The Queen's Nursing Institute (QNI) has announced the publication of new workforce standards for district nursing (QNI, 2022). These were developed by the QNI's International Community Nursing Observatory (ICNO) over the past 18 months, led by its director, Alison Leary, and were based on modelling using data from several sources, including activity analysis (2015-2021), NHS benchmarking data, qualitative data on perceptions of workloads and a literature review. The findings were contextualised using data from an analysis of Prevention of Future Deaths reports in England and Wales (2016-2019), which focused on recurrent concerns from coroners, the most common of which were missed, delayed or uncoordinated care, lack of care planning and elements of the nursing process.
The standards should be read alongside the Royal College of Nursing's Workforce Standards (2021) and the NHS Staff Council document Welfare Facilities for Healthcare Staff (2021).
This new document sets safety standards for the district nursing workforce in the UK, setting out areas of risk and giving examples of major ‘red flags’ that require escalation. Leary commented:
‘Workloads are far exceeding the capacity of services. From the qualitative data we have collected over the last 7 years, there appears to have been a shift towards district nursing teams acting as a failsafe for other NHS and social care services … Patients are being referred to district nursing simply because other services are short-staffed or are not offered as a 27/4 service. District nursing services rarely refuse patients or close a caseload, leading to unremitting demand, which is a high-risk strategy.
‘Nursing is a profession of vigilance, not simply one of task delivery. Scheduling of work must be person-centred and individualised, and the named registered nurse must determine the appropriate window of time to deliver holistic care. This should not be delegated to scheduling platforms or applications, as these are currently unproven.’
Crystal Oldman, the QNI's chief executive, commented:
‘The new standards will be very useful to community service provider organisations, commissioners of services and district nursing teams themselves. The standards explain the key factors to be taken into consideration when planning workforce to meet demand, and the overriding requirement to always apply the professional judgement of the expert nurse. We would be very interested to hear how these standards are used in practice at all levels, and their utility in supporting the evidence for workforce planning at organisational and system levels.’
Key themes of the standards
Caseloads, capacity and time
An effective district nursing service should serve the need for nursing care in a defined community. District nurses understand the needs of their local community, but there must also be clear referral criteria for other services.
A growing and ageing population, economic deprivation, communication issues, social isolation, acuity, multimorbidity, the number of inexperienced staff, travel time, frailty, cognitive issues, lack of other services and lack of home support systems all affect the demand for healthcare delivery in the community.
Maximum caseloads are not defined in the new standards, as there is no single definition of a ‘caseload’ used in the community. Currently, there is no limit to district nursing caseloads, which is problematic in itself. However, a caseload of over 150 per whole-time equivalent (WTE) seems to be a tipping point for more work left undone and deferral. For district nurses and community staff nurses in the teams, conducting between nine to ten visits a day is also associated with people deferring work.
The consensus of professional opinion, borne out by the data, was that a registered nurse visit should be a minimum of 30 minutes to allow for the entire nursing process to be enacted (assessing, planning, implementing and evaluating). Travel time should be factored into scheduling visits. Route planners and other resource allocation applications should not override the priority of clinical care and professional judgement.
A ‘timed task’ approach to plan work or workforce allocation should not be used, as this was shown to be a trigger for workforce discontent and even resignation. The safety of timed task approaches has also been called into question. Digital scheduling tools or apps may be used to inform or plan work and workload, but they should not be used to decide the nature and time of the work itself.
Nursing establishment and skill mix
The skill mix within a team should reflect the demand placed upon them by populations and their needs. Work should be allocated with a focus on risk, unpredictability, complexity and acuity of the situation, and not simply by competency to carry out a task. Situational awareness is crucial for safe care.
Views regarding an appropriate and realistic skill mix for a district nursing team were sought as part of the research for the development of the new standards. Considering the experience, knowledge and skills of team members, the consensus was for a team comprising 60% experienced registered nurses; 20% newly registered nurses and 20% nursing support workers, including healthcare assistants and nursing associates.
When calculating the nursing workforce, an uplift must be applied that allows for planned and unplanned leave and other absences. Underestimation of either or both planned and unplanned leave will result in an establishment that cannot meet day-to-day staffing requirements, and an overreliance on supplementary staffing, such as bank and agency staff. This will impact on the overall cost and quality of care.
A registered nurse should make the initial assessment and then attend every fourth visit as a minimum to carry out the nursing process in full, evaluating care, assessing new needs and initiating the changes required. Although nursing support workers can be involved in the nursing process and play a vital role in the delivery/implementation of care, the assessment, nursing diagnosis, planning and evaluation of care is the responsibility of the registered nurse.
Red flags
According to research conducted for the development of the standards, signs that a district nursing service is not operating in a way that will facilitate the delivery of high-quality care include:
- District nursing services unable to close caseloads, leading to unremitting and unsustainable demand
- Deferring work either everyday or most days; this should be escalated
- Deferring any high priority work (for example, end-of-life care, people with blocked catheters, etc), which should be escalated as a safety concern
- High staff turnover and high absence due to sickness should also be considered a red flag for both patient safety and system resilience.
Conclusions
Commissioners of community healthcare services should work with district nursing teams to understand patient need in the community, undertake a realistic estimation of demand, and determine a nursing establishment that is wholly appropriate for the needs of individual and population health, now and in the future.
The new standards can be accessed here: www.qni.org.uk/wp-content/uploads/2022/02/Workforce-Standards-for-the-District-Nursing-Service-2022.pdf.