Developing and implementing guidance for staff delegating clinical tasks to informal carers and relatives during the COVID-19 pandemic

Our aims were:

• To reduce the waiting time for patients to receive symptom control
• To increase nurse capacity

A fundamental part of end of life care is ensuring that patients are comfortable and have timely and effective symptom control and pain relief. The likelihood of patients remaining symptomatically well managed at home is enhanced by domiciliary care services, informal carers and personal health budget (PHB) Personal Assistants (PA).

As Devon is a geographically large and a predominantly rural county access to swift timely healthcare can sometimes be challenging, in particular within out of hours when staff are required to travel across the county in any one shift. This could inevitably lead to delays in access to timely care. There may be times, in order to provide health and social care that are accessible, when it would be helpful for informal carers and PAs, with the right skills, to work alongside healthcare professionals to support and deliver symptom management and care at home in a way that respects the differing needs of the individual.

During these unprecedented times of COVID-19 where the most vulnerable have been shielding we have the opportunity to avoid unnecessary visits by delegating tasks to families and carers where appropriate. Contact and support can still been maintained via telephone.

The policy sets out to provide clarity on the roles and responsibilities of LiveWell employees when delegation of care from the registered practitioner is made to individuals who are not employed by LiveWell Southwest and provides assurance that appropriate tasks are always undertaken within the clear parameters of safe delegation in order to ensure that service users receive safe and effective care.

LiveWell Southwest is a recognised provider of integrated health and social care services. It serves a population of approximately 270,000, over a mixture of urban and rural settings in South Hams, West Devon and Plymouth with additional responsibilities for delivering specialist services to people living in parts of Cornwall and South Devon. LiveWell Southwest is an employee-led organisation and the largest community health and social care enterprise in the UK.

The company provides a significant amount of care to patients at the end of life. Approximately 1,300 are cared for during their last months, weeks and days of life by community services. This care is predominantly provided by community registered nurses, nurse associates and healthcare assistants working within the District Nursing service. LiveWell have approximately 110 registered nurses, 10 associate nurses and 45 healthcare assistants working within the district nursing service, all of whom will have some input to palliative and end of life care. Where required, specialist advice is sought from the local hospice. A fundamental part of end of life care is ensuring that patients are comfortable and have timely and effective symptom control and pain relief. The likelihood of patients remaining symptomatically well managed at home is enhanced by domiciliary care services, informal carers and personal health budget (PHB) Personal Assistants (PA).

As Devon is a geographically large and a predominantly rural county access to swift timely healthcare can sometimes be challenging, in particular, within out of hours night shifts which are covered by 2 registered nurses and 2 healthcare assistants, when staff are required to travel across the county in any one shift. This could inevitably lead to delays in access to timely care. There may be times, in order to provide health and social care services that are accessible, when it would be helpful for informal carers and PAs to work alongside healthcare professionals to support and deliver symptom management and care at home in a way that respects the differing needs of the individual (Livewell South West Equality and Diversity Policy).

In recognition of this, LiveWell Southwest sets out to provide clarity on the roles and responsibilities of Livewell employees when delegation of care from the registered practitioner is made to individuals who are not employed by Livewell Southwest and to provide assurance that appropriate tasks are always undertaken within the clear parameters of safe delegation in order to ensure that service users receive safe and effective care.

In the wake of the Covid-19 pandemic and high rates of community transmission in the UK and subsequent shielding advice given to those most clinically vulnerable to infection, the rationale for this policy and its implementation was further reinforced. The publication of NICE’s rapid COVID-19 guidelines  provided an opportunity to ensure the development of the policy was aligned to recommendations within the guidance.

Taking a collaborative approach, the team, led by the End of Life Care (EOLC) care lead, led development of the policy through a medicines optimisation group which brought medical and pharmacy input into the development of the policy.

Development of the policy involved wide-ranging consultation with a number of key stakeholders including: St Luke’s Hospice, District Nurse Matron, Livewell SouthWest education team, NHS Devon CCG Rowcroft Hospice, Hospice care UK, Livewell Pharmacist, Royal Devon and Exeter NHS Foundation Trust and Marie-Curie.

Stakeholders felt it was important to address willingness of informal carers to undertake tasks and the education, assessment and competencies of informal carers to undertake the tasks required. It was also important to ensure that the person who was dying consented to the tasks being undertaken by informal carers. We also felt it was important to ensure that the informal carers had ongoing support from professionals and that they had clear guidance and boundaries. Staff would also need to be reassured that they were supported by their employers and governing bodies to delegate tasks that are traditionally seen as a nurse’s role.

The policy draws upon the recommendations in NICE guidance NG163 in the following areas:

Recommendations in section 4 – Communicating with patients and shared decision making: Specifically:

• Minimising non-essential face-to-face contact and using different delivery methods to get medicines to patients. LiveWell Southwest are also working on an Advanced Care Plan (ACP) and sharing of this information with our GPs and other organisations within the locality. We have devised an electronic ACP that professionals can complete with their patients when the time is right. This will then be printed for the patient to keep at home and is also able to be shared with others with the patient’s consent. This is still in the draft stages of development at the time of writing.
• Recommendation 6.1.1 – Care planning in the community
• Recommendation 6.1.6 – Managing medicines for patients

If there are fewer health and care staff you may need to prescribe subcutaneous, rectal or long-acting formulations, and carers or family members may need to administer them.

The team also engaged with local GPs in order to overcome initial concerns they had around family members administering certain medications.

There were some concerns about competencies, abilities, mental capacity and home environment. This has been overcome with robust risk assessment of the patient and the person being asked to deliver the task. Staff have also undergone training in Third Party Delegation, what this entails, exclusion criteria what is required of them and what they are permitted to delegate.

There was also considerable engagement with the local hospice team around the development of the policy.

The local hospice was involved and consulted with from the outset of this policy. Clinical nurse specialists, educators and directors inputted to the policy and provided training to staff within the hospice and LiveWell Southwest. The hospice was keen for this policy to be implemented as they could see the benefit to our patients and both organisations had anecdotal evidence of where this could benefit patients and reduce anxiety for families. This is a joint working policy with the hospice.

Staff using the policy were trained remotely, initially using Zoom but then moving to Microsoft Teams as a collaborative working tool. Initial concerns raised by staff were around the principle of family members and informal carers providing symptom control relief and any potential clash on registration and NMC Code of Practice regulations. These were overcome through initially face to face training and reassurance before this moved to virtual training during COVID-19.

The Hospice also assisted with rolling out training on use of the policy to staff. Powerpoint slides used for training can be accessed here.

Shared with kind permission of Gail Wilson, Deputy Director of Clinical Services (St Luke’s Hospice).

Since the policy has been introduced there has been anecdotal feedback from staff, patients and their families.

Feedback from staff has led to some changes in the policy:

• Additions to appendices where staff felt that the wording or diagram were unclear.
• In order to provide additional support and clarity to informal carers administering the treatment we changed from carers contacting nurses either before or after giving an injectable medication to before administration.
• New version of policy is attached as a supporting document.
• Although some delegation of symptom control medication has been successful, wound care/dressings has had hugely more uptake given the aspect of reducing footfall into patient’s homes and care homes to prevent risk of Covid-19. This also helped reduce the numbers of visits on caseloads which enabled more patients to be seen and also helped where staff were off sick or isolating due to Covid-19. The need for care home residents to still receive the same standard of care supported at a distance while reducing the footfall in the homes has been achieved by the district nursing (D/N) service with telephone, email support and using technology in optimising reviewing of wounds from a distance. Although the training of careers and the assessment process can be time consuming and there is often a large turnover of staff.
• The use of technology to assess patients virtually caused problems for some staff and education around this has and continues to take place.
• Wound care has also been delegated to family members where their relatives have been involved with supporting shielding patients to maintain a strict social bubble. However, as family members have returned to their work and shielding restrictions eased some families have felt the need for wound care to be taken back by D/N service.
• Nurses assess the suitability of carers to undertake tasks on their physical, mental and emotional ability along with the suitability of the environment.
• Some nurses felt it would be quicker to complete the task themselves but do understand the need for autonomy.A survey to measure feedback and experience from patients and their families and carers is in development. A separate survey is in development to capture staff experience and feedback.
• To date there has been no incidents or complaints reported during the period that the policy has been in use.

For future evaluation, we will be looking at themes that will include:

• The ease of which carers were able to use the written information,
• Experiences of the education they received from practitioners,
• Whether they felt confident to administer the treatments,
• Length of time from when symptoms were first recognised to when treatment commenced and whether this was effective, and:
• Whether further advice and support was needed from a registered practitioner.
• I am sure that by the time we survey families further feedback will determine the actual survey questions.

• Staff engagement and getting senior directors buy-in was important as was engaging early with all relevant stakeholders including the local hospice and GPs.
• Ensuring staff did not feel pressured to delegate to informal carers either by the carers, patient or colleagues was important.
• The lead for EOLC attended team meetings to introduce the policy and respond to any concerns raised which increased staff buy-in.
• Staff education was crucial in implementing the policy.

Engagement with patients and families:

It can be difficult to meet the expectations of people who are going through a very difficult and stressful time and we need to have the confidence and expertise to have these difficult conversations. We have found that listening to the concerns of families and acting on these concerns where possible helps with the therapeutic relationship.

It has been difficult when families have asked to undertake a task that the nurse has felt they are not competent to undertake. Competence is not only about the physical ability to undertake the task but could be the mental and emotional ability. However, this can be overcome by talking to all involved and explaining the rationale for decisions.

Informal carers/families needed to know that they had support over 24 hours per day and that they could contact a professional whenever they needed to.