible and responsive service within a multi-disciplinary, multi-agency context.
It was hoped that published research would provide ample evidence to support the development of a model for nursing practice in the community. The quantity and quality of the research evidence found in the literature review was insufficient for this task. Information has been gathered, however, from sources accessed outwith the commissioned literature review, the international Family Health Nursing Pilot in Scotland and from the Review consultation process, and this has been used to influence and shape the design of the model. The conceptual model of Family Health Nursing set out in the final report of the project is similar to, but less-developed than, the new service model.
Seven core elements of nursing in the community
Through its consultations, workshops, consensus conferences and online survey activity, the Review identified seven core elements of practice that need to underpin the activity of nurses in the community to ensure they can contribute maximally to the implementation of Delivering for Health. Nurses are already practising many of the elements to varying degrees of consistency. They build on the strengths of District Nursing, Public Health Nursing and Family Health Nursing to provide the central elements of the new Community Health Nursing role.
Working directly with individuals and their carers
Nurses need well-developed assessment, intervention and evaluation skills to identify where their skills and those of others are necessary to provide high-quality support and care to patients, carers, families and communities.
Adopting public health approaches to protecting the public
Protection of children and young people has been identified as a national priority. Embedding issues of public health approaches to protection of children and young people in the practice of all nurses is necessary not only in relation to ensuring their safety, but also because the principles of protection of children and young people can, and should, be applied to the support and protection of all people who may be in vulnerable situations.
Co-ordinating services
Individuals, carers, families and communities look to nurses to take a strong co-ordinating role not only within nursing teams, but also in relation to services delivered by the entire primary health care team, by secondary care services, by local authority services and by services provided by the non-statutory sector.
Supporting self care
Nurses have a key role to play in supporting individuals to develop the knowledge and skills they need to improve their health and manage their health-related conditions. They are also vital in helping carers manage their caring responsibilities and in working with community-based groups and organisations on improving public health. This means they must be prepared to move from a culture focused on 'doing for' patients to one in which they become 'enablers' of individuals' self care, as Delivering Care, Enabling Health stresses.
Multi-disciplinary and multi-agency teamworking
It is essential that nurses have the right skills to enable them to work within teams. The integrated care approach that is vital to implementing Delivering for Health depends on good multi-disciplinary, multi-agency teamworking. Teams must move forward in common purpose, learning and developing alongside each other, understanding and respecting each others' contributions and co-ordinating their services for the maximum benefit of individuals, carers, families and communities.
Meeting health needs of communities
A key element of Delivering for Health is the ability of services to reach out to communities who traditionally find health services inaccessible. Members of these communities are particularly vulnerable to health problems, but may not present to services until their conditions are at an advanced stage. The social inclusion agenda and the prominence of anticipatory care in improving public health demand that services take measures to identify these individuals and communities and work with them towards health improvement. Nurses have a proud record in this area, often using innovative community development approaches to service delivery, and their expertise and drive will be crucial in taking the agenda forward.
Supporting anticipatory care
Nursing needs to develop its health improvement focus, moving away from an illness orientation to one that looks to promote health. To do this, nurses' work needs to have a strong emphasis on assessing risk, promoting health, preventing illness and understanding and addressing health inequalities.
These core elements are represented in Figure 3.2
Figure 3.2 Core elements of nursing roles in community settings
The new service model presents the right environment from which nurses can build on their existing expertise to develop new skills and acquire new knowledge within these core elements of practice.
Implementing the model - what happens next
The Scottish Executive will establish and lead a two-year project that aims to ensure the new model:
- is ready to be implemented across Scotland in a safe, efficient and effective manner
- ultimately provides nursing services which meet the needs of individuals, carers, families and communities
- supports the implementation of Delivering for Health.
Patients' and carers' representatives, staff organisations, NHS Boards and other service partners will be fully involved in the development and delivery of the project.
Initially, NHS Boards which collectively reflect the diverse nature of Scotland's geography and demography will be invited to become Development Sites. These NHS Boards, working with local communities, councils, educationalists, care homes and other independent providers, will begin to introduce the model in 2008 following the development of detailed local and national plans. Plans will be measured against clinical, staff and financial governance standards.
The model will be tested and refined during the planning process and in the early stages of implementation to ensure it is sufficiently flexible to adapt to the needs of Scotland's diverse communities, taking into consideration differences among urban, rural and remote areas and the wide range of health care needs across Scotland.
The process will identify the appropriate interface between members of the nursing team and other nursing and non-nursing services such as public health, children and young people's services (including child protection services), services for people with mental health problems and those with learning disabilities, and services supporting people who are in vulnerable positions.
The work will interact with many strands of health and social policy and will link with projects focusing on issues such as workload and workforce planning, information and technology, unscheduled care, children and young people and the Joint Future initiative. Work streams developed to support the implementation of the model will include:
- workforce modelling
- revision of education programmes for new practitioners and those designed to support existing practitioners
- an eHealth project to support nursing practice and decision making in the community
- a review of children's nursing.
The impact of the new model will be evaluated. The evaluation will measure not only nurses' contribution to meeting the aims of Delivering for Health, but also the experiences of individuals, families, communities, nurses and professional colleagues.
NHS Boards and partner organisations not identified as Development Sites will nevertheless be involved throughout the project, as the learning will inform the shape and nature of services they will be providing in future.
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