The challenges facing the district nursing workforce cannot be divorced from what is happening elsewhere in the world as the current UK healthcare workforce challenges echo those globally. The World Health Organization (WHO, 2023) has asserted that the global healthcare workforce has declined significantly over the last decade independent of the COVID-19 pandemic (18 million in 2013; 15 million in 2020; projected 10 million in 2030). However, Boniol et al (2022) have estimated that there were in fact 29 million nurses globally and there will be a shortage of 4.5 million nurses by 2030. Globally, the healthcare workforce is rapidly ageing, especially in Organisation for Economic Co-operation and Development (OECD) countries, including the UK. To maintain the 2020 healthcare workforce density, the WHO (2023) has asserted that an additional 13.7 million healthcare workers will be needed through to 2030 within OECD countries to grow their own workforce and become less reliant on migration from low- and middle-income countries (LMICs).
The UK has an ageing population with a fertility rate of 1.58, which is below the population replacement level of 2.1 (last attained in 1970); nonetheless, the UK fertility rate is higher than some European countries (World Bank, 2022). The changing population demographics, with the growing burden of ill health as people age, have major implications for healthcare as well as the consequent demands upon primary care and other community-based services, including hospital services. Additionally, the reduced numbers entering the working age population will impact the availability of funding as well as the size of the caring workforce (Watt et al, 2023). The potential reduction of those entering the UK workforce including the healthcare sector will inevitably impact the community nursing workforce. This makes attracting and retaining a diverse nursing workforce hugely important because community nurses are recruited from the wider NHS nursing pool (Hemmings et al, 2021).
Zapata et al (2023) noted how the COVID-19 pandemic took a heavy toll on healthcare staff in the European Region of the WHO. This included damage to the physical and mental health of healthcare staff, with staff emerging feeling undervalued, overworked and some burned out by their efforts. They also noted that there is growing disaffection and distrust among healthcare staff of healthcare employers, which has culminated in strikes across various countries with healthcare staff seeking improved working conditions and reward packages together with greater respect and appreciation. They listed the four reasons for workforce attrition as:
‘To maintain the 2020 healthcare workforce density, the WHO (2023) has asserted that an additional 13.7 million healthcare workers will be needed through to 2030 within Organisation for Economic Co-operation and Development countries to grow their own workforce and become less reliant on migration from low- and middle-income countries.’
Drawing on the WHO (2022) Regional Office for Europe's report, Zapata et al (2023) recommended:
The pre-pandemic Queen's Nursing Insitute survey (QNI, 2019) of district nurses (n=2858) noted how district nurses were an ageing workforce with 60% over 45 years and 46% reporting that they planned to retire (25%) or leave (21%) within the next 6 years (Swift and Punshon, 2019). The more recent 2023 QNI survey of district nurses (n=1518; response rate unclear) revealed that there has been a slight increase of those aged 25–44 years, but most district nurses are more than 45 years old (33.1% being 45–54 years; 20.7% being 55–64 years; 1.3% over 65 years old) with 64.1% reporting that they had no plans to leave the community nursing service (Bushe et al, 2024). However, workload and service capacity issues were evident with 56.6% (61.7% in 2019) of the respondents reporting that they did not have to refuse referrals because of capacity or workload issues. Nearly one fifth (18.5%) (11.7% in 2019) of the respondents reported refusing referrals on a daily basis and 12.8% in 2023 (11.7% in 2019) refused at least once a week. The percentage refusing at least once a month remained similar (5.9% in 2023; 6.1% in 2019). The continued willingness to accept referrals despite staffing or other resource issues confirms the adage that the district nursing service is like a sponge which absorbs healthcare demands as they emerge from anywhere in the health system, with some district nurses reporting feeling unable to refuse referrals due to their employer's policy or pressure from their managers. The most common aspects of care not completed due to capacity/workload issues were: psychological care/support (43.3%), assessment (38.6%) and managing continence (30.8%). The focus on task orientated work rather than person-centred care was a source of professional dissatisfaction. More than three quarters (74.6% in 2019) of the sample reported that there were unfilled or frozen posts. District nursing caseload size appears to be rising with those having 101–200 clients (20% in 2023; 24.8% in 2019) reducing while over 600 clients (16.2% in 2023; 11.5% in 2019) have increased. Unpaid overtime was reported to be common (43% doing 4–7 hours unpaid overtime per week; 33.3% doing 1–3 hours; 15% doing 7–10 hours; 8.7% more than 10 hours). The 2019 and 2023 survey questions were different so the 2023 survey did not collect data on deferred training due to workload pressures; however, most had annual appraisals (88.7% in 2023; 95.5% in 2019) and at least monthly clinical supervision (64.6% in 2023; 61.0% in 2019). The 2023 survey revealed an increasingly well-qualified district nursing workforce with the number of team leaders without a prescribing qualification falling, and over a quarter of team leaders (27.9% in 2023; 18.5% in 2019) holding the V300 qualification. Similarly, 43.4% (38.2% in 2019) had completed an advanced clinical assessment course. As expected, virtual wards and remote monitoring were reported as having a growing impact on community nursing services and, while 46.2% of the respondents stated that they had made no difference to their workload, 28% reported that they had increased workload (4.5% reported that they reduced workload). In the free text responses, it was apparent that some district nurses felt a lack of recognition compared to hospital nurses, and undervalued and overworked with underfunding of the district nursing services making it difficult to deliver high-quality care.
‘Lone working during home visits presents a range of challenges to district nurses, from personal safety, ergonomic considerations of the home environment and lack of peer support, to professional isolation and potentially loneliness.’
The NHS Confederation (2023), while welcoming the NHS Long Term Workforce Plan (NHS England, 2023), noted that staff shortages were a major concern across the NHS and vacancies were in excess of 100000. This echoes the Royal College of Nursing's (RCN) campaign regarding the growing shortage of Registered Nurses and healthcare assistants, and associated unremitting work pressure drawing on the March 2022 survey asking nurses and midwives (n= 20325; 22% of whom worked in a community setting) about experiences during their ‘last shift’ (Castro-Ayala et al, 2022). While recognising the potential bias of the RCN survey sample, this report noted that there had been an increase in nurses reporting that staffing levels were compromising care with insufficient Registered Nurses on a shift (62% in 2022; 57% in 2020; 53% in 2017) while patient acuity had increased and they were seeing ‘poor’ or ‘very poor’ care. Further, 82% of the RCN survey respondents reported that they did not have enough time to provide the level of care to which they aspired. Some of the survey's findings were reported by care setting. A total of 4472 respondents worked in the community (here referred to as community nurses and includes general practice, district nursing, hospice and school nurses). Only 25% of community nurses reported that their last shifts were staffed with planned Registered Nurse numbers and only 18% of community nurses reported that the staffing levels on their last shift were sufficient to meet their service users’ needs and dependencies. Some 37% of community nurse respondents agreed that the skill mix on their last shift was appropriate to meet their service users’ needs and dependencies safely and effectively; 47% reported that care had been compromised and 37% reported that necessary care had been left undone due to lack of time. Some three quarters of the community nurses rated the nursing care as good or very good on their last shift. Importantly, 71% of community nurses reported that they could not take breaks and 72% reported that they had to work additional hours beyond their shift, most of which were unpaid. Regrettably, challenging staffing levels have been commonplace in district nursing teams for some time (QNI, 2016; Swift and Punshon, 2019; Bushe et al, 2024).
Unlike hospital-based nurses or nurses working in clinic-based settings in the community, district nurses and their teams deliver care during lone domiciliary visits. Lone working during home visits presents a range of challenges to district nurses, from personal safety, ergonomic considerations of the home environment and lack of peer support, to professional isolation and potentially loneliness. All employers of district nursing staff have a legal duty of care to ensure the health and safety of nursing staff and they discharge this duty through risk assessments, lone working protocols, lone working devices, training, reporting and root-cause analysis of incidents (NHS Employers, 2022). District nursing staff also have responsibility for their own health and wellbeing (Duncan, 2019) and should adhere to lone working protocols, attend training, report incidents and highlight safety issues as they arise.
During the COVID-19 pandemic many people started working from home and gradually the phenomenon of workplace loneliness—that is loneliness at work—emerged (Walz et al, 2023). While remote working may have a range of benefits for the employees such as greater autonomy and flexibility, it inevitably increases the distance between employees/co-workers and may mean that an individual's social needs are not met adequately within the work setting (Wright and Silard, 2020). District nurses and other staff in the district nursing team are similarly distant from colleagues while delivering care in clients’ homes. While there is no research focusing on the lone working aspect of district nursing, a qualitative interview study of health care assistants (n=16) working in hospice at home teams for less than 12 months across England, Scotland and Northern Ireland reported how they experienced loneliness and isolation within their role of delivering care in the home (Patynowska et al, 2023). To counter these feelings the healthcare assistants described the emergence of informal and organic peer support systems, in addition to formal support, and a community of practice which could be used for support without fear of judgement. Peer support was perceived as very valuable and it helped reduce the decision burden of being a lone worker. Some of these findings may be relevant to district nursing staff.
Bowers et al's (2023) mixed method study explored the administration of anticipatory prescribing using general practice and community nurse records relating to 167 deceased adult patients. Only 59.9% of those prescribed anticipatory medications had them administered with administration rates varying across general practices, but not between those who died of cancer and non-cancer diseases. Nearly all anticipatory medications (n=1310) were administered by community nurses (91.4%) (7.9% by hospice at home nurses) and all first-time administrations took place as part of home visits with the decisions to give an injectable medication based on clinical judgement at the time. Bowers et al (2024) noted that there was little information in the patient records regarding the clinical effectiveness of administered medications including perceived comfort at death. They suggested that the data relating to the first administration of an injectable medication may indicate that lone working community nurses may have varying understanding of anticipatory medications in patient care, together with limited access to relevant contextual information and limited awareness of alternative pharmacological options. Bowers et al (2024) highlighted the wide discretion and responsibility offered by anticipatory prescribing, which requires expert decision-making regarding symptom control, and the use of medications at the correct time and dosages. This study not only highlights the decision burden on lone working community nurses but also their need for support and training regarding clinical assessment, symptom control and the importance of adequate record keeping regarding medication effectiveness and perceived patient comfort.
The continued emphasis upon hospital avoidance and the increasing emergence of virtual wards and hospital at home schemes alongside the existing district nursing service highlight the imperative of addressing district nursing workforce issues including recruitment, retention, training, and support alongside staff wellbeing. Without a competent and adequately funded district nursing workforce, ambitions to deliver as much care as possible nearer to the home will not be achieved.