The purpose of this paper is to discuss ways to improve the working environment for district nursing (DN) teams and foster resilience within the team. The NHS is an organisation that most are justly proud of, but it is struggling to meet the demand for its services within the existing funding arrangements and associated staffing pressures. DN services are at the forefront of experiencing the aphorism that, while resources are finite, demand for healthcare is infinite. This article will focus on resilience within DN teams and survey findings from district nurses about their teams.
Resilience
Resilience refers to the amount of flexibility in the team—at what point does the team become so over stretched that it cannot maintain a reasonable equilibrium between capacity (funding and staff availability) and demand (workload and both clinical and quality standards), causing it to buckle? As set out in Figure 1, if any one (or more) of these four variables exerts pressure in excess of what the team can withstand under normal working arrangements, the equilibrium shifts and pushes normal working into the resilience buffer zone. The effect on the team depends on both the intensity of the pressure and the size of the buffer zone, which acts as a shock absorber. If the pressure is too great or the resilience buffer zone is too small, the team is unable to absorb the impact, and there is a knock-on effect on one or more of the remaining pressures. For example, if workload pressures increase, the response might be that clinical and quality standards fall, staff sickness and turnover increase or the budget becomes overspent with temporary staff.
Efficiency savings are a powerful driver to stretch teams as much as possible to obtain maximum productivity, and cost-improvement programmes (CIPs) that identify schemes to increase efficiency or reduce expenditure can cut into or even remove the resilience buffer zone. Resources that are needed for resilience in the buffer zone may appear to be superfluous, and although eliminating those resources can be seen as savings, the reality is that there may be unforeseen future costs. It is the resilience buffer zone through which the team can step up capacity to absorb peaks in demand. If demand for services exceeds the ability of a team to respond, there are three possible outcomes.
Stage 1
This outcome involves a limited response with rapid recovery in which the team can continue working relatively normally. This is still within the resilience buffer zone. A DN team, either as a stand-alone team or part of a wider multidisciplinary community service, experiencing a large increase in demand is likely to increase the workload of the team members and/or reschedule work, so that some patients must wait longer for care. While this style of working should not continue indefinitely, the team has the capability to meet the surge in demand and return to normal working fairly quickly. To recover from stage 1, escalation plans need to be in place so the entire team is trained and prepared, in much the same way as acute hospitals have agreed procedures to manage surges in demand when bed availability is severely compromised.
Stage 2
The recovery period, in which the team meets increased demand, is protracted, and the response is compromised for a short time afterwards and then returns to normal. This breaches the resilience buffer zone for a relatively short period. A DN team faced with increased demand beyond its capacity might prioritise care to focus on the most dependent patients, delay taking on planned hospital discharges, extend shifts and call for extra staff. After such a surge, it would take time until the team could return to normal. To recover from stage 2, escalation plans need to be in place, as in stage 1, but extended to include options to either increase resources or delay care, with team members being clear about the agreed actions to take.
Stage 3
A sustained increase in severe pressure on one or more of the four drivers set out in Figure 1 calls for a longer-term transformational change. Sustained pressure breaches the resilience buffer zone for a much longer period and requires both a short-term fix with actions outlined for stage 2 and, in the longer term, a strategic response that is likely to take time to implement. This is the stage many DN teams find themselves in now. The recommendations in the Queen's Nursing Institute's (QNI) 2019 report on outstanding models of DN are clear in their strategic direction:
Implementing plans for any of the three stages outlined above depends on confident, pro-active leadership and good communication between employing organisations, team leaders, team members, referral sources and other agencies, such as local authorities and, above all, patients. This entails prior planning to predict what ‘normal’ demand for services is on a daily basis and, as far as possible, trying to predict what future demand might look like to inform escalation arrangements. Such actions will help to reassure team members that their frustrations with workload pressures are being heard and acted on and may help to reduce workplace stress, sickness and staff turnover. Chalk and Legg (2017) identified seven key areas of concern that could help to focus planning strategies for DN teams. These are:
The employing organisation and team need to be adequately prepared for their response to any of the three stages. This will require investment in training and could be part of a continuing professional development strategy (albeit within diminished resources), especially in relation to implementing the recommendations of the 2019 QNI report and safe caseload management. The House of Commons Health Committee Nursing Workforce Report (2018) stated:
Our evidence argues that reductions in the availability of funding for continuing professional development (CPD) is a major issue contributing to nurses leaving the profession. The budget for nurses' CPD has fallen from £205 million to £84 million in two years. 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.
Capacity in district nursing teams
In September 2009, there were 7055 whole-time-equivalent (WTE) qualified first-level district nurses working in the NHS in England. By April 2019, this number had shrunk to 3974 (Figure 2). The replacement plans for new entrants to training are unlikely to fill the gap. Research from the QNI (2018) reports that 464 district nurse specialist practitioners qualified in 2017, compared to 517 in 2016. Planned commissions for DN training places in 2016/17 were 498, while the actual uptake was 416; planned training places for 2017/18 were 522. If head count is considered, rather than WTE, the service requires between 600 and 700 district nurses per year to replace district nurses who are currently in their 50s and 60s. The WTE number of assistant practitioners working in community settings has increased during this time from zero in September 2009 to 1062 in April 2019. While the registration of assistant practitioners in January 2019 by the Nursing and Midwifery Council is a welcome changes to strengthen the healthcare workforce, and the contribution of these professionals, community staff nurses and other staff such as community matrons is invaluable, these are not enough to substitute for the downward trend in qualified district nurses and associated loss of specialist skills.
Ball and Philippou reported in their survey commissioned by the RCN in 2014:
The typical district nursing team is made up of approximately 15 members of staff (mean average), representing 11 whole time equivalent (WTE) posts. This team typically consists of approximately two district nurses, 5 registered nurses (without DN qualification), one community matron, 2 HCAs/other support workers, one clerical/administrative staff and half an ‘other’ staff. But these averages mask considerable variation in the composition of teams; in 16% of cases there were no district nurses employed, 43% of teams had no community matrons and 38% did not have any administrative/clerical support staff. Across all teams, district nurses comprise an average of 20% of staff employed (WTE).
The survey revealed district nurses to be one of the groups reporting most work-related pressure. It reported dissatisfaction with grading bands for district nurses under the Agenda for Change (Ball and Philippou, 2014). Nurses working in DN teams were generally positive about their work lives. Almost all (94%) felt that, where care was delivered, ‘the team provided good care for patients’ but at some cost.
Key points from the survey are as follows:
Demand
The demand pressures on DN services are a combination of an ageing population with either long-term or complex health needs and a drive to relocate services previously provided in hospitals to community settings. This means that community nursing services, led by district nurses, are crucial to ensuring that clinically safe and high-quality care is available in community settings.
The demand for DN care and the capacity to provide it are well documented. The King's Fund (Maybin et al, 2016) set out the issue succinctly:
Activity has increased significantly over recent years, both in terms of the number of patients seen and the complexity of care provided. However, there are significant problems with recruitment and retention of staff, and available workforce data indicates that the number of nurses working in community health services has declined over recent years, and the number working in senior ‘district nurse’ posts has fallen dramatically, creating a growing demand–capacity gap. This is having a negative impact on staff wellbeing, leading to poor morale, stress and fatigue. Some staff are leaving the service as a result.
Getting the best out of staff and nurturing resilience
Ball and Philippou (2014) asked their survey respondents what they found most satisfying about working in the community. Respondents were very positive about their community-based role of providing direct nursing care to people in their own homes, keeping them out of hospital and providing good palliative care to patients at the end of life. However, the overwhelming issue appears to be high workload exacerbated by both staff shortages and rising numbers of referrals to DN services.
Safe caseloads
The point at which capacity meets demand is the caseload. In their report to NHS Improvement on evidence for safe caseloads for adult community nursing services, Jackson et al (2016) found that only the QNI paper (2016) on understanding safe caseloads in the DN service directly addressed safe community nursing caseloads by demonstrating the complexity of creating, maintaining and predicting safe caseloads in DN. The QNI's (2016) position on safe caseloads is that:
The QNI advocates using the term ‘safe caseloads’ rather than ‘safe staffing’ to reflect a more comprehensive and inclusive approach to nurse workforce planning and deployment in the community setting, which aims to provide assurance that the right nurse, with the right skills, will be in the right place, at the right time delivering high quality care. For these reasons, the safe caseloads approach is not based on using nurse to patient ratios.
Jackson et al (2016) concluded that:
… a number of workforce tools exist, but these tend to be localised and context specific, meaning their usefulness more generally is difficult to determine and has often not been evidenced. Continued development of such tools could be more beneficial than searches for more generalizable offerings, which may never be able to take account of the wide-ranging complexity across settings and environments.
Progress on case management tools is being made. Chapman et al (2019) tested the Sheffield Caseload Classification Tool (SCCT) and found good inter-rater reliability for individual patient care packages and moderate reliability for complexity of care. More work will be needed on this tool, but it could be a promising resource to assign patients on community nursing caseloads to the appropriately skilled nurse. Grundy and Wheeler (2018) have developed a tool to standardise caseload reviews and provide quality and safety assurance within the Staffordshire and Stoke-on-Trent Partnership Trust. Initial feedback has been positive, with the tool helping staff to manage their caseloads more effectively.
Conclusion
If demand and capacity are to be better aligned, the demand for DN services should be predicted and plans made accordingly, so that lead times are taken into account and resources are available. District nurses cope with complexity, variety and uncertainty in their workloads and have so far accommodated these pressures by rarely closing their caseloads. However, a time will soon come when this is no longer sustainable.
The recommendations of the QNI report (2019)— namely, safe caseload management, modelling demand and investing in both staff numbers and professional development—will guide the way forward for strategic change.