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Improving communication

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Community and practice nursing services on the whole work well together, but some district nurses have criticised the way that general practice interacts with them.

The QNI released a five-year progress report at the beginning of June on its 2020 Vision project, which outlined the results of a survey gauging district nurses' views five years after the 2020 Vision was launched. Opinions on areas such as workload, capacity and technology were sought.

One of the questions asked community nurses how good they felt their relationship was with general practice. The response was encouraging in comparison to answers given about relationships between district nurses and hospital discharge wards, showing that communication between primary care teams is positive. However, 31 per cent of respondents did express a degree of criticism about relationships with practices. One respondent stated the relationship was 'good, but only if the nurses make it good.'

The most frequently stated causes of concern were that the standard of communication varies between one practice and another; that communication has become more difficult because the district nursing team has moved to a separate location, losing the traditional face-to-face opportunity to engage GPs regularly; that communication relies on fax; and that the role of district nurses is either misunderstood or taken for granted by practice staff.

Chief inspector of the CQC Steve Field told Independent Nurse that the CQC recognises that communication between these teams needs to be strengthened to improve patient outcomes. 'The area that I am concerned about is how practice and community nurses link together for the benefit of their communities. We really need a much more joined-up community nursing service with better links between school, practice, and community nurses.'

Communication boosts outcomes

Both practice and district nurses understand that communication between the nursing teams is crucial to ensure their optimal performance and for patients to receive the best care.

'The relationships between practice nurses and district nurses are key to improving patient outcomes,' says Kay Kane, an independent community nursing consultant in Northern Ireland with 20 years' experience in the public sector.

'It's absolutely vital that the relationships are based on good communication and partnerships in working together.'

Debbie Brown, a specialist practitioner at a practice in Lewisham who has advised the CQC, agrees: 'Building up relationships with the district nurse is paramount as this builds trust and a clearer understanding of each other's roles. Without this in place conflict and frustration can occur, which will have a detrimental effect on the workforce. This may impact the care patients receive if accurate information has not been shared with the correct people.'

The size of the practice can determine the strength of communication between nursing teams says Claire Green, a district nursing sister working across three practices in Maidenhead. 'In the larger of the surgeries I am lucky because we have a good working relationship between myself and my team and the GPs and the practice nurses. Being surgery-based means we have closer contact, where issues or patient concerns can be discussed on an ad-hoc basis or when GPs don't object to being disturbed during surgery for urgent matters.

'This contrasts with the two smaller surgeries that I cover where it can be more difficult to get in to see the GP or the surgery may be closed for parts of the day,' she added.

Challenges to better relationships

Respondents to the QNI's survey who expressed concerns about the relationships between GP practices and district nurses said that technology was one of the main reasons for inconsistent working between the two.

Both Ms Kane and Claire O'Connor, a practice nurse from Woolwich, say that their district nursing teams and GP practices work on different computer operating systems, which do not sync with each other. 'For example, the GPs have to ring the referrals into a centralised referral system when they would probably prefer to just do them online. I believe that there are efforts to rectify this, but they are still a long way off,' says Ms Kane.

'We have to send information to each other over fax which is unreliable and also very time consuming,' says Ms O'Connor.

A lack of professional understanding between the two different nursing teams is another one of the main barriers to seamless working between the two, Ms Kane believes.

She suggests the lack of understanding of practice nurses and district nurses roles can result in professional rivalry or jealousy. 'Its rare when this happens, but when it does steps should be taken to avoid that happening.'

Ms Brady agrees: 'It is important to understand each others' roles and where those misunderstandings are is when barriers occur.

'Even within practices, practice nurses have very different roles, some are very involved with home visits or in the community so they will bump into their district nursing colleagues and have a better working relationship with them. Others will be more practice bound so won't get out into the community as much. This diversity in the roles can create tension.'

There is also diversity in the way that nurses are commissioned and this can cause barriers to closer working, Ms Brown thinks. 'General practice runs as individual businesses so it is very difficult to commission nursing teams,' she says. 'District nurses are now employed by trusts or other organisations and this can cause a disjointed team.'

Anne Moger, programme director of general practice nursing at Health Education Wessex and Health Education Thames Valley, explains: 'Largely they are commissioned by and employed by different organisations. District nurses are commissioned by provider trusts and commissioned by CCGs and practice nurses are employed by GPs who are independent contractors commissioned by NHS England.

Joined up commissioning for practice populations 'based on patient outcomes, rather than by bricks and mortar as is the current situation,' would be better she believes.

'[The nurses] also undertake different training so are not skilled in the same way. They have distinct roles and areas of responsibility.'

Joint education

As well as joining up the commissioning structure for primary care nurses, education could also be combined to increase understanding of each others' roles.

Ms Brady believes joint education is one way that integrated working and closer relationships can be achieved. 'Especially in terms of long-term conditions where the roles cross over there's no reason why district nurses and practice nurses need separate training or CPD. Things like social media or online forums can be a platform to link with other colleagues.'(See box).

She also thinks that by improving the commissioning structure joint education will be more available. 'The route that practice nurses and district nurses enter the profession could be joined up more as they cover many of the same things. There could be a rolling programme of CPD to sustain that need. At the moment everyone is working in their own little areas and there is no opportunity to meet and have clinical supervision and share ideas and experiences.'

One suggestion is that the district nurses could have a morning or an afternoon in a practice to work with a practice nurse. 'This would allow an exchange of knowledge and will also encourage the bond between the practice nurse and the district nurse,' says Ms Kane.

'Our district nurses hold seminars on clinical topics and we always invite the practice nurses to those. Practice nurses in our area run evening seminars and they would let the district nurses know so that they can attend too. Its about sharing at all levels,' she says.

Louise Brady, a practice nurse from Hyde, Cheshire, agrees.

'Obviously there needs to be more joint working between district nurses and practice nurses because sometimes the roles overlap. There are things that I can learn from district nurses and things that they can learn from the practice nursing team,' she says.

Ms Kane says that when she managed the district nursing service in South and East Belfast, the majority of practice and district nurses worked well together and that closer working and communication can be fostered at all levels. 'The tissue viability nurse gave a whole set of evening seminars on leg ulcer treatment and wound management. The Trust paid for that as they felt it was worthwhile because it meant that they were bringing the skill level up to improve patient care. Its important for managers to see the bigger picture and not see the district nursing team and the practice nursing team as two separate things.'

Good practice: bringing learning to a local level

Ms Brady set up a forum between three CCGs, Tameside and Glossop CCG, Stockport CCG and Pennines Care, for all nurses to be able to share ideas and experiences and clinical guidance.

'I started the forum around four months ago, as it was clear that there was a need for clearer communication between healthcare professionals in the areas. Due to the onset of CCGs, training seemed to have dissipated for practice nurses certainly, and district nurses were probably in a similar situation. Even within my CCG there are district nurses, practice nurses and nurse specialists and a long term condition team and they all come under different CCG structures.

'We found that often not all nurses were informed of training opportunities. So we developed this forum via NHS mail so we could post privately and share training information. For example if I wanted training in mental health I would link in with one of my community colleagues in Pennine Care to see how I would access that training as a practice. The forum allows us to post that information and share ideas and experiences so we are all linking in with what's available currently. The forum is hosted on a website called Yammer because it is secure and will only allow members to access the forum if they enter an NHS email address.

'We would encourage other nurses to set up a forum up in their areas. Although we do have national forums like the Practice Nurses Forum or the ones from the RCN, but they are not always applicable, particularly when you want to make changes in your local area, so it would be great if other nurses would set up forums in their locality.'

Encouraging change

Ms Brown believes that the way practice and district nursing teams operate may have to be altered in the future to meet the changing needs of the population. 'We may have to look at a generic nursing team to work across the community and general practice. There needs to be a clearer understanding of community and primary care workload and the diverse roles which the district nurse and practice nurse have. Ideally this would involve nurses, who are working at the coalface of community/primary care and who have an overall idea of what drives the changes, workforce and the financial crisis.'

For district nurses lucky enough to be co-located in a GP practice, communication can be easier to initiate and maintain. 'The district nurses are based upstairs in the practice. We have weekly meetings to discuss patients on their caseload and this is also an opportunity to clarify if there is any care involved and what support signposting has been offered,' says Ms Brown.

'We have monthly meetings with the community matron, the heart failure specialist nurse and the district nurse. We also have teleconferences with DSNs and the respiratory CSN if required, ' she says.

These experiences were echoed in the QNI survey's responses, with location cited as having a role in the relationship between practice and community nurses.

Crystal Oldman, the chief executive of the QNI, says that she hopes the report will encourage conversations with the influential members of nursing such as Health Education England, Public Health England, the Department of Health and the Chief Nursing Officers, on how the QNI can help support them to improve working conditions for district nurses. 'We will continue to analyse the narrative data that we have received through this survey and approach the key organisations so that district nurses are given the support they need,' she says.

The DH will be releasing a piece of work on how to improve integrated care in the next year. 'There is an integration piece focusing on service components as the key areas to support integration looking at multidisciplinary care and care planning to support integration,' says Susan Swientozielskyj, who is leading the work on the future community nursing strategy at the DH. She expects this will be available in the lead up to the Community Nursing Strategy, due to be released some time next year.

In the meantime, practice and community nurses will continue to form the best relationships they can in the circumstances they find themselves to deliver the care that patients require.

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