26 | Nursing in Practice | Spring 2022
MY DAY
Working as a complex care nurse
Jennifer Crozier shares the highlights of a day in her role supporting people over 65 living at home with varying degrees of frailty
NEIL O ’ CONNOR
08.30
Today I am the team coordinator , so I start by checking the complex care email inbox . It is empty , but I will check it throughout the day . When a referral is received , I check it is appropriate ( that is , for a person aged over 65 living with a degree of frailty ) before phoning the person to introduce our service and complete an initial frailty assessment using a PRISMA-7 questionnaire . This is a brief , seven-item yes / no form used to identify elderly people with a severe loss of autonomy . A person scoring four or lower is allocated to a care coordinator to make contact ; a score of five or higher will lead to a nurse arranging a full home visit assessment .
09.30
Time for our team huddle . We all gather to discuss any concerns , and support each other with problem solving and complex cases . We discuss plans for the day and advise on any team updates . Today I have two firstassessment visits and a best-interests meeting to attend .
10.30
I arrive for my first patient visit . The lady has been referred to us by her GP , who advised that although she is a high service user , this relates to social needs and loneliness more than medical issues .
I complete a full assessment . The patient lives alone and is housebound . She tells me that she used to own a dog and felt safe but has been has very lonely since he passed away . I comfort her and we start to build a rapport . Her physical observations examination is normal but she feels weak on her legs and we discuss the available interventions . She agrees to physiotherapy to help with leg-strengthening exercises ; the falls team will support with falls-prevention measures . Pharmacy will also conduct a structured medication review , as her multiple medications could contribute to the risk of falling . The patient is also interested in a befriending service , and animal therapy support through social prescribing . I arrange a review visit in a month ’ s time .
12.30
I am back at the office typing up my home visit notes and completing the agreed referrals . We add all comments to the practice IT system and to our own frailty tracker , which is used for data collection , measurement of referrals and key performance indicators .
13.00
Lunchtime offers an opportunity to interact informally with colleagues . We share stories , laugh and switch off from the working day . As a team , we stress the importance of stepping away from our computers at lunch time to allow ourselves to recharge , focus and bond with each other . Today was particularly good , as a colleague brought cakes to share with the team – lemon drizzle , delicious .
14.00
I arrive at a patient ’ s home to be part of a multidisciplinary team for a best-interests meeting , alongside a social worker , a family member ( next of kin ) and the patient ’ s physiotherapist . The patient had been assessed as not having the capacity to make decisions . We discuss the patient ’ s needs , and agree on how to support her care safely , guided by her best interests .
15.00
I am on the way to my next home visit . The patient has been referred by the primary care network paramedic , who said the gentleman is deteriorating medically but does not want to go into hospital and so may benefit from some advanced care planning . I complete a full ACP with him . He says he feels like a weight has been lifted off his shoulders as all his future wishes are now down on paper and ready to be uploaded on to the GP system .
16.00
Back at the office , I am typing up the home visit notes and updating the system with the advanced care plan details , including the patient ’ s preferred place of care and death , his wishes , next of kin details and hopes for future care . I reflect that my role is extremely rewarding as it allows me to support people in their own homes to live well for longer . I also signpost to many different services and help people plan ahead . I have a supportive team and we all work well together for our patients .
16.30
Home time . I start my ‘ second job ’ of being a wife and a mother to two young boys . This is my time to spend with my family . I believe it is important to wind down , relax and release any stresses the day may have created . This ensures I will be ready to give it my all again tomorrow .
Jennifer Crozier works as part of a team of nurses and care coordinators at Stalybridge , Dukinfield and Mossley Primary Care Network
What the role involves
• Complex care teams support both adults and children with complex health and social care needs at home or in the community .
• The nurse-led service supports people with a variety of complex conditions including mental health , physical disabilities , end-of-life , and learning disabilities and autism .