The district nurse is a registered nurse who has completed a Specialist Practice Qualification in district nursing (Queen's Nursing Institute (QNI), 2014), and the role is considered a generalist one that is multifaceted in nature (Randall and Ford, 2011). This includes assuming responsibility for the leadership and management of the team that the district nurse leads (QNI, 2015; Royal College of Nursing (RCN), 2013) and being accountable for the standard of nursing care that is delivered in the community by this team (Bain, 2015). Within this managerial role, the district nurse faces significant challenges (Box 1). This article discusses the challenge of caseload management, in terms of the issues that the district nurse faces within this aspect of their role, and it offers ways in which the district nurse can overcome and manage these issues.
Various strategic drivers (see Box 2) have resulted in a shift in care from the acute care setting to the community setting, which has in turn increased the pressure experienced by district nursing services.
Key factors that further contribute to the pressures that district nurses face include earlier hospital discharge, the increased and changing complexity and acuity of patient need, the growing gap between demand and capacity and demographic changes, such as population ageing, whereby an increased number of people are living with chronic and multiple health conditions, disability and frailty (Haycock Stuart et al, 2008; Bennett and Nicholson, 2013; McDonald et al, 2013; Maybin et al, 2016; McComiskey, 2017; Gould, 2018). The QNI (2016) highlighted that the complexity, breadth and depth of the care delivered in the community is constantly increasing, alongside people's expectations of what the district nursing service can offer.
A district nursing caseload can be defined as a selected population within a specific area for which the particular district nurse is responsible (Bain and Baguely, 2012; QNI, 2016; National Quality Board (NQB), 2018). Bain and Baguely (2012) also described caseload management as an organisational method that a community nursing team can use to meet the healthcare needs of patients and their families. As a caseload manager, the district nurse is responsible for ensuring that these needs are identified and met, and that an equitable service is provided to all those within their caseload (Bain and Baguely, 2012; Roberson, 2016).
Alongside the needs of patients already identified on the district nurse's caseload, unplanned demand, new referrals and additional demand from the existing caseload must also be accommodated (QNI, 2016; McComiskey, 2017). The district nursing caseload has often been referred to as ‘a ward without walls’ (Haycock Stuart et al, 2008; Bain and Baguely, 2012; Gould 2018), and it is difficult to define (Bain and Baguely, 2012). Haycock Stuart et al (2008) have explained that the district nursing caseload is constantly expanding and that, unlike the hospital setting, the number of patients receiving care within it cannot be limited (QNI, 2009; Bliss and Dickson, 2016). This can result in the workload being out of the control of the district nurse, highlighting the importance of the prioritisation and organisation of care alongside difficult decision-making (Gould, 2018). Other issues highlighted by QNI (2016) and Chapman et al (2017) in relation to caseload management include the face-to-face availability of staff, the variability of workloads, the number and skill mix of team members and the geography covered.
Caseload management
The importance of effective caseload management is highlighted by its inclusion as one of the three core components in the district nursing service model (DHSC, 2013). As a key component of the district nursing role (Bain and Baguely, 2012), caseload management ensures that workload is reasonable, risks to patients are minimised, patients' needs are met and resources are used to their best effect (QNI, 2009; Bain and Baguely, 2012; QNI, 2016). To achieve this, district nurses need strategies to effectively manage their caseloads (Bain and Baguley, 2012). Caseload management is a complex process, which includes good clinical assessment skills, confident decision-making (QNI, 2009), caseload profiling, referral processes, documentation, judgement of skill mix and delegation (Bain and Baguely, 2012), and it is essential in allowing district nurses to evidence the effectiveness and efficiency of their service (Roberson, 2016).
Care management, prioritisation of patient needs and directing of resources are also a professional obligation that are imperative to cost-effectiveness and provision of high-quality care (Gould, 2018). If a caseload becomes unmanageable or is managed incorrectly, poor co-ordination can lead to poor patient outcomes, inadequacies in provision of fair and timely access to care (DHSSPS, 2015) and a district nursing service that is reactive and responsive to crisis rather than one that is proactive and preventative (Ross et al, 2011).
The study by Ervin (2008) simplified caseload management as a process of organising and co-ordinating care for a group of patients. It highlighted three skills as key elements of caseload management: organisation, priority setting and co-ordination. It referred to the organisation element as the ability to organise a large amount of work through the use of calendars, filing systems and e-mails and completing each day's work and then planning the following days' work. Once these basic elements are in place, they can be relied upon for arranging more complex tasks and workloads (Ervin, 2008). This is supported by Bain and Baguely (2012), who suggested that effective organisation of a workload is the structure that a well-managed team relies on, as it allows time and resources to be managed effectively.
Setting priorities is identified as the second skill for caseload management (Ervin, 2008) and includes how and who is admitted to the caseload, how their care is managed and how their visits are planned (Bain and Baguely, 2012).
The third skill, that of co-ordination, allows community nursing team members, patients and members of the multidisciplinary team (MDT) to work together (Ervin, 2008; Bain and Baguely, 2012). Co-ordination can include communication skills, meetings and conferences (Ervin, 2008).
Although dated and simple, the ideas put forward by Ervin (2008) are still in widespread use by district nurses. Strategies that can be implemented by district nurses to help overcome the challenges to effective caseload management include effective delegation, triaging of referrals, use of caseload analysis and referral tools, and supervision.
Co-ordination and delegation
With demands on the district nursing service increasing and many nurses feeling overwhelmed and undervalued by their workload (Haycock Stuart et al, 2008; McComiskey, 2017), the co-ordination of care and delegation of calls to the right nurse with the right skills who attends patients at the right time is of utmost importance (McComiskey, 2017). Although the district nurse will have overall responsibility for the care of the patients on their caseload, they themselves will not be able to carry out all aspects of care (RCN, 2017) and will have to delegate care activities to other team members. Delegation is described as the allocation of a task/care to a competent person (National Leadership and Innovation Agency for Healthcare (NLIAH), 2010; Bain and Baguely, 2012). The district nurse is responsible for the tasks that they delegate; they must ensure that the person to whom the task is delegated is competent in completing the task and that they are adequately supported and supervised in doing so (Nursing and Midwifery Council (NMC), 2015; RCN, 2017). The district nurse must then confirm that the result of the delegated task meets the expected outcome (RCN, 2017). The responsibility of the delegator does not only rest within their professional responsibility; they also have a duty of care and a legal liability to the patient receiving the care (RCN, 2017). To enable safe and effective delegation, the district nurse must ensure that they are aware of the teams' knowledge, skills and capabilities (NMC, 2015), while also considering clinical experience, geographical location and weather conditions (Gould, 2018).
Appropriate delegation allows a responsive and safe service to be provided (NLIAH, 2010), and this is highlighted throughout the literature, which consistently mentions the importance of having the right nurse with the right skills in the right place at the right time (QNI, 2009; DHSSPS, 2011; DHSC, 2013; RCN, 2013; NQB, 2016; McComiskey, 2017). This concept is analgous to sustainable staffing, the capacity and capability to provide safe and effective care to patients, alongside ensuring that staff have the time to undertake training and continuous professional development and meet revalidation requirements (NQB, 2016; 2018). Having the correct skill mix within district nursing teams enables them to safely nurse patients at home, which in turn highlights the importance of skill and professional development among staff (RCN, 2013). The concept also includes working as part of an MDT team to enhance patient outcomes, help recruitment and retention, optimise patient flow and improve productivity, alongside ensuring the flexibility and efficiency of the nursing service (NQB 2016; 2018).
Although the role of the district nurse as caseload manager in ensuring that the right people get the right care at the right time is emphasised by QNI (2009), it is important to note that safe and effective delegation and care co-ordination not only protect the patients on the district nurses' caseload but also protect the healthcare staff by ensuring that the staff work within their competencies and deliver care that is safe and effective.
In their qualitative study, which explored workload management and challenges faced by district nurses, as well as their job satisfaction, Haycock Stuart et al (2008) found that district nurses prioritise patient contact time and, with increasing workloads, they tend to postpone paperwork, computer work, meetings and equipment provision, often completing these at the end of the day or in their personal time. This has resulted in staff feeling frustrated, overwhelmed and dissatisfied (Haycock Stuart et al, 2008), having a negative effect on the care they provide to their patients. It is important that, when allocating, co-ordinating and delegating care, the district nurse should take into consideration the time constraints that administrative activities have on staff members' working days, alongside their availability to take on calls (Ervin, 2008; McComiskey, 2017). Otherwise, overburdened staff may experience burnout or decide to leave (Ervin, 2008). McComiskey (2017) suggested that evaluating the delegation of calls against staff numbers, skill mix and working hours will help maintain safe equitable workloads, and the QNI (2009) recommended ringfencing time for non-patient facing and indirect patient activities to counteract such issues.
Implementation of referral criteria
When delegating and prioritising calls, the district nurse needs to consider the appropriateness of the referral, taking into account the most significant or urgent of the identified clinical needs (Gould, 2018). Referral criteria in district nursing are becoming increasingly complicated (Gould, 2018), considering the increased complexity of care in the community, the expanding role of the district nurse and the blurring of geographical boundaries, alongside the expectation that district nurses will make up for the shortfalls in other services (RCN, 2003). The implementation of referral criteria is essential in assisting in appropriate care delivery (Bain and Baguely, 2012), reducing the number of inappropriate referrals, clarifying and legitamising the district nursing role and ensuring the best use of the district nurses' skills and judgement (Gould, 2018).
It has been previously identified that that there would be an unsustainable demand on the district nursing service if the referral criteria and system remained poorly defined (Bowers and Cook, 2012). Therefore, appropriate triaging of all referrals is essential in the management of district nursing caseloads and ensuring that patients receive the best care outcomes (Bowers and Cook, 2012). Gould (2018) also highlighted the importance of timely discharge planning in avoiding inappropriate visits. Without appropriate triaging of referrals and timely discharge planning, the provision of inappropriate care can have a negative impact on the workload of the district nursing team and its capacity to provide care to those who are in most need of nursing support at home (QNI, 2011; Health and Social Care Knowledge Exchange, 2014; Kane, 2014; Gould, 2018).
Referrals received by the district nursing team are categorised into three groups: urgent, non-urgent and routine. As these referrals can be activated by patients, families and members of the MDT, it is imperative that the district nurse assess the appropriateness of the referral, alongside its urgency, weighing up the significance of the numerous factors that contribute to the complexity and urgency of patients' need (Gould, 2018). However, as Bowers and Cook (2012) have highlighted, defining someone's need for district nursing input has been a subjective and contentious topic, although they have indicated that tactful negotiation and judgement skills will ensure that patients receive support in a timely manner. When accepting referrals and co-ordinating the care required within the appropriate response time, it is imperative that the district nurse considers staff skills, clinical expertise, resources and geographical areas, in order to support safe and sustainable patient care (Bowers and Cook, 2012; Gould, 2018). In some cases, the district nurse may be able to receive help from teams in neighbouring geographical areas to assist in any shortcomings experienced (Bowers and Cook, 2012).
Having set referral criteria and process enables a consistent, open, transparent approach to be applied and centralises all clinical information (Harding et al, 2010; Chapman et al, 2017), while adding legitimacy to the district nursing role (Gould, 2018). Research by Chapman et al (2017) around the development of a caseload classification tool, which localised demand and focused resources, suggested that it helped caseloads become more organised and safer, enabling patient needs to be predicted. It also proposed that the use of an electronic caseload tool improved teamworking, with work allocation seeming more equitable. This is supported by Kane (2014) and Maybin et al (2016), who suggested the establishment and implementation of referral processes as central to the organisation and management of nursing care in the community.
Caseload analysis
Another method of reducing inappropriate referrals, encouraging best practice, quantifying workload, categorising and recording clinical activity and developing services is caseload analysis (Bain and Baguley, 2012; Reid et al, 2013). Caseload analysis is a process of examining the types and numbers of cases, case complexity, age range attended, numbers of new referrals and the number of crisis situations that require attention (Ervin, 2008). This is further reinforced by Reid et al (2013), who highlighted that caseload analysis examines the district nursing workload in terms of activity, aiming to develop activity-based caseloads and benchmarking district nursing teams against model caseloads. Caseload analysis can provide a better understanding of nursing activities and has the potential to enable district nurses to identify potential resource, education and training implications, which may improve the effectiveness of care delivery (Reid et al, 2013).
Despite considerable discussion in the literature that encourages the use of caseload analysis (Ervin, 2008; Bain and Baguely, 2012; McDonald et al, 2013; Reid et al, 2013; Kane, 2014; McComiskey, 2017), it is not without its difficulties. The reliability of the data generated by caseload analysis depends on robust data collection methods, which may, in the short term, increase the workload of the district nursing service (Reid et al, 2013). Caseload analysis has also been criticised as an attempt to reduce district nursing to a list of tasks (Reid et al, 2013) that is unable to capture the essence or quality of nursing care. Bain and Baguely (2012) have highlighted that, although district nurses have seen an increase in their workload, there has been a reduction in the number of visits they make to patients; there is a danger that caseload-analysis tools will not capture this pattern and therefore provide an unreliable representation of the district nursing workload.
Nevertheless, in Ervin's (2008) publication, it is suggested that caseload analysis can help improve productivity among nursing staff and provide evidence of staffing needs during a time of decreasing resources and funding. The use of caseload analysis is further supported by Kane (2014) and McComiskey (2017), who suggested that this practice is necessary to ensure fair and equitable working and for evaluating team efficiency and effectiveness, estimating required staffing numbers and appropriate skill mix, improving performance management and modernising services.
Clinical supervision
Although they are not directly linked, clinical supervision is another process that can be used to aid caseload management. Clinical supervision is recognised as a process of professional support and learning that enables staff to develop and share their knowledge, skills and competence (RCN, 2002; Care Quality Commission (CQC), 2013; Tomlinson, 2015), in line with the standards identified in the NMC (2015) code of conduct. Clinical supervision can help support quality improvement, risk management and performance management and supports clinical governance in relation to accountability and responsibility (RCN, 2002), the importance of which is highlighted by its inclusion in NHSCT's community teams' operational policy (this is the trust's internal policy document). It helps staff to assume responsibility for their own practice and enhances patient protection and safety in complex clinical situations (RCN, 2002; Snowdon et al, 2017), by providing staff with the opportunity to reflect on and discuss their personal and professional responses to their work (CQC, 2013).
There are three main types of supervision, as highlighted by the CQC (2013). These are described as clinical supervision, managerial supervision and professional supervision. Managerial supervision provides staff with the opportunity to review their performance, set priorities and objectives in line with the workplace's service needs and identify further training and development needs (CQC, 2013; Bifarin and Stonehouse, 2017).
Clinical supervision and professional supervision have patient safety and quality of patient care as their primary purposes (Tomlinson, 2015), and they allow staff to reflect on and review their practice, discuss individual cases in depth, change their practice, review professional standards, keep up to date with professional developments and ensure that they are working within the codes of professional conduct (CQC, 2013). With regard to caseload management, clinical supervision can help to ensure that patients receiving care from the district nursing team receive high-quality care at all times from staff who are able to manage the personal and emotional impact of their practice (CQC, 2013).
Supervision has been shown to be associated with improved effectiveness and quality of care, including enhanced patient health outcomes (Bifarin and Stonehouse, 2017; Snowdon et al, 2017). It has also been associated with increased job satisfaction, retention and effectiveness and reduced turnover among staff (CQC, 2013), alongside reduced emotional stress and burnout among staff (Bifarin and Stonehouse, 2017). The relevance of this is more pronounced considering the increased workloads and complexity of patient needs within the community setting. Clinical supervision benefits staff not only by helping them cope with the personal and professional demands of their work but also by contributing to their professional development needs and the requirements of the professional bodies to which they belong (CQC, 2013). It is essential that district nurses recognise the value that supervision brings to their team, their professional development and the delivery of quality care (Bifarin and Stonehouse, 2017).
Conclusion
This article outlined caseload management as a challenge that district nurses face on a daily basis, and it provides an overview of some of the methods that district nurses can use to overcome and manage this challenge, although the list is not exhaustive. District nurses are regarded as experts who specialise in leading and managing a team that delivers a high standard of patient-centred care in the home and community (QNI, 2015). This in itself is a substantial responsibility and can be achieved by using effective caseload management techniques. It is imperative that district nurses overcome the challenges they face in their professional life to ensure the provision of high-standard, person-centred care that is evidence based, timely and effective.