Assistant Practitioners in the District Nursing Service Gabbie Parham Senior Matron for Community Nursing e: gabrielle.parham@oxfordhealth.nhs.uk t: 07833295413 @gabbieparham

Legally, there are only a small number of clinical activities that non-registered staff cannot undertake: • Controlled Drug administration • Verification of death • Patient Group Directions (PGD’s) Irridiation Therefore, local services are required to develop their own specifications for the role, competencies and governance arrangements

Local Background The District Nursing Service review was completed in 2011. This identified that whilst the service had employed and trained Assistant Practitioners for some years, there was no agreement in the service regarding their role or governance arrangements. Consequently, the AP’s had not been used to their full potential in the service. Similarly, that the role of HCA’s was variable across the county and there was a lack of governance arrangements

Non-registered workforce The proportion of registered to non-registered staff is the DN service is currently 80% to 20%. This is likely to change in the near future to incorporate a higher proportion of non-registered staff Of the non-registered staff, approximately 20 are AP’s or trainee APs. The majority have been trained within service, at Oxford Brookes University

Scope of Practice Sets out the decisions made on the delivery of DN care tasks, by and different levels of non-registered staff. Decisions were made by District Nurse specialists and leaders in the service – clinical leads, CDLs. The decisions were made on the basis of meeting current patient need and future projected needs appropriately and efficiently.

Clinical Roles Overall, Registered nurses main role is a Named Nurse, undertaking assessments, careplanning, delivery of more complex care, and reviews of their caseload of patients. They are heavily involved in delivery of all patient care, and in the future will focus more on the most complex clinical care Overall, the role of the non-registered staff will is an Associate Nurses, delivering care prescribed by the Named Nurse, to stable patients, according to their role and competency. In addition, APs are now taking the lead on the continence caseload – including continence assessments, treatment pathways and product provision.

Broadly, non-registered staff deliver: Observations Wound care, including compression bandaging Catheterisations and catheter care Bowel care Equipment ordering Phlebotomy Palliative support visits

In addition, Assistant Practitioners, Band 4 deliver: Injections – B12, heparin for prophylaxis, Insulin for stable patients IV’s – via PICC or central line Re-assessments Dopplers Continence assessments and care Blood glucose and ketone monitoring

Competencies Competencies, related to the scope of practice, were required Some national competencies were available Most were developed within service, with help from specialists

Training Provision of the training required for the competencies has either been identified through current learning and development opportunities, or bespoke training is delivered within Community Nursing. The training covers the knowledge elements of the competencies. The skills element of the competencies is undertaken in clinical practice, with a registered nurse mentor to help train and support the non-registered staff member through the competencies. Registered Nurse supervisors help AP’s to work through the competencies and formally sign them off

Accountability Accountability of registered nurse when delegating any task to non-reg Is the task within the scope of practice document for their banding/role? Has the staff member been formally signed-off by a registered nurse in the competency associated with that task? Has the patient been seen by a registered nurse at the frequency specified by the service? Is the non-reg staff member happy to accept the delegation of that task?

Tips for implementation Be clear on Trust Governance structures and sign-off Communication to service – frequent, repetitive Bring APs together for peer support Involve all levels of staff from service in development of role Be clear on what your service, or areas within your service most need Evolve scope of practice in line with changing caseload Grow your own APs from HCAs Have a clear workforce plan