24/7 Community Nursing Service Model

What was the issue you were addressing or working on?

To implement a 24/7 community nursing service throughout mainland Shetland and the islands.

What you did?

The implementation of a 24/7 Community Nursing service was identified as a priority through the work undertaken in the development of the NHS Shetland Clinical Strategy.

Traditionally NHS Shetland had provided a 24/7 community based nursing service via the provision of a District Nursing service from each of the Health Centres during the normal working day of 0830-1700hrs, Monday to Friday, with an oncall arrangement being in place to respond to any emergency calls in the out of hours period each night.

The District Nursing service also provided a limited weekend service, providing an “essential visit” service to patients who required this or responding to an emergency call out only.

This model of service provision existed on mainland Shetland, on the outer isles of Yell, Unst and Whalsay, as well as on the 5 Non-Doctor Islands.  The nurses who provided the oncall service were oncall between their shifts and thus any call out presented a disruption to their rest or sleep time.

A shift based 24/7 model of Community Nursing services was established on 2 April 2012. This was enabled through monies from the change fund initially.

This model has District Nursing services provided from each of the Health Centres 0830-1700hrs, Monday to Friday, and from 1700 – 0800hrs an out of hours service covering all of mainland Shetland is provided on a shift system, with the evening shift being 1700-2130hrs and overnight 2115-0815hrs.  The service is based at the Gilbert Bain Hospital.

This new service model was developed in partnership with the Community Nursing staff, with representation from the Area Partnership Forum being provided through the Employee Director and lay representation achieved via discussion at the Public Partnership Forum.  This service provides a 24/7 service to individuals resident on mainland Shetland.   All other areas have maintained the oncall service in the out of hours period because the level of activity and geographical challenges mean that it would not be appropriate to move to a shift based system.

What were the outcomes - benefits or otherwise?

The information presented below provides details on service activity in the first 12 months. The data relates to the period from 2 April 2012 to 31 March 2013.

Clinical Activity

Overall, 274 patients were seen by the community nursing team either in the extended core hours period (1700-2130hours) or overnight (2130-0815hrs).  These calls took place during the following time periods:

One patient was transferred to the day service because the day staff would have been on shift by the time the call was responded to and thus they were able to attend to the patient quicker than the night shift staff member travelling from Lerwick.

The following table shows that the number of calls are variable throughout the days of the week, with the highest number of calls being on a Saturday, closely followed by Tuesdays and Sundays.

Numbers of Calls by Day of the Week:
Shetland Comm Nursing days table

It was noted that a number of patients had Anticipatory Care Plans (ACPs)  in place e.g. palliative care patients and they were appropriately completed and up-to-date. This meant that on 16 occasions, for patients seen in the out of hours period who had an ACP, that the plan was followed as opposed to any alternative which may have resulted in an inappropriate admission to hospital.

In addition to the above the Community Nursing Advanced Nurse Practitioner postholders participated in the delivery of a range of services within the Gilbert Bain Hospital.  The nurses undertook the following duties:

  • Clinical procedures, e.g. catheterisation, venepuncture, cannulation, administration of intravenous antibiotics;
  • Participated in the care of patients in particular circumstances e.g. providing 1 to 1 support to patients with Mental Health issues, supporting the management of complex care issues in the ward areas eg patients with Dementia, or acutely unwell patients, and supporting of A&E team in the management of minor and major trauma;
  • Undertook nurse escort duties to Sumburgh with Scottish Ambulance Service;
  • Provided another Senior Nurse within the Gilbert Bain Hospital in the overnight period when nursing and medical staff are at minimal levels;
  • Updated/refreshed and developed new skills eg opportunity to gain competency in practical administration of intravenous medication, use of syringe pumps, management of trauma.

All of these activities have supported the delivery of the clinical service and the overall resilience of the Gilbert Bain Hospital at night.

From the data presented it may appear that the provision of a Community Nursing service on a shift based 24/7 system is not required due to the relatively low number of patients seen in the out of hours period.  However, the Community Nursing service faces the same challenge as the range of services provided in Shetland where there is a relatively low volume of activity but still a requirement to provide a service.

The move to a shift based system was initially supported by monies from the Change Fund, however, service redesign has enabled the delivery of this service to be achieved by the redistribution of our resources within the overall service.

Contacts - to find out more

Edna Mary Watson, Edna.watson@nhs.net