For all nurses, midwives and nurse associates, practising in accordance with the Nursing and Midwifery Council (NMC) code (2018a) is firmly embedded in every element of what they do. These values and principles can be applied to the delivery of nursing care, regardless of the practice setting, and they represent the standards that patients and members of the public expect from their healthcare professionals (NMC, 2018a). The role of community nurses can be dynamic, multifaceted and can encompass a wide range of responsibilities that are delivered with compassion and expertise (McBride et al, 2024). As the NMC (2018a) stipulates, to practise effectively, a registrant must assess and deliver care to the best of their ability, using the best evidence available. Therefore, the range of what might be considered in the ‘out-of-hospital’ care setting is quite extensive.
The NMC (2018a) clearly outlines how this will be achieved within the ‘practising effectively’ section of the code:
Record keeping
As the Royal College of Nursing (RCN) (2023) suggests, good record keeping is integral to promoting safety, ensuring continuity of care and is a vital part of communication. Good documentation is also important as it supports professional evidence-based decision making and care (NHS England, 2023).
The NMC Code (2018a) is very clear that patient records should be completed at the time or as soon as possible after the event, and that they should be accurate, without falsification and be attributed to the individual making them—clearly written, dated and timed. For community nurses, there has always been an emphasis on documenting accurate information about their patients. However, record keeping can be challenging and if the community nurse has a large caseload, then this can be perceived as a burdensome extra (Dowie, 2024).
All nurses need to remember that they can be held liable if there is no documented evidence of the care they have provided, and in the community many areas are now ‘paper light’ with the implementation of electronic patient records systems. Therefore, there are additional challenges with completion of documents contemporaneously, which Lezard and Deave (2021) have summarised as issues around practicality and confidentiality, limited reliability of IT systems and differences in team ethos to embrace the technology.
It has been suggested that some nurses perceive using electronic devices as a barrier between them and their patient and often display a lack of knowledge relating to what good documentation looks like in a digital context (NHS England, 2023). The International Community Nursing Observatory (2023) dispute this, postulating that community nurses have a good level of digital literacy and an appetite for high functioning technology, but are often faced with network coverage issues and inappropriate hardware or software.
In general, community nurses are making effective use of electronic patient records, collaborating with the patient, and making informed clinical decisions, using IT innovatively to improve patient care (Lezard and Deave, 2021). For those that are choosing to complete records much later than the patient consultation, they must be aware of the legal implications for this and be aware that they could be breaching the NMC Code (2018a).
Using unqualified interpreters
The complex phenomenon of communication is one of the most essential elements of the nurse-patient relationship, associated with health promotion, education, treatment and rehabilitation, and is influenced by many factors (Afriyie, 2020). Often, the power of communication can be impaired by a lack of common language and reduced health literacy. The world is becoming increasingly linguistically diverse, and the changing demographics mean that nurses will often be the first point of contact for patients within healthcare (Gerchow et al, 2021). Therefore, if barriers are encountered, this can influence patient experiences or outcomes.
NHS England (2018) states that all patients should have access to interpretation and translation services that are responsive to their linguistic needs, and that their care should not be disadvantaged. The role of healthcare interpreters is often multi-faceted; they are delivering complex messages rather than simply translating words and without them, important information could be lost (Salavati et al, 2019). However, community nurses may often find themselves in unplanned situations in patients’ homes where they are using family members or friends as the interpreters which although seems like the most logical solution, can present significant challenges.
The NMC Code (2018a) is clear that nurses must take reasonable steps to meet people's language and communication needs, which can be verbal or non-verbal with a focus on considering cultural sensitivities, so it could be suggested that nurses must make an educated, informed decision as to whether to use adult family members or not in any given situation. As Hilder et al (2017) suggest, there are often high levels of trust between family members, patients can feel more relaxed and time can be saved. However, it must be remembered that the NHS has a legal responsibility to make sure that the services they provide have access to professional translating services which also addresses safeguarding issues and aids accuracy of translation (Office for Health Improvement and Disparities, 2021).
Taking this all into consideration, it is evident that at times, community nurses can find themselves in a conflicting position where they wish to provide the best person-centred care for their patients but also need to abide by regulation, and there is a concern that family will not have adequate knowledge of medical terminology or withhold critical information (Salavati et al, 2019). There is also the issue of checking the veracity of the interpretation or ensuring that the family member remains neutral and passive, which is very challenging (Rimmer, 2020). The nurse needs to have a higher level of experience and skill to understand the potential risks and be able to explain the options to the patients under their care. Much of the research to date has been carried out with medical staff, in hospitals or primary care settings, rather than in patients’ homes.
Delegation
This section of the NMC code (2018a) also addresses accountability and the decision to safely delegate. Delegation is defined as the ‘transfer to a competent individual, of the authority to perform a specific task in a specified situation’ (NMC, 2018b). Registered nurses are accountable for what they choose to delegate, and this may be to another registered professional, an unregulated member of staff or even a family member or carer. This must always be in the best interests of the service user or patient and the whole process must be risk assessed (RCN, 2023).
However, regardless of the task or duty that has been delegated, this must be within the other person's scope of competence, provisions should be made to ensure they are adequately supervised and to confirm that the outcome of any delegated task meets the required standards (NMC, 2018b). While this is applicable to all registrants, there are often extra issues to consider within the community as staff are often lone workers and need to be autonomous practitioners making independent decisions, a reality reflected in the scenario in Box 1.
Skill development in community nursing
Farah has been a healthcare support worker, performing her duties alongside district nurses in a community nursing team for nearly 5 years. She feels fulfilled and is a valued member of the team. Following recent service review, competencies have been updated for staff in her band and insulin administration will be an expected clinical activity. Farah is worried about this, as she is not familiar with medication administration and is concerned that her patients will also be apprehensive.
As Stenner et al (2024) identified, it is common practice in the UK and other countries for registered nurses to delegate medication administration to a healthcare support workers. This should always occur within a framework of local governance and include training, competency assessment and implementation of protocols. It is important to consider the relationship between the delegator and the delegate and ensure that adequate support is provided to ensure patient safety. Communication is key throughout to increase confidence and boost team morale (Shore et al, 2022).
Although one of the main drivers for delegating medication management may be to free up registered nurses to undertake more complex care at peak times, there must be perceived benefits for the patients and healthcare support workers (Stenner et al, 2024). If delegation is not performed in accordance with the specified guidance, then the registrant could be held to account both by law and the NMC as their professional body.