Working in Community Response

Alison's Story

Interview with Alison, Discharge to Assess

First name and title, please.

So I’m Alison Bamber. I’m one of the nurses from Discharge to Assess.


How long have you been in this role for?

I’ve been in this role currently for three years and I’m really enjoying it. Prior to this role, I used to work with the district nurse team. I came over to discharge to assess because I like the idea of working within a multidisciplinary team. We’ve got the physiotherapist, the occupational therapist, and it’s just more integrated, which I really enjoy. It works well as an integrated team because you can bounce ideas off each other and patients get seen on the day of discharge, which is really good. This means hopefully we can pick up any concerns. It’s only a short service, but there are other teams and to support once our team discharges after the seven days.


What was it that attracted you to this role?

With this team, because it was more integrated — with the physios, the occupational therapist, we’ve got a pharmacy and then we’ve got clients to support us — I just feel like there’s more support. The patients are offered a more rounded service, which is positive and helps us hopefully move them along successfully… That’s what I find really enjoyable, having those success stories on a day-to-day basis. That is brilliant.


What’s it like in a community-based setting?

With our team (Discharge to Assess), we are in the house for quite a long time because we’re doing the initial assessment. A patient has usually just come home from hospital and can be exhausted, but obviously, they still need to do your assessment.

The purpose of our visit is to make sure that they’re safe and well after coming home. We’ve got to make sure that they’re clinically well, but then we’ve also got to make sure that they can make sure that they’re able to do everything. For example: getting up off the bed, and using the toilet.

We do all that in our initial assessment, so we can actually be there for between one to two hours with some patients. Obviously when they’ve just come home this can be quite overwhelming, but once we’ve explained to them why we’re there we can help. Sometimes we may have to come back the next day to offer they need care or support. This can often involve the reablement as part of the planning. It can be a long visit, depending on how the patient is.

I really enjoy my work though and what I enjoy especially is that every day is different. You don’t know what you’re going to walk into because we have a day a week where we coordinate. So, we accept all the referrals or decline them depending on what comes through. I prefer being out and about because that’s what community is.  Sometimes problem solving can be difficult in the community, but you’ve got so many colleagues with expertise who can always help.


Biggest challenges?

One of the biggest is patients coming home who we don’t know. So part of our standard operating procedure is that we know that a patient is coming home but sometimes, obviously, patients fall through the neck, we’re not always told and when we get there, patients are unwell and we need to problem solve quite quickly. So that can be stressful and it can also be stressful sometimes staffed, we’ve got sickness and things and between us all we seem to get there but they’re the main two things that obviously patients become unwell. That’s part of our role and we have to deal with that and shortages and staff, we can never predict that. You just need to be able to manage it and deal with it as a team.


Biggest rewards?

“I think it’s the people who you work with, I think they make this job what it is. Sometimes it is stressful, but we just managed to deal with it together.

Even though you are on your own in the house, you know that you are only a phone call away from someone who can help you. And if you do make that call, I feel like you always do get the support.

Here we have regular team meetings too. If there are any concerns, people are allowed to have a voice and that is actually encouraged.

Our managers encourage us and come around every day asking people if they’re okay and if they have any concerns on the calls or anything. You’ve got managers who are willing to listen and help you.”


Do you have an example of when the service works well?

“Recently we had a patient that reaching the end of their life. In those situations, we needed to work quite quickly. So as a team, we discussed with Crisis if they could help with anything and we got equipment quickly. Our healthcare staff were able to support them with the social needs, like washing and getting dressed, and we were able to do the therapy. Once all the equipment was in and it was safe, then we referred over to the Macmillan and the district nurses.

So, although that referral wasn’t technically suitable for our service we were able to problem-solve and refer on to the right people once everything was in place. We just didn’t say to district nurses ‘that’s it, you get on with it’. We put things in place, we let the family know everything openly and honestly and the patient was able to stay at home and remain comfortable until they passed away.

That’s just one example, but we always work very closely with Crisis and the IV team on the home pathway. Everyone always takes each other’s views on board.”


Why join?

“I’d say it’s a very rewarding, exciting job to have. It can be stressful, like any job but you feel well supported and people are there for you. Community is such a fantastic place to be.”