Introducing a named nurse model of care in a community nursing service
Intended for healthcare professionals
Evidence and practice    

Introducing a named nurse model of care in a community nursing service

Donna Jones Formally a locality clinical manager, Shropshire Community Health NHS Trust, England

Why you should read this article:
  • To recognise the challenges that community nurses commonly experience in practice

  • To learn about the benefits of implementing a named nurse model of care in community settings

  • To be aware of the challenges with introducing changes in practice such as the named nurse model

The named nurse model has the potential to promote person-centred, high-quality care in the community setting, while also enhancing the job satisfaction, morale and retention of community nurses. By giving responsibility for a small group of patients to a named community nurse, any deterioration in their health can be identified quickly, resulting in a reduction in patient safety incidents. Additionally, the continuity of the named nurse model can foster therapeutic relationships, enhancing experiences of care for both patients and nurses. This article details a service evaluation project in which the named nurse model was introduced across a trust-wide community nursing service. Following the introduction of the model, the capacity of the service increased, and the quality of care provided by nurses improved. However, it was identified that some community nurses experienced moral distress when reprioritising patient care to maintain service capacity.

Primary Health Care. doi: 10.7748/phc.2024.e1824

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@DonnaJones2709

Correspondence

donnajones2709@gmail.com

Conflict of interest

None declared

Jones D (2024) Introducing a named nurse model of care in a community nursing service. Primary Health Care. doi: 10.7748/phc.2024.e1824

Published online: 24 January 2024

Community Nursing services are a vital part of the NHS. The delivery of home-based assessments and nursing care enable many patients to remain healthy in the community, while community nurses are also able to provide essential end of life care in people’s homes where required (Maybin et al 2016). The ageing population in the UK means that many patients are increasingly likely to live with chronic disease, multiple health conditions, frailty and/or disability, which when combined with government plans to shift more care out of hospitals and into community settings, has resulted in a rise in demand for community nursing services (Maybin et al 2016, NHS 2019).

Despite this increased pressure on services, an NHS Confederation (2022) report outlined the chronic staff shortages experienced by community nursing services. For example, the numbers of district nurses fell by almost 43% between 2009 and 2019 (Queen’s Nursing Institute (QNI) and Royal College of Nursing (RCN) 2019).

In addition, following the coronavirus disease 2019 (COVID-19) pandemic, the RCN District and Community Forum commissioned a survey of 492 community nurses to understand the post-pandemic pressures in community nursing and found that services were at ‘breaking point’ (Green 2021). The findings revealed that: 96% of community nurses reported patient acuity was continuing to increase; only 1% regularly left work on time after their shifts; only 4% said they were always able to deliver their very best care; 79% said the time allocated to patient visits was insufficient; and half had no time to include advice on health promotion or disease prevention in consultations (Green 2021).

This article details a project in which a named nurse model of care was introduced in a community nursing service, then evaluated to determine its effectiveness.

Project background

Historically, the community nursing service in the author’s trust was staffed by approximately 35 senior nurse caseload holders (band 6) who each oversaw a patient caseload and were responsible for a team of 4-5 community nurses (band 5). To deliver patient consultations with an appropriate skill mix, each senior nurse caseload holder’s small team also included nursing associates and healthcare assistants. The senior nurse caseload holders were in turn managed by team leaders (band 7 nurses), with one team leader managing four senior nurse caseload holders on average. Each caseload comprised around 90-150 patients who were registered with various local GP practices.

The community nurses were allocated their patient visits for the day based on their individual competencies, with patient locations considered to minimise travel time. However, evaluations of patient care were not consistently scheduled, nor was the effectiveness of care provision robustly reviewed. Each senior nurse caseload holder held a 30-minute daily handover to discuss any staff concerns, but this was often brief due to the time pressures involved in managing large numbers of patient visits.

This model of care also often resulted in a loss of continuity, with patients being visited by multiple staff members at various times. In the literature, nurse-patient continuity is a significant factor in safe and effective care and is also valued by patients as a quality indicator, enabling them to develop trusting relationships with nurses (Francis 2013, Maybin et al 2016). Maybin et al (2016) argued for nurse-patient continuity as a means of providing holistic and person-centred patient care, and enabling nurses to identify improvements or deterioration in patients’ conditions more effectively. Continuity of patient care can also be beneficial for nurses’ morale, while enabling nurses to work autonomously has been found to improve their job satisfaction, health and well-being (RCN 2015). Furthermore, researchers have identified that enhancing staff workplace experiences can be linked to improved patient outcomes (Powell et al 2014, West 2016).

Key points

  • Nurse-patient continuity can be a means of providing holistic and person-centred patient care, and can enable nurses to identify improvements or deterioration in patients’ conditions more effectively

  • To address issues with patient continuity, a named nurse model was introduced into the community nursing team, with every patient on the caseload being allocated a named community nurse

  • The overall effect of the named nurse model and demand-and-capacity tool was positive in terms of providing protected time for the community nurses to provide high-quality care

  • There were some isolated issues with the implementation of the new system. For example, the rescheduling of low-priority patient visits when demand outstripped capacity caused some nurses to experience moral distress

Introducing a named nurse model

Due to the issues with continuity in the previous system of care, the author decided to introduce a named nurse model into the community nursing team in her trust, with every patient on the caseload being allocated a named community nurse. In this system, patients are allocated a named nurse by one of the senior nurse caseload holders, with consideration given to the named nurse’s specific skills and competencies. The named nurse is responsible for the planning, monitoring and evaluation of each patient’s management to improve the safety, effectiveness and quality of care delivery.

The named nurse concept has been used in inpatient, mental health and children’s services previously, and was a recommendation made in the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013). The benefits of the named nurse model are that it can promote person-centred care, prevent task-oriented care and improve patient outcomes, resulting in greater satisfaction among patients and families. The named nurse model also empowers nurses and increases nurse autonomy, which may subsequently improve staff satisfaction and retention (Mitchell and Strain 2015).

As well as introducing the named nurse model locally, the author also investigated the skills required to safely manage a community caseload. The QNI’s (2022) workforce standards document discussed the subject of safe caseloads in district nursing and emphasised the complexity of the care required in patients’ homes. According to the QNI (2022) document, overseeing quality care for a broad caseload of community patients ideally requires nurses with a specialist practitioner qualification in district nursing. This qualification not only enables nurses to exercise judgement, discretion and decision-making skills, but also to monitor and improve standards of care through the supervision and development of staff (QNI 2015).

To provide a community nursing service with appropriate oversight of patient care, the author implemented a system of named nurse reviews, which were led by senior nurse caseload holders with the specialist practice qualification in district nursing. These reviews were scheduled for one hour each month, or more often if the named nurse required additional support. They provided a forum to discuss each patient’s care with a focus on ideal visiting frequency, the quality of documentation, assessment and onward referral, the patient’s ability to self-care, and the identification and mitigation of risk. The meetings also enabled the senior nurse caseload holder to identify any training and development needs for the named nurse.

Training, development and support

The previous service model lacked an opportunity for community nurses to access on-the-job training, development and support. This was proving to be a concern since staff, particularly newly registered nurses, were reporting high levels of stress and burnout with staff retention being affected as a result. Ensuring learning and development opportunities for staff is essential to providing high-quality patient care (QNI 2015), as well as maximising staff health, well-being and career potential (RCN 2015).

To address the lack of opportunity for community nurses to access training and support, the author requested that senior nurse caseload holders ‘check-in’ with staff during the named nurse review meetings to ensure they were supported with any challenges they were experiencing at work or in their personal lives. This promoted a caring environment where the community nurses could discuss any personal issues, while the senior nurse caseload holders could identify any areas of development required in the nurses’ knowledge, skills and competence.

Achievable workloads

Unlike inpatient facilities, community nursing services have no finite number of beds, which can lead to a lack of clarity as to when a service’s capacity had been reached (National Quality Board 2017). Work pressures are a significant issue for community nurses and can result in them staying late on shifts and describing the workload as ‘relentless’ (Green 2021). Furthermore, West (2016) discussed the link between work-related stress and low-quality patient care with a lack of clear roles and responsibilities being a contributory factor.

Under the previous community nursing model at the author’s trust, anecdotal staff feedback suggested that high workloads were proving detrimental to the community nurses’ health, well-being and work life balance, and were also affecting the quality of patient care. The nurses also reported feeling under pressure, with little time to deliver patient care. This was because the volume and complexity of the patients they were allocated often resulted in unachievable workloads. As a result, they were feeling overwhelmed and stressed.

The author recognised that adopting the named nurse model would be ineffective unless staff were given the appropriate time and capacity to implement it. To prioritise the community nurses’ workloads and provide them with appropriate capacity, the author developed a demand-and-capacity tool for the service. This tool uses a spreadsheet to provide a daily update of the available community nurse capacity, which is calculated by inputting the time required for nurses’ travel, safety ‘huddles’, non-patient-facing time and other essential requirements necessary to deliver patient care in the community. The nurses’ clinical workload is also factored into the tool to calculate a positive or negative capacity figure. A negative capacity figure requires the nurse coordinator (a senior nurse identified each day and who is responsible for workload allocation) to increase the service’s clinical capacity by employing bank staff or reprioritising the workload by rescheduling low-priority patient visits to maintain safe patient care. The purpose is to achieve a balance between using the nurses’ time productively and preventing them from becoming overloaded with visits.

Project evaluation

Aim

To evaluate the effectiveness of a named nurse model in improving patient care and safety while supporting the work of community nurses.

Method

Following discussions between the author and the team leaders, four areas were identified as contributors towards high-quality patient care and a positive workplace for staff, but which were not being currently being achieved:

  • Patient continuity.

  • Senior review of patient care.

  • Training, development and support for staff.

  • Achievable workloads.

To address these four areas, the named nurse model was rolled out across all of the trust’s community nursing teams over a 12-month period between December 2021 and December 2022.

The effectiveness of the named nurse model was evaluated by the author asking team leaders if they or any of their staff wanted to provide anecdotal feedback on the implementation of the model or examples of the effects that it had on patients or themselves. The author received 13 comments from staff via email, and these staff members were asked to complete a consent form which stated that their comments would remain confidential. The author also consulted trust data on team caseload sizes and numbers of new referrals. The feedback and data were then collated by the author to identify broad themes.

Ethical approval for the project was not necessary because it constituted a service evaluation.

Findings

Following collation of the feedback from nurses and consideration of the trust data, the author identified three main themes:

  • Safe and effective patient care.

  • Improved patient experience.

  • Improved staff experience.

Safe and effective patient care

After implementation of the named nurse model in December 2021, there was an improved flow of patients through the caseloads and a reduction in the overall caseload size by 440 patients, from 3,120 in January 2022 to 2,680 in February 2023. This was achieved despite a 10% increase in referrals into the service during the same period. According to the finance team in the author’s trust, a 10% increase in referrals would normally be expected to require a 10% increase in nursing staff, at a cost of around £607,000 at NHS pay rates or £1.1 million at agency rates.

Figure 1 shows trust data on the effect of the named nurse model on caseload sizes and numbers of new referrals.

Figure 1.

Trust data on the effect of the named nurse model on caseload sizes and numbers of new referrals

phc.2024.e1824_0001.jpg

This improved flow of patients indicated that patient care was being more effectively managed, for example with wounds healing more quickly and more patients than before engaging in self-care, which subsequently resulted in reduced caseload sizes. One of the senior nurse caseload holders commented on how implementation of the named nurse model had enabled them to promote self-care:

‘During a named nurse review we identified a patient who was on a low dose of insulin and had a stable blood glucose level. We considered whether his diabetes could be manged with oral therapy. The named nurse discussed this with the patient, the patient’s mother [carer], his consultant and the diabetes specialist nurses. The consultant and the diabetes specialist nurses agreed, although the patient and his mother were anxious at the prospect of discontinuing insulin due to concerns about the patient becoming unwell. The named nurse was able to work with the patient and his mother to provide education, support, and reassurance, and together they were successful in titrating his insulin dose down until it was discontinued. The patient and his mother now self-care by following a healthy diet and with regular monitoring of his blood glucose level to ensure it stays within normal limits.’ (Senior nurse caseload holder A)

The previous model of community nursing in the author’s trust focused on the treatment of patients’ conditions resulting in task-oriented care. However, the named nurse model promoted holistic, person-centred care, with a focus on developing relationships and trust with patients through continuity of care. For example, one nurse team leader commented:

‘A female patient was referred to us requiring wound care for a category 4 pressure ulcer. Our team struggled to gain access to provide treatment as she would often decline or cancel our visits. On implementing the named nurse model in our team, the patient’s named nurse invested time and worked on building a relationship with her. Over time, the patient confided in her named nurse that her son became verbally aggressive towards her when we visited, which was having a negative impact on her health. The named nurse supported her to access safeguarding support and the son was removed from her property with her consent. She expressed her gratitude to her named nurse for her help and we were able to provide her with the wound care she required.’ (Nurse team leader A)

The named nurse model also enabled community nurses to identify other members of the multidisciplinary team who might be better placed to assist patients with specialist input. One senior nurse caseload holder commented:

‘One of my patients was discharged from hospital with a complex spinal injury following a fall. As his named nurse, I identified that he required physiotherapy and speech and language input. Our three professions worked closely together around the patient to meet his mobility, transfer, nutritional and proactive pressure ulcer prevention needs. We supported this gentleman and his wife to have the knowledge, confidence, and equipment to self-care for his skin integrity and successfully prevent any pressure ulcer damage.’ (Senior nurse caseload holder B)

Another senior nurse caseload holder related their experience of holding a multidisciplinary meeting to optimise patient care:

‘My patient has multiple sclerosis, lives at home with her husband and is unable to move her body or communicate. She has two calls a day from a care agency, was seen daily by our community nursing team for wound care but was alone at home for periods of the day when her husband was at work. The husband was clear that the patient did not want any additional care in place, but I was concerned that she would be unable to call for help if she became unwell or if there was an emergency. Discussions with the husband about these concerns had not been successful in reducing the risk and I therefore organised a multidisciplinary meeting with the patient, her husband and multiple other professionals that were involved in her care. We listened to the wishes of the husband advocating for his wife and discussed our concerns. As a team, we were successfully able to find solutions to reduce the risk to the patient that were in line with the wishes of the patient and her husband.’ (Senior nurse caseload holder B)

The continuity provided by the named nurse model also had a positive effect on patient safety. For example, nurses began identifying and acting on patient deterioration more promptly than before because they saw patients regularly and were better able to identify subtle clinical changes in their wound status, thereby reducing the number of patient safety incidents (Figure 2).

Figure 2.

Effect of the named nurse model on patient safety incidents between January 2022 and February 2023

phc.2024.e1824_0002.jpg

Historically, the most common patient safety incident reported in the author’s community nursing service was the development or deterioration of pressure ulcers. However, according to data taken from an audit of community pressure ulcers by the quality assurance team in the author’s trust, since implementing the named nurse model the percentage of pressure ulcers developed by patients while on the caseload (out of the total number of pressure ulcers reported) reduced from 44% in 2022 to 24% in 2023, with the largest reduction seen in the number of category 4 pressure ulcers.

Improved patient experience

The log of complaints kept by the community nursing team showed a reduction in the number of patient complaints received by the service following the implementation of the named nurse model. Some of the nurses also reported that they were capturing more positive feedback from patients than before the implementation of the system:

‘My patient told me that she and her family felt reassured and comfortable knowing that I was their point of contact. She had noticed an improvement in her care since before the named nurse model was implemented in that now she always has a sufficient supply of bandages, whereas before we would sometimes run out of bandages. Being a named nurse made care planning and working with the family easier, and when she was at the end of her life, the very complicated system we had before was removed, which made for a much nicer environment for all involved.’ (Community nurse A)

‘My patient told me they were very grateful for all the care they had received and thought the team were wonderful.’ (Community nurse B)

‘My patient fed back to me that they felt I had gone above and beyond to ensure he got the right care, and was very grateful for the wonderful care I had provided.’ (Community nurse C)

‘I was named nurse for a palliative patient who recently passed away. His wife told me: “A huge thank you for your wonderful care for my husband over the past few weeks. You all know how much you helped me to cope. I will never forget the kindness you gave us both.”’ (Community nurse D)

Improved staff experience

The evaluation found that the community nurses valued the patient continuity provided by the named nurse model, which enabled them to develop positive therapeutic relationships:

‘I enjoy the continuity with patients because I can build a rapport and get to know my patients.’ (Community nurse C)

‘I love the named nurse model. It offers continuity for our patients and allows us to build a therapeutic relationship through our strong rapport with them.’ (Community nurse F)

Another community nurse discussed how the model had enabled them to develop their assessment skills:

‘As a nurse coming to the end of my preceptorship programme, the named nurse model has helped me to understand the needs of the patients more and the process of undertaking a holistic assessment. I feel that I have more continuity of care with my patients and am better able to identify supporting services to improve the quality of patient care.’ (Community nurse E)

Community nurses also mentioned the demand-and-capacity tool and how it protected the time they required to provide holistic patient care:

‘Before the demand-and-capacity tool, I used to feel completely overwhelmed with visits and end up working over every day, thankfully, the tool has stops this and I now have a manageable day.’ (Community nurse F)

Senior nurse caseload holders related how they valued using their knowledge and skills under the named nurse system to oversee the quality of patient care and develop their staff:

‘The named nurse model allows me the time to support and develop my staff to identify training needs and increase their confidence’ (Senior nurse caseload holder C)

In addition, nurse team leaders reported that the community nurses were taking more responsibility for the care of their named patients following the implementation of the system and were achieving improved patient outcomes as a result. The nurse team leaders also reported an improvement in staff morale. This had a positive effect on staff retention, which is essential for a sustainable workforce. As patient safety incidents and complaints reduced, some of the nurse team leaders described how they enjoyed spending more time proactively developing the trust’s community nursing service:

‘It’s made us feel like nurses again.’ (Nurse team leader B)

‘Complaints and patient safety incidents are reduced which means our time is spent being proactive rather than reactive, which is proving to be a safer way of working.’ (Nurse team leader C)

Although the overall effect of the named nurse model and demand-and-capacity tool was positive in terms of providing protected time for the community nurses to provide high-quality care, anecdotal reports from some of the nurses indicated that there were isolated issues with the implementation. For example, the regular rescheduling of patient visits according to the demand-and-capacity tool caused some nurses to experience moral distress because they wanted to provide the same level of care for all patients at all times (Baker and Vincent 2023):

‘When we don’t have sufficient capacity to visit patients it can be demoralising. You don’t come into nursing to let people down.’ (Nurse team leader C)

Discussion

The most significant challenge with implementing the named nurse model was the culture change required from staff. Balancing the demands on the community nurses with the service’s capacity was challenging, and despite attempts to increase capacity, the senior nurses often had to reprioritise patient visits after consideration of the level of individual patient need, the complexity of conditions and risk of deterioration.

Baker and Vincent (2023) argued that nurses can be motivated to join the profession due to a desire to help others, even to the detriment of their own well-being, which they described as the ‘super-helper syndrome’. Healthcare often imposes impossible demands on nurses due to staffing challenges, which can result in many nurses reporting moral distress (Baker and Vincent 2023). Jones (2021) described moral distress as a phenomenon that occurs when nurses are prevented from acting ethically due to work circumstances such as low staffing levels. This was reflected in the findings of this evaluation, where the need to reschedule low-priority patient visits when demand outstripped capacity caused some nurses to experience moral distress. This was due to their desire to provide care equally to all the patients on their caseload. This demonstrated that although the named nurse model provided a safer, more clinically effective and efficient way of working, there was a risk that staff could still be negatively affected during staffing shortages. Therefore, it is important to note that the named nurse model should be used in conjunction with regular workforce reviews.

Another challenge with implementing the model was initial anxiety among some of the community nurses around accountability and being identified as the named nurse for a group of patients. This occurred at the beginning of the roll-out and was rectified by the implementation of the named nurse reviews, during which the community nurses were able to discuss any anxieties with senior nurse caseload holders and as a result felt more supported in their role.

Conclusion

The named nurse model provides community nurses with the continuity and time necessary to provide holistic, person-centred care. In this evaluation, the named nurse model not only improved the quality of patient care, but also improved the morale of community nurses, which is essential for a sustainable NHS workforce. Patient safety was also improved and the flow of patients through the community nursing service increased, thereby improving efficiency. However, during periods of short staffing, reprioritising patient visits caused some community nurses’ moral distress. Therefore, the named nurse model should be used in conjunction with regular workforce reviews.

References

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  3. Green J (2021) RCN survey reveals ‘relentless pressures’ on district nurse services. Primary Health Care. 31, 2, 11-13. doi: 10.7748/phc.31.2.11.s5
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