The focus of this article is the duty of care owed by employing authorities to district nurses. Throughout this article, the term ‘district nurses’ refers to qualified nurses who have undergone specialist training in district nursing and hold the Specialist Practice Qualification in District Nursing (SPQDN. This is to distinguish them from ‘community nurses’ which, while including district nurses, also encompasses other nursing staff who may or may not be registered nurses, but who are also working in community settings as district nursing team members. Solo domiciliary visits expose district nursing team members to risks associated with lone working because they are usually working in isolation from other team members.
Negligence and the standard of care in district nursing to patients has been clearly set out in Griffith (2019). However, it is also important to consider the duty of care to district nursing team members, including promoting health and safety to ensure safe solo (lone) domiciliary visits, because it calls into question the responsibilities of employing authorities and, acting in accordance with delegated responsibility, those of district nurses themselves, who may be managing district and community nursing services. As team leaders and professionals, district nurses are responsible for ensuring that the workload, tasks, staffing structures and necessary supporting mechanisms are in place for other district nurses and their community nursing teams to undertake their work safely and to achieve the required standards of care set out by their profession, employer and the law.
At present, district nurses and their teams are working in a climate of austerity in the NHS and local authorities. Financial limitations are having a severe impact on both the numbers of staff employed and their level of training (supply factors). Alongside these severe pressures on supply factors, the numbers of patients requiring care, their associated acuity of illness and the financial eligibility threshold constraints for publicly funded social care in either the patients' own homes or residential settings continues to increase (demand factors). An additional constraint for district nurses and their teams is that much of their work is done in isolation (lone working). NHS Employers (2018) defines lone working as ‘any situation in which someone works without a colleague nearby or when someone is working out of sight or earshot of another colleague’. The Health and Safety Executive (2013) defines lone workers as ‘those who work by themselves without close or direct supervision’, and this is highly pertinent to community nurses who may not be qualified district nurses.
The whole-time equivalent number of qualified district nurses in England has decreased from 7643 in September 2009 to 4325 in June 2018 (NHS Digital, 2019), while the number of patients who experienced delayed transfers of care (DTOCs) because they were awaiting further non-acute NHS care in England rose from 16 424 in August 2010 to 25 591 in April 2019 (NHS England, 2019). Sir Robert Francis QC, Chair of the Mid Staffordshire inquiry and honorary President of the Patients Association, is quoted in the House of Commons Health Committee report (2018), The nursing workforce: second report of Session 2017–19, as saying:
‘A huge number of staff are working in, frankly, unacceptable and unsafe conditions. I believe that must impact particularly on nurses, because of their role in the front line, being professionally responsible for the standard of care delivered on a minute-by-minute basis to patients, allied sometimes to the feeling that they cannot do it—I have heard a lot about that—and the stress of not being able to deliver what a nurse or a professional knows should be delivered. That must make life impossible. That will discourage people from joining the profession. It will encourage people to leave it’.
Evidence presented to this report from the Royal College of Nursing (RCN) argues that reductions in the availability of funding for continuing professional development (CPD) are a major issue contributing to nurses leaving the profession (RCN, 2018). Nursing is a continuous learning profession, as new drugs, clinical practices and interventions are further developed. The Health Education England (HEE) budget for ‘workforce development’, which is largely used for CPD for nurses, has been cut from £104.3 million to £83.49 million in 2017–18, after it was almost halved from £205 million the year before (RCN, 2018). NHS Employers highlighted this as a ‘fundamental’ priority for national action, arguing that:
‘The level of disinvestment limits not just the opportunities for advanced practice, but a standard way of investing in the training of people to carry out the jobs they need to carry out, particularly in specialist settings such as intensive care and community settings’.
Duty of care
‘Duty of care’ refers to the obligations placed on people to act towards others in a certain way, in accordance with certain standards. Professionals are judged against the standards of their profession in accordance with the Bolam test: those acting as professionals are expected to act in accordance with a competent body of professional opinion in situations where it is ‘reasonably foreseeable’ that the practitioner might cause harm through their actions or omissions (Terry et al, 2017). It is generally assessed as the standard to be expected of an ‘ordinarily competent practitioner’ performing that particular task or role. This is the case regardless of whether that practitioner is a nurse, midwife, healthcare assistant or assistant practitioner. It exists when the practitioner has assumed some sort of responsibility for the patient's care. This can be basic personal care or a complex procedure.
For district nurses and other registered nurses, the relevant standards are set out by the Nursing and Midwifery Council (NMC) (RCN, 2016), and although healthcare assistants (HCAs) and assistant practitioners (APs) are not regulated by the NMC or any other professional body, NMC guidance is useful when considering best practice. Acas (Advisory, Conciliation and Arbitration Service) sets out clear expectations that employers should take all steps that are reasonably possible to protect the health, safety and wellbeing of their employees (Acas, 2012). Employers have a moral and ethical duty not to cause, or fail to prevent, physical or psychological injury. Further, employers must conform to relevant health and safety as well as employment law and must fulfil their responsibilities with regard to personal injury and negligence claims.
Examples of an employer's duty of care include:
If an employer fails to do everything that was reasonable in the circumstances to keep the employee safe from harm, the employer can be deemed to have breached their duty of care. A secondary issue about duty of care is the delegated responsibility the qualified district nurse has in terms of case management and delegation to members of the district and community nursing team who may not be qualified district nurses or indeed, qualified nurses. Inadequate staffing levels and skill mix, resource constraints and increased caseloads are pressures that can lead to failures in duty of care. Guidance from the Royal College of Nursing (RCN) states:
‘Some examples of situations where your employer's expectations may conflict with your duty of care include excessive or unsafe workload, taking on tasks for which you are not trained or competent and being expected to work in an unsafe environment’.
Employees have responsibilities for their own health and wellbeing at work, and they are entitled by law to refuse to undertake work that is not safe, without fear of disciplinary action.
Lone working
The RCN has provided guidance on lone working in response to concerns from its membership about alarming circumstances where they are driving through unfamiliar roads at night trying to find an address or they are unable to find somewhere safe to park when they are visiting patients about whom they have very little information. The membership also cited being alone in isolated healthcare buildings seeing patients who are becoming aggressive (RCN, 2016).
Common situations where district nursing staff may be working alone are:
The RCN quotes an analysis by NHS Protect (2015) which found that the risk of sustaining injury from physical assault for lone workers is around 9% higher than that for non-lone workers in health and social care. The same RCN document provides a useful checklist for nurse managers of lone workers focusing on the importance of employing authorities having up-to-date policies in place for lone workers and the importance of staff training in risk management, personal safety, handling aggressive behaviour, using safety devices such as trackers on mobile phones, reporting incidents and debriefing after incidents.
Conclusion
District nurses and community nursing teams are not the only professionals working under pressure in the NHS, but they face additional pressures because of a steeply increased demand for their services, a severely compromised skill mix within their teams, their exposure to the risks of lone working and much of their work being ‘invisible’. These additional pressures may expose the employing organisation to breaches of duty of care towards district nurses and community nursing teams.
The risks can be mitigated by employing organisations engaging with district nurses and their community nursing teams to better understand how the resource and lone working pressures are affecting them and ensuring that up-to-date policies are in place for lone working. District nurses are a vital resource for vulnerable patients who would otherwise require hospital care. It is essential that they continue to be qualified and hold a SPQDN, and that their contribution to both the avoidance of hospital admissions and to securing earlier discharge from hospital is recognised.