Transforming Nursing, Midwifery and Health Professions’ (NMaHP) Roles: pushing the boundaries to meet health and social care needs in Scotland
The district nursing role in integrated community nursing teams
This series of brief papers on the Transforming Roles programme aims to update stakeholders on the professions’ contribution to the wider transformational change agenda in health and social care in Scotland. The third paper outlines how district nursing roles are being developed in NHSScotland.
The Chief Nursing Officer is committed to maximising the contribution of the nursing, midwifery and health professions ( NMaHP) workforce and pushing the traditional boundaries of professional roles. The Transforming Roles programme aims to provide strategic oversight, direction and governance to:
- develop and transform NMaHP roles to meet the current and future needs of Scotland’s health and care system
- ensure nationally consistent, sustainable and progressive roles, education and career pathways.
Phase 1 of Transforming Roles focused on nursing roles.
Integrated community nursing teams
Shifting the balance of care from hospital to community and primary care settings at or near people’s homes aims to improve population health, increase quality and safety, and secure best value from health and social care services.
Delivering on these aims requires a different approach that enables community nursing staff to develop new and innovative ways of working to provide safe, effective, person-centred care and clinical interventions tailored to need. District nurses and their teams will work with practice nurses, mental health nurses, specialist nurses, and nurses in the third and independent sector as an integrated community nursing team to provide a seamless interface and reduce any boundaries between their practice and place of care.
Integrated community nursing teams will play a key role in planning, providing, managing, monitoring and reviewing care, building on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings.
Annex 1 sets out responsibilities and roles in the wider community nursing team, with examples of levels of knowledge and skills from healthcare support worker level to advanced practitioner. The framework is organised around the four central pillars of practice. 
Developing a district nursing role for the future
Work that began in 2015 in light of recommendations from the national out-of-hours services review outlined the future role of a senior practitioner/district nurse (Level 6). The work emphasised district nurses’ leadership role in areas such as anticipatory, palliative and end-of-life care. The aim was to develop, agree and drive implementation of a refocused district nursing role for NHSScotland by:
- developing a vision and model to meet future health needs
- defining key components of future roles
- identifying specific core education required
- considering future guidance on caseload and resource-allocation models.
Analysis of the current challenges and complexities in delivering district nursing services included a review of:
- the wider policy landscape and implications
- the need for seven-day/24-hour services
- the move towards locality multidisciplinary teams
- the public health review and policy, including place-based and community approaches to care delivery and outcome-focused care
- the GP contract and refocused GP and general practice nurse roles
- the integration and creation of health and social care partnerships
- care home and independent/third sector links and requirements
- current district nurse roles and services
- workload and workforce challenges
- current education provision.
A rapid review of evidence to identify effective home-based nursing interventions provided by district nurses was carried out by the Chief Scientist Office Nursing, Midwifery & Allied Health Professions Research Unit at Stirling University to support the review. Findings from two national scoping exercises also informed review processes, and NHS Education for Scotland hosted three full-day participatory events that effectively engaged stakeholders from across health, education, social care and the third and independent sectors.
Future vision for district nursing in Scotland
District nurses will play a pivotal role in integrated community teams. They will be at senior practitioner level within the career pathway and will be supported by the wider community team, including healthcare support workers, registered nurses and advanced nurse practitioners, to promote health and wellness, enable self-care and deliver personalised health outcomes in people’s own homes or communities. Services will be integrated appropriately with social care and other partners and properly signposted to ensure a full range of locally led, co-ordinated, high-quality, accessible and well-understood services are in place.
District nurses will have defined high-level generalist competences and be able to work flexibly and in partnership with patients, carers, communities and a range of other professionals, including social care and voluntary workers and carers. They will be enabled to work across hospital and community boundaries and beyond traditional professional and employment demarcations, with flexible skills and the ability to adapt and innovate.
This vision aims to support people to stay longer at home and in their communities. It balances the role of the district nurse in managing complexity alongside promoting self-care, independence, prevention and community engagement. It reflects a public health approach based on evidence of what works and is underpinned by fundamental principles that define the focus of the role as being about:
- promoting prevention
- adopting strength- and asset-based approaches
- practising relationship-based care
- promoting self-care and independence
- enabling people to manage their own health
- providing continuity of leadership and care delivery
- adopting a lead role in care, including complex care and case management
- promoting ownership, responsibility, accountability and independent decision-making
- working in wider integrated community nursing and multidisciplinary teams that include general practice nurses to achieve effective outcomes realised through interventions by appropriately qualified professionals
- working in localities/neighbourhoods and drawing on local infrastructure and resources
- basing interventions on evidence from research and evaluation and knowledge of individuals and communities
- getting it right for every person every time
- utilising skills in the social care sector and working in partnership.
The district nurse role must be patient-centred, aim to reduce variation, and ensure individuals and their families receive high-quality services that improve health and reduce inequalities. This is achieved by a model that:
- clarifies the unique (specialist generalist) district nurse role of providing care while promoting enhanced integration between health and social care, reflecting the views of professionals and key partners and building on best evidence of what works
- defines relationships with the National Health and Wellbeing Outcomes and related policy work streams, such as the public health outcomes frameworks, and patient safety and quality programmes.
Key features of the district nursing role
The model highlights seven core elements where it is expected district nurses will play
a key leadership role:
- public health
- anticipatory care
- care/case management
- intermediate care
- palliative and end-of-life care.
Further work is being undertaken on developing a model of caseload weighting and resource allocation that will complement the national workload and workforce planning tool. This will be based on a validated tool and population data and will incorporate factors such as deprivation, risk prediction, prevalence of long-term conditions, and estimations of complexity, dependency and time.
The aim is to underpin the provision of safe, effective and proactive interventions and care through the ability to direct capacity and additional time to deliver more complex interventions in identified deprived areas. In addition, work will begin to explore the interface and role of general practice nursing, to complement and enhance integrated team-working and development.