In Nottingham, hospital nurses offer prostate cancer risk assessment clinics in community centres. How does one go about setting up services that bridge the gap between hospital and community?
Traditionally, nurses tend to work either in hospital or in the community but rarely combine the two. This article explores how hospital-based nurses can take on roles and set up services that bridge this gap, what challenges they face and how their project needs to be planned to achieve success. Issues around clinical governance, business plans, clinical skills training, support networks and the risks of autonomous practice are discussed. The author uses her experience of creating and delivering prostate cancer risk assessment clinics in community centres in Nottingham to make recommendations to others who want to work on similar initiatives.
Citation: McAllister BJ (2018) How hospital nurses can deliver services closer to the public. Nursing Times [online]; 114: 8, 48-51.
Author: Bría J McAllister is urology nurse practitioner at Nottingham University Hospitals Trust.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
The NHS is increasingly looking at innovative approaches to bring healthcare services to the public in open and accessible ways. Whether this involves offering prostate cancer risk assessment in community centres (as provided by Nottingham City Clinical Commissioning Group in 2016), providing lung cancer screening in supermarket car parks (Donnelly, 2017) or undertaking health promotion at music festivals (chillwelfare.org.uk), services previously only available by appointment at GP surgeries or in hospital are being brought to the public. However, while engaging patients, these new ways of working can also present challenges for nurses.
In 2016, I was involved in the creation and delivery of a prostate cancer risk assessment pilot scheme aimed at men from black and minority ethnic (BME) backgrounds in an inner-city area. The scheme, developed in response to requests from community leaders, aimed to encourage an at-risk group of people who traditionally often find it difficult to trust formal healthcare services to take part in a screening programme. The clinics, set up as a joint venture between the NHS and a local charity, were funded by the local clinical commissioning group (CCG) and delivered in community centres managed by the BME community.
This article sums up what I have learned from my experience of moving from a traditional care setting to a non-clinical one, and provides insight and guidance for other nurses who are considering setting up similar services.
There are many reasons why people do not access healthcare, such as lack of time, dislike of clinical settings, their chaotic lifestyle or a lack of knowledge. By raising people’s awareness of common conditions and giving them easy access to screening in settings where they feel comfortable, nurses can facilitate the early diagnosis of conditions and diseases such as cancer, diabetes or hypertension. Targeted health checks aimed at groups who do not normally access universal screening programmes can significantly increase the uptake of screening, thereby leading to improved patient outcomes (Visram, 2013).
A new service
Setting up a new service outside of one’s habitual work setting can be difficult, especially in the current financial climate, but the benefits for staff, service users and the greater community can be wide reaching. Ideally, the nurses who will provide the service will be involved at all stages, from concept to delivery, as this will give them the opportunity to interact with departments, such as finance and practice development, and influence the shape of the project. Setting up a community service can enhance hospital nurses’ practice and give them experience of project management while retaining some of the stability of their habitual role.
My work in Nottingham has allowed me to identify five key topics:
- Preparing to work in a new environment;
- Learning the clinical skills required for outreach work;
- Ensuring the presence of support networks;
- Assessing and reducing risks, including those of lone working;
- Giving staff professional and personal satisfaction.
Providing services directly to the community can be an exciting challenge for hospital nurses who are brave enough to step outside of their comfort zone. Identifying areas where healthcare can be delivered in new and innovative ways enables nurses to develop their knowledge base, experience and careers. Projects aimed at breaking down barriers can also enhance the reputation of the NHS and local services.
Nurses undertaking these roles will normally be highly skilled in their own fields and may feel ready to take their skills to new areas. With sound backing, they can create services of real value to their community. However, getting these projects up and running can be a daunting task. There are several points that both nurses and nurse managers need to bear in mind when planning to deliver care in public spaces. They are summed up in Box 1 and discussed below.
Box 1. Preparing to work in a new environment
- Involve the nurses who will deliver the service in all aspects of planning
- Agree protocols and clinical governance requirements
- Ensure strong lines of communication
- Arrange site visits to become familiar with sites and assess their suitability
- Consider audit requirements – what data will be captured and how?
- Ensure appropriate equipment is available
- Make any arrangements with other relevant departments, such as IT and pathology
The planning stage is the time to gather input from all interested parties to create a robust service that will answer the needs of the target group while adhering to clinical governance principles. A steering group that includes members of the public and community leaders as well as nurses, medical staff and CCG representatives will ensure a variety of expertise is available to:
- Build a business case;
- Set clear aims and objectives;
- Create a service that is fit for purpose.
This steering group will be available to provide guidance and feedback as the service develops. It is also a valuable means of ensuring effective collaboration between all parties.
Communication can be tricky when you are dealing with multiple groups. I found that the level of personal investment on the part of the community partners I worked with meant that they required more in-depth communication than is often the case between departments within the NHS. However, once a steering group had been established, communication became much easier. It is important to make sure all partners are kept involved in the conversation to avoid accidentally causing offence by omission.
The business case examines why the new service is required and deals with all its aspects, not just financial ones, thereby providing an overview of the project and its objectives (Hatchett, 2008). If the proposed service is linked to a sustainability and transformation plan (STP), a Commissioning for Quality and Innovation framework or a local health-promotion strategy, this should be included here. Accessing support during the creation of the business plan will go a long way in shaping an effective service. The local CCG will often be able to help with this.
Protocols and governance
The planning stages are the ideal time to draft the protocols that will govern the service and ensure it will be appropriate for the target group and adhere to clinical governance principles. Pathway planning can be difficult, but getting it right at the start will give nurses the base they need to make the service a success. Obscure or vague protocols, or a lack of clear guidance, may increase stress levels among staff and destabilise the entire service. By contrast, having a clear pathway incorporating clinical governance oversight will enable staff to focus on the task at hand. Protocols and guidelines will need to evolve with the service, so strong lines of communication and regular steering group meetings will be a vital part of the delivery.
Site and facilities
Site visits at the planning stage will:
- Enable nurses to inspect the area where they plan to work;
- Help them familiarise themselves with the space;
- Allow them to evaluate its suitability for healthcare interventions.
Facilities for handwashing, toilets, disabled access and areas for confidential discussion or examination all need to be taken into account.
Confidentiality extends to the collection and storage of information, the transmission of forms and the transportation of samples. Encrypted laptops, confidential waste disposal facilities, clinical waste containers and sample transport containers may be required. Hospital IT services and pathology laboratories can help address these practical needs.
In my experience, the ability to access existing NHS systems allows for a much more streamlined and effective service. Having an encrypted laptop connected to the hospital’s network via a secure Wi-Fi link enables nurses to access patient records, view recent blood test results and update contact details. For some services, it may be useful to have remote access to general-practice systems.
Admin and data collection
The planning stage is also a good time to think about administrative aspects:
- Will existing forms and paperwork be appropriate or will new ones be required?
- How will letters to GPs and attendees be phrased?
- Will the service need secretarial or administrative support?
- How will the service be audited?
- How will data be captured and evaluation be managed?
Getting these fundamentals right will make all the difference once the project goes live. Nurse managers need to think about providing protected time outside of actual clinics for staff to deal with paperwork, process results and send letters to GPs. Protected time is also needed to collect data on patient attendance, demographics, diagnoses and outcomes – which can be used to assess the service and inform future projects. Planning sufficient administration time will help to reduce stress for nurses and ensure the success of the service.
The clinical skills required for outreach work need to be considered at an early stage. Skills such as clinical examination or venepuncture – which, in a large team on a hospital ward, may be routinely carried out by others – may become the responsibility of the nurse who will be delivering care outside of the hospital environment.
Competence must be demonstrated before nurses take on extended roles in autonomous practice. The Nursing and Midwifery Council’s (2015) code states that nurses must work within the limits of their competence at all times to preserve the safety of patients and the public. While it is the responsibility of individual nurses to ensure they are confident and competent in any new roles they are undertaking, the code also makes clear that managers have a responsibility for their nurses’ safe practice, as they retain responsibility for tasks they delegate to others. Nurses and managers must, therefore, work together to ensure learning pathways are appropriately completed.
It can take some time for nurses to complete appropriate training and gain competency in a new skill but by involving the nurses who will ultimately deliver the service in its planning, tailored training plans can be made. Nurses who work in the same team may have different skillsets: for example, one may be trained in venepuncture while another may be skilled in clinical examination. An awareness of the skills already in place, as well as of those that need to be learned, will help.
Training time should be built into the planning for the new service and nurses should be given an appropriate amount of supported learning time. It may be necessary to create learning protocols or extended practice packages to demonstrate learning and competency, and this may require input from the local practice development team. Some training may incur fees, which will need to be built into the business case.
Box 2 sums up key points regarding clinical skills.
Box 2. Learning the clinical skills for outreach work
- Carry out an assessment of each individual’s training needs
- Consider funding and the time required for training
- Ensure staff have acquired the necessary competences before launching the service
Just as nurses working in a team need support from their colleagues, those working in an outreach capacity need support in their role. It is important to agree a clear pathway for advice and referral, and include in it the clinical governance structure before the new service is put in place.
What is required will vary depending on what service is being provided; for example, a service that assesses the risk of cancer will need to have in place a pathway for referring to specialist services those patients who are found to be at risk of the disease – this referral pathway should be similar to that for urgent referrals from general practice to hospital. Likewise, a service providing advice, in the main, may warrant extensive input in the first instance but not require much follow-up care.
It is useful to have a named consultant on board who is involved, however peripherally, in the planned service and can provide advice, either on a casual basis through an informal chat or via a formal referral. How this is managed will depend on the shape of the service, but having an agreement in place before launch will help smooth the process.
To work effectively outside of their normal environment, nurses also need the support of their line managers. Finding an ‘open door’ to discuss any problem or talk over the events of the day can be the difference between success and failure. Line managers also act as sounding boards for new ideas, offer advice and guidance, and encourage staff along the way as they expand their skills and gain confidence.
Finally, the importance of peer support – which remains a vital aspect of nursing work – should not be underestimated. The ability to chat with a colleague in the staff room can help put difficulties into perspective or help to identify a solution to a problem. Even staff members who are not directly involved in the new service can contribute to its success.
Box 3 sums up key points regarding support networks.
Box 3. Ensuring support networks are available
Ensure staff have access to support and guidance from:
- A named consultant
- Line managers
Risk assessment and lone working
All services in the NHS require appropriate risk assessment to ensure the safety of patients and staff, especially when they are provided in non-clinical settings. Many tools are available to identify the risk, and help to contain both the risk itself and its potential consequences. If a thorough risk assessment is carried out, the results will not only safeguard individuals and improve decision making, but also help inform similar services.
Lone working is a potential safety issue for all nurses, regardless of the environment in which they practise, but the danger may be increased for those working in community or outreach situations. It should be given extra consideration at planning stage.
The Health and Safety Executive (2013) defines lone workers as “those who work by themselves without close or direct supervision”. Lone workers are not necessarily alone at all times; periods where they are unsupervised or have no colleagues nearby include:
- Times when they are seeing patients in a separate room;
- Times when they are travelling back to their main work setting with supplies or samples;
- Staggered break times.
Help and guidance for lone workers is available. The Royal College of Nursing (2016) has produced advice on keeping safe when working alone and each trust will have a lone worker policy that can be referred to for guidance.
Community centres, shopping centres and football stadiums are all locations that can be used to bring health services to otherwise hard-to-reach groups. Each brings its own challenges, but there are several questions around the risk of lone working that will always need to be considered:
- What environment will staff be working in? Is there safe access/parking nearby?
- Can staff easily contact their base in case of an emergency?
- Are there any special risks associated with the setting?
- Are there factors that make staff more vulnerable, such as lack of training, lack of experience, pregnancy or disability?
By carefully considering these questions, both at planning and delivery stage, the risk to staff can be reduced, if not eradicated completely.
Box 4 sums up key points regarding risk assessment and lone working.
Box 4. Assessing and reducing risks
- Carry out a comprehensive risk assessment
- Consider times when staff will be isolated or vulnerable
- Ensure staff can contact base for help if needed
- Consider any risks specific to location
- Refer to lone worker policies for guidance
When speaking formally and informally to the staff involved in delivering our community-based prostate cancer risk assessment service, the overwhelming feedback was that extending their role to bring healthcare into the community had been a rewarding experience. Nurses spoke enthusiastically of their personal and professional satisfaction at being able to engage with patients in a less-formal manner and break down barriers between “us and them”. Small touches, such as providing refreshments and a place to sit and chat, and the absence of uniforms (our staff and volunteers wore T-shirts designed by the community group), helped to maintain a relaxed, non-clinical feel.
Staff spoke positively of the opportunity to “speak to the healthy before they become unhealthy”, raise awareness of health conditions and encourage healthier lifestyles. They spoke of the mutual respect and camaraderie that developed between hospital and community staff. This atmosphere of collaboration and friendship helped create a warm, open environment in which staff, volunteers and attendees all felt safe and welcome. This in turn encouraged attendees to spread the word, and more men attended the clinics after they had been recommended to them by friends or relatives.
This increased service uptake through word of mouth has been noted in similar projects targeting vulnerable groups. In fact, word of mouth to promote screening and health checks is increasingly recognised as a powerful tool for improving the success of community-based healthcare (Martin, 2017; Sadler et al, 2007).
The freedom to arrange their workload and run the community clinics autonomously was another aspect about which staff spoke positively. Nurses agreed that having clear protocols, along with strong back-up and support, allowed them to take ownership of the practicalities of service delivery, knowing there was a safety net in place. Overall, nurses saw the community service as an extension of their established role delivered in a manner that enhanced their sense of achievement and gave them opportunities for professional development.
Box 5 sums up key points regarding staff satisfaction.
Box 5. Professional and personal satisfaction
Creating and delivering services in community settings can increase or promote staff satisfaction as it gives hospital-based nurses opportunities to:
- Directly improve the health of the community
- Learn and develop professionally and personally
- Engage with local communities in positive and health-affirming ways
Bringing healthcare out of traditional settings helps break down barriers, improve awareness of health conditions and increase uptake of screening services. By supporting and encouraging hospital-based nurses to leave their habitual base and develop services in non-clinical settings, the NHS can engage with hard-to-reach groups while developing and enhancing nursing practice.
- The NHS is looking at innovative ways of making healthcare services more open and accessible
- Hospital nurses working on providing services in the community need to be involved from concept to delivery
- When setting up clinics in the community, nurses need to consider governance, business planning, training, support and risk
- Getting involved in a community service gives nurses opportunities for professional development
Donnelly L (2017) Cancer tests in supermarket carparks in bid to boost detection rates. The Telegraph; 21 November.
Hatchett R (2008) Nurse-led clinics: 10 essential steps to setting up a service. Nursing Times; 104: 4, 62-64.
Health and Safety Executive (2013) Working Alone: Health and Safety Guidance on the Risks of Lone Working.
Martin S (2017) Toward a model of word-of-mouth in the health care sector. Journal of Nonprofit and Public Sector Marketing; 29: 4, 434-449.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Royal College of Nursing (2016) Personal Safety when Working Alone: Guidance for Members Working in Health and Social Care.
Sadler GR et al (2007) Breast cancer knowledge, attitudes, and screening behaviors among African American women: the black cosmetologists promoting health program. BMC Public Health; 7, 57.
Visram S (2013) PP19 Formative Evaluation of a Community-based NHS health check service. Journal of Epidemiology and Community Health; 67: A56.