The number of district nurses (DNs) employed in the NHS has fallen by 43% in the past 10 years in England alone (Launder, 2019). The impact of this reduction in the DN workforce has resulted in existing DNs managing enormous workloads, with approximately 4000 nurses delivering care for almost 55 million people (Queen's Nursing Institute (QNI), 2019). It is estimated that, by 2039, 18% of the population will be aged 65 years and over, and although healthcare has improved, people are not necessarily living healthier lifestyles (Government Office for Science, 2016). Mehta (2017) suggested that wider factors than healthcare services alone determine a person's health, for example, whether they exercise, what they eat and where they live and work; therefore, to improve health and lifestyles, these determinants need to be addressed. This increase in the older population will place increased pressure on the NHS, particularly district nursing services, as most people cared for under these services are older (Ham et al, 2016). Robineau (2016) reported that more than 40% of the NHS budget will be devoted to people in this age group. The care of a person aged 85 years costs the NHS roughly seven times more than that for a person in their late 30s (at around £7000 a year) (Office for National Statistics, 2019).
Around 15 million people across England are living with one or more long-term condition (LTC), and it is believed that, by 2025, this figure will increase to 18 million, accounting for 55% of all GP visits, 68% of hospital appointments and 77% of hospital admissions (George and Martin, 2016). An LTC is defined as one that cannot be cured but can be essentially managed with the use of medication and medical interventions. This includes several incurable diseases such as diabetes, chronic obstructive pulmonary disease (COPD), asthma, dementia, heart disease, arthritis, mental health conditions and frailty (Seddon, 2018). An increase in the number of patients diagnosed with LTCs has seen more care being pushed onto community services, increasing the demand on DNs to manage these conditions in patients' homes (Maybin et al, 2016). The decline in DN numbers and the increase in the need for district nursing services (Drennan, 2018) will naturally impact patient safety (Royal College of Nursing (RCN, 2017a).
Role of the specialist community practitioner district nurse
A specialist community practitioner district nurse (SCPDN) is tasked with effectively managing complex caseloads and ensuring that patients are receiving the correct care. SCPDNs carry out a holistic assessment and work collaboratively within the wider multidisciplinary team (MDT), communicating with specialist nurses (for example, for diabetes and wound care) and GPs to enable a person-centred, individualised care plan. Within community settings, the SCPDN acts as a coordinator, ensuring that all staff adhere to trust policies and guidelines and communicate effectively. The SCPDN can delegate work effectively by assessing the skill mix within the team and can act as an advocate for patients (Gerber, 2018). The QNI (2015) further supported this, suggesting that the SCPDN leads and manages staff; coaches, teaches and supports registered nurses and students; manages complex caseloads; promotes collaborative working within practice; and advocates for patients. Thus, the role of the SCPDN is to initiate and facilitate strategies and evidence-based interventions in order to support the health of patients, families and carers.
Safety huddle
A safety huddle is a meeting held among DNs, allied health professionals, specialist nurses, administrative staff, community matrons and healthcare assistants, also known as the wider MDT. It was designed to focus on patients who are at risk of sustaining harm, highlight new patients on the caseload and discuss effective care regarding palliative patients. The safety huddle is an essential aspect of district nursing as a way of preventing harm (RCN, 2017b). Complying with safety huddles is vital in order to prevent incidents in practice. Safety huddles enable DNs to practice effectively, preserve safety, prioritise people and promote professionalism and trust, in line with the Nursing and Midwifery Council's (NMC) code (NMC, 2018).
An effective safety huddle comprises agreed actions and discussions regarding patient care and gives the opportunity to praise staff who have been successful in reducing harm (NHS England, 2019). Cross et al (2018) defined a safety huddle as the discussion of patient information among health professionals and the transfer of responsibility and control over patients in the team's care, thus preventing admission to acute settings. Providing care closer to home is a priority in the NHS Long Term Plan (King's Fund, 2019). Maybin et al (2016) indicated that providing care in a community setting as opposed to the acute setting has numerous advantages: it reduces pressure on hospitals, is cost-effective to the taxpayer and improves patient experience.
Why safety huddles were designed
Safety huddles were designed and implemented in community nursing in 2016, to ensure all key harms were addressed daily, whereby patient and staff safety could be ensured (QNI, 2017). The aim of safety huddles is to improve and document clinical handovers within community nursing teams, using a template to evidence the handovers (QNI, 2017).
Within the community setting, the safety huddle takes place each morning, commencing at 9.30 am for 15 minutes. The daily elements discussed include care for patients with diabetes, fragmin injections, catheter care, bowel care, palliative support for those with a terminal diagnosis, syringe drivers and care for patients on the high-risk register. It is mandatory that all nurses and allied health professionals attend, and it is the SCPDN's responsibility to ensure that staff are informed and the importance of attending is communicated effectively. Understandably, safety huddles are not always kept to time, and staff members get held up with patients. However, poor attendance at safety huddles leads to ineffective communication and potential harm to patients if all staff are not aware of what has been discussed (RCN, 2018). Buus et al (2017) acknowledged that information exchanged by staff members is complex, and there are multifactorial influences that can impact the outcomes of a safety huddle. Ernst et al (2018) indicated that effective handover would reduce the risk of communication failures between health professionals, thus improving patient safety and reducing harm. MDT meetings are fundamental to ensuring that quality care is provided to patients and that all their care needs are met (Soukup et al, 2018). Moreover, district nurses have exceptional communication skills (Health Foundation, 2016), and unnecessary harm to patients can be prevented and staff safety can be maintained if they share their knowledge and experiences with the team (Edwards, 2014). In contrast, communication failure within the MDT could lead to poor staff morale, poor patient outcomes and stress among team members (Health Education England, 2017).
Case of a pressure ulcer
Ford (2016) supported the idea that poor communication among care team members can lead to poor patient outcomes, and the impact of poor communication was also noted in a case at the author's institution, where a patient developed a pressure ulcer, because the risks and concerns surrounding this case where not communicated during the safety huddle. As a result, the patient required district nursing input for wound care and was provided pressure-relieving equipment. The SCPDN liaised with the tissue viability nurse regarding appropriate dressings and a plan of care, as drawing on specialist interventions was expected to improve the wound healing rate. At discharge, the SCPDN also educated the patient on prevention of pressure ulcers, enabling them to self-manage. The RCN (2019b) supports this, stating that patient education is vital to patient recovery.
A meeting known as a 72-hour review was held, wherein the MDT discussed the steps involved in the development of pressure ulcers, and the nursing team gauged whether the ulcer in the present case was avoidable or unavoidable. Eventually, the pressure ulcer was deemed avoidable. Then, a discussion took place within the team surrounding lessons learnt, so as to prevent reoccurrence, highlight good practice, review areas of development and identify training needs (Phelan and Davis, 2015). Following this, the SCPDN observed standards of care improvement, with the use of clinical audits and clinical supervision (QNI, 2016). Brewster et al (2018) stated that pressure ulcers can be avoided if the correct interventions are used. Within the author's organisation, the NHS safety thermometer tool is used for this purpose on a weekly basis. This tool aims to promote harm-free care and monitors improvements across services.
The National Institute for Health and Care Excellence (NICE) (2019) discussed a new technology designed for detecting changes to a patient's pressure areas, whereby pressure-induced tissue damage can be identified with a machine known as a sub-epidermal moisture (SEM) scanner. Moore et al (2016) stated that damage to soft tissue can occur days before presenting on the epidermis and, therefore, early detection of deterioration can reduce the risk of pressure ulcers developing. According to the RCN (2019a), training for nurses to understand the risk factors and what is healthy skin ensures that they have the skills to identify deterioration. Although further research is required into the benefits of the SEM scanner, the use of the scanner is being trialled across the author's locality, with evidence that fewer pressure ulcers have been noted within the caseload. Since it is within the SCPDN's remit to promote new technology to staff, implement changes and provide good-quality care (Gilsenan, 2019), the author recommends further research on this tool in order to reduce patient harm.
Use of the SBAR tool in safety huddles
The term SBAR stands for Situation, Background, Assessment and Recommendation (Shahid and Thomas, 2018). Shahid and Thomas (2018) characterised the SBAR tool as a situational briefing tool used to successfully convey patient information to other health professionals in a more succinct manner, thus preventing communication errors. Additionally, Beigmoradi et al (2019) suggested that using this particular tool provides a brief overview of the patient and their condition and relays information regarding the patients' medical history and background. Using the tool, health professionals can implement a clinical plan to manage the patient and their condition successfully, as well as provide recommendations to improve care.
The SBAR tool was initially established by the US military in 2002, and was then expanded for patient safety (Renz et al, 2013). The tool has been used in a hospital environment thus far and has been recognised worldwide for long, becoming a vital part of the healthcare society (Muller et al, 2018). In 2007, the World Health Organization (WHO) recommended that the SBAR tool be used in clinical settings to improve communication and patient handover between health professionals (WHO, 2007), although Riesenberg et al (2019) found little evidence to support the use of the SBAR tool. However, over the years, the SBAR tool has been successfully used in the hospital environment, so Shahid and Thomas (2018) suggested that using this tool during safety huddles might provide a more structured approach to the meetings and improve communication within the MDT.
Holistic assessment
Holistic assessments are seen as an essential role of the SCPDN, as they are vital for improving patient care (QNI, 2015). The Roper-Logan-Tierney model allows nurses to complete holistic assessments, identifying patients' health needs relating to the activities of daily living (Holland and Jenkins, 2019). The SCPDN should educate patients on the importance of self-management in order to improve overall health and prevent complications related to existing conditions, although Miles et al (2017) stated that providing self-management education is not always successful, due to barriers such as culture, language and patients' attitudes to learning, which are barriers that DNs face daily. Nonetheless, the SCPDN needs to ensure that they have the knowledge and skills to educate and support staff within the district nursing teams to ascertain that patients are given individualised, holistic care; they also need to build staff competence and confidence to enable the best evidence-based practice. Owens and Keller (2018) supported this with a quantitative analysis study, stating that confidence affects performance and that good leadership in nursing teams is essential for providing quality care. Conversely, lack of confidence has been linked to failures within patient care (Owens and Keller, 2018).
NHS England (2015) acknowledged that, in order to formalise an individualised care plan, a full holistic assessment must be completed. This should include social, psychological, physical, environmental, spiritual and cultural factors. A collaborative approach not only improves patient outcomes, but also enhances the SCPDN's knowledge and skills in the specialist field of practice. Boot (2016) recognised that the role of the SCPDN is best suited to facilitate this due to them having high levels of knowledge and skills. Before an assessment can commence, consent must be gained, and the SCPDN must ensure the patient is provided adequate information to enable them to make an informed decision (RCN, 2017c). Full mental capacity must be deemed when this decision is made (Mental Capacity Act, 2005). Marshall and Sprung (2017) advised that, if a patient is deemed to lack capacity, then a decision would be made in the patient's best interest by a family member awarded with lasting power of attorney. The SCPDN must ensure that this is discussed during safety huddles, so the MDT is informed of the plan of care and can thereby provide continuity of care and avoid repetitive questions (RCN, 2017c). The SCPDN should encourage all nursing staff to incorporate the 6Cs of nursing (caring, compassion, courage, commitment, competence and communication) in their everyday practice, keeping the patient at the centre of care delivery at all times (NHS England, 2013).
Additional strategies used in safety huddles
A priority board is included in safety huddles to ensure all patients are discussed daily. This is a suitable aid to document a list of patients and what is required, to ensure that all needs are met. For example, the safety huddle highlights new pressure ulcers that occur, which are then reviewed and seen within 48 hours. Discussing at-risk patients guarantees better levels of communication within the team (QNI, 2017). A qualitative study using semi-structured interviews to explore staff experiences and perceptions of safety huddles was conducted by Stapley et al (2017), and the thematic analysis indicated that nurses perceived safety huddles to help increase awareness of important issues; improve communication within the team; increase efficiency, anticipation and planning; and facilitate teamwork. However, the study also reported challenges with safety huddles, for example, added demands on staff time and workload and junior nurses being excluded. Other challenges were related to leadership, time and capacity issues associated with senior nursing staff and managerial staff (Stapley et al, 2017). In the author's experience as well, safety huddles have advantages and disadvantages; although they improve communication and teamwork, they also can be seen as an inconvenience within practice, as they take up time allocated for daily duties (Baird et al, 2016). Contrastingly, Wasser (2016) stated that having 10–15 minutes at the beginning of the day to plan their work helps nurses work more efficiently and improves patient care. This helps staff focus less on paperwork and more on patients (Wasser, 2016).
Going digital
Safety huddles are being implemented electronically in the author's district nursing team, and all teams and localities use the same safety huddle template. However, most teams are completing safety huddles incorrectly, and written documentation is not being completed appropriately. The author is working alongside a safety huddle focus group to share the information and training needed to effectively complete safety huddles electronically. According to the QNI (2018), the digital agenda has accelerated in the past 6 years. Implementing technology well necessitates great leadership from nurses, and nurses need to be open to change (Kodama and Fukahori, 2017). The SCPDN needs to ensure that all staff feel supported and knowledgeable to adapt to change. On reviewing national policies in the form of the Five Year Forward View (NHS England, 2014; 2017), it is apparent that a digital NHS is the focus of the future, wherein health services will be able to work collaboratively and ensure continuity of care is delivered with the use of electronic systems. Maguire et al (2018) suggested that healthcare services are struggling with increasing demand due to demographic changes and decreasing funding. Thus, implementation of digital technologies could see a transformation in the NHS, as services will be better equipped to cope with pressures. Further, service providers and health commissioners are looking to be able to plan services better, keep records more secure and provide better-quality care from the point of delivery with the use of digital technology. In the author's organisation, staff have laptops, which are used in patients' homes, thus allowing an uninterrupted workflow. Staff are able to deliver all interventions in one visit with the use of electronic patient notes, allowing nurses to access patients records immediately.
Conclusion
Safety huddles reduce patient and staff harm while also improving communication and collaborative working, as they enable health professionals to work together as part of the MDT. It is evident from the literature that, due to staff communication failures, patients are experiencing harm. New technology, such as that used for electronic documentation and early detection of pressure ulcers, is being implemented, but little evidence is available to suggest whether this will be beneficial to practice and patient and staff safety. Although staff can often view safety huddles as time-consuming, the benefits of these meetings for preventing patient harm cannot be denied.
Safety huddles could be improved to make them more efficient. The use of a communication tool, similar to the SBAR tool, would be beneficial, alongside safety huddle documentation, as it would enable a more streamlined, dedicated and task-focused discussion.
KEY POINTS
- District nursing caseloads are rising at a remarkable pace, with approximately 4000 nurses caring for almost 55 million people
- Safety huddles are daily meetings attended by members of the multidisciplinary team in community settings, which were designed to focus on certain patient groups (e.g. those with long-term conditions, those at risk of sustaining harm and those needing palliative care)
- These meetings aim to prevent patient harm and promote patient and staff safety, and poor attendance at these meetings leads to ineffective communication and potential harm to patients
- Promotion of digital technology is needed to enhance nursing practice, as a digital NHS is the focus of the future.
CPD REFLECTIVE QUESTIONS
- Consider the use of the safety thermometer tool within your team. Are there any elements not included in the tool that could be implemented to reduce the risks of pressure damage?
- What tool is used within your trust to prevent patient harm?
- Consider the future of a digital NHS. Is there anything that can be implemented that is not already used in community nursing today?