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QNI warns of loss of district nursing skills and identity


Less than half of patients receiving home nursing care know if the person treating them is registered, fuelling fears that district nursing is losing its identity, according to a Queen’s Nursing Institute study.

The report said patients often view the person that treats them as part of an “invisible army” of community staff but often cannot distinguish between a district nurse and a healthcare assistant.

This is indicative of the changing skillmix among community nursing teams, of which an “alarming consequence” is a “growing loss of nursing skills”, the institute warned.

It highlighted falling district nurse numbers over the past decade combined with an increase in use of HCAs to deliver elements of care previously the done by experienced community nurses, such as tube feeding patients, treating leg ulcers and changing urinary catheters.

The QNI’s report “Nursing People at Home” is based on a survey of 265 patients, in-depth interviews, and discussions with patient organisations. It forms part of the institute’s “Right Nurse, Right Skills” campaign which calls for a properly skilled and trained home nursing workforce.

The survey found the majority of patients - 70% - reported receiving a good or excellent standard of care from community nurses, but that the experience of some patients was “far from satisfactory”. The problems most commonly highlighted were lack of dignity and respect, feeling unsafe and inability to ask questions or voice concerns.

The institute said feedback on care quality was linked with the type of nursing staff that provided it. Of the 31% of patients who rated care as “excellent”, the report said “the vast majority received their care from a registered nurse only”.

One nurse quoted in the report said: “When patients see a uniform, they presume that the person wearing it is capable of the role but I fear this is often not the case.”

The government last week confirmed moves to introduce voluntary regulation for HCAs. Despite this, the QNI said it was renewing its call for mandatory regulation so HCAs could “play a full and accountable part in the delivery of care”.

The QNI also called on the Department of Health to introduce a regular national survey of patient experience of community services, comparable to the national inpatient survey.

  • The institute also announced the induction of 31 new Queen’s Nurses at an awards ceremony in London on 15 November, bringing the total to 199. QNI fellowships were awarded to former chief nursing officer for Northern Ireland professor Martin Bradley and Ann Rowe, Department of Health implementation lead for the Family Nurse Partnership programme.

Readers' comments (6)

  • michael stone

    'with an increase in use of HCAs to deliver elements of care previously the done by experienced community nurses, such as tube feeding patients, treating leg ulcers and changing urinary catheters.'

    That does not look like 'basic care' to me, as it happens.

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  • I would also like to add that patients cannot distinguish between a registered nurse, an HCA or a carer in a residential home because quite often we are all wearing the same uniform so maybe when questioned the patient might not have been fully aware of who gave the care.

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  • Little One

    "That does not look like 'basic care' to me, as it happens."

    I have to agree on this point, whilst on my community placement I was amazed at the work that HCAs were allowed to undertake without the direct supervision of a nurse, compared to HCAs in hospitals. Although I have to say that 'tube feeding patients' probably means connecting the PEG feed up and pressing 'Go' and 'changing urinary catheters' means changing the leg bag every week. As for leg ulcer care, the Nurse has to approve the dressings used and has to reguarly review the patient to gauge their progress.

    I was more intrigued by administration of medications and the fact that HCAs could draw up and administer insulin and eyedrops. I'm not suggesting that HCAs shouldn't be able to do so but it was just a surprise to see the extent of their roles within the community and how there was very little that the qualified staff did that the HCAs didn't, ie compression bandaging.

    I'm very pleased to hear that the majority of patients rated their care well but I do think that it is important that unqualified members of staff do not feel like they are having to cover work that they are unsuitable to provide due to pressures on time and staffing etc.

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  • michael stone

    Little One | 22-Nov-2011 9:24 pm

    'As for leg ulcer care, the Nurse has to approve the dressings used and has to reguarly review the patient to gauge their progress.'

    That is the point - when dressing a leg ulcer, you should also be deciding if it is improving or getting worse - which is why the application of the derssing, and the assessment, taken together are not 'basic care'.

    This report might be 'distorted by incomplete description' as you have suggested - lots are - but I don't really understand why such distortion is necessary, and unless the description of the care being provided is sufficiently detailed, we are left making assumptions (as you have done, with your 'corrections').

    I hope you realise, that if you agree with me and actually say that, you are likely to get 'attacked' on this site (you could be aware of that already, but I may as weel warn you in case you aren't aware of it).

    But your 'HCA's do different things outside of hospitals' point, is why I have previously suggested that it isn't a national-level registration schem for HCA's which is imporatnat, but a local and role-specific record of what any particular HCA has been trained to do, and assessed as competent in performing. That way you do not reduce things to 'a set minimum', and the record is much more useful.

    Big report out today, suggesting that many patients are not impressed by 'home care'. Not all, but more than should be the case, in anything close to 'a decent world'.

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  • and when hca's are regulated, this will result in a further dilution of the skill mix and fewer nursing posts. if you think the skill mix is bad now, just wait until the years following compulsory regulation of hca's!

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  • michael stone

    Anonymous | 23-Nov-2011 2:21 pm

    I'm not 100% sure, but I'm pretty certain, there will not be compulsary registration/regulation of HCAs. From what I seem to remember reading in the press, the 'Scottish method' has found favour - that was a 'sort of binding contract, that employers should locally provide guaranteed training' for their HCAs.

    It is essentially, the same thing as I have suggested on this site.

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