NHS Improvement’s district nursing safe caseload improvement resource has now been published and is open for comment until 28 April 2017.

This blog puts the resource into context by highlighting the nature of district nursing for anyone unfamiliar with it or whose experience was some time ago, reflecting on the issues that district nurses and their patients face today.

The Queen’s Nursing Institute invited me to shadow a Queen’s Nurse to observe the reality of district nursing today. ‘Queen’s Nurse’ is a title available to nurses who have demonstrated a high level of commitment to patient care and nursing practice. All nurses who work in the community, as well as health visitors and midwives, are eligible to apply – including practice nurses, specialists and educators. The next application date will be in 2018 and will be advertised on the QNI’s website.

I was impressed by the nurse’s energy and passion for excellent patient care and for the team with which she works. Her day began at 8am with patients needing bowel care at home. She saw these patients on her way to the DN office. With a bottle of water, a phone and a car boot full of nursing equipment, we set off.

The first patient lived 10 minutes’ drive from the office. He was unable to walk, speak or swallow after a stroke, and lived alone with his cat. A front door key was in a locked box on the outside wall of the house.

The patient had an abdominal feeding tube. The nurse prepared his medication in the kitchen using syringes left to dry by the sink. She sprayed the preparation area with kitchen cleaner. Towels hung on the bathroom door, out of the cat’s reach. We chatted and shared a joke with the patient, communicating by facial expression. He wore an alarm on his wrist to call for assistance. Carers would later help him wash and dress, and his neighbour would take him out in his wheelchair.

Lone working can bring risks: the nurse described how she’d previously been locked in the house by the patient’s brother. He’d wanted someone to ‘listen to him’ about his brother’s care.

The trust is introducing iPads, but her team doesn’t have one yet. She used the patient’s paper record in his home, later updating the electronic record in the office. This included ordering more syringes, making a note on the paper schedule she’d printed from the electronic record. This isn’t unusual (Smart New World: using technology to help patients in the home, QNI 2012).

We visited another three patients that morning before returning to the office for handover with the team: using professional judgement to balance demand and capacity for the next 24 hours. It was possible to reallocate one DN to avoid postponing two patients’ care until the following day. The locality manager and the DN assessed staffing levels for the coming week. They were interested in which metrics they could use to assess safety of caseload management. These are highlighted in our improvement resource.

Recruitment and retention were issues the DN raised. One member of her team planned to retire (after 24 years) and return for two days a week: her experience was invaluable. The third-year student nurse found working in the community a ‘culture shock’ and intended to apply for a post in the local hospital.

My own reflections

  • Working together: NHS Improvement and the NHS

It was a great help to me to observe the reality of district nursing in 2017. I encourage others to shadow both clinical and support staff. It’s a two-way process. We learn and update our knowledge, and put their words into context. The person we shadow has the opportunity to understand our work and our context.

  • Patient care in the community

I was surprised to see a patient at home with such complex care needs. But as we talked about how his care and social needs were met, I couldn’t think of any aspect that wasn’t being met – somehow – by someone. The patient appeared very happy.

Home is so different to hospital: imagine a cat in a hospital. The DN is a guest in a patient’s home, and working within the patient’s rules demands resourcefulness and creativity from the nurse. The patient’s safety is of course paramount as in any care setting, and achieving it requires flexibility. The DN’s safety is also part of safe caseload management.

  • How to improve care

I saw a great team, whose members worked together and shared their practice. They ate together and talked about how they could manage their patients more effectively. Everyone’s view mattered.

Team members used professional judgement to assess the safety of their caseload management. They weren’t sure what else to use. Technology and mobile working will enhance care and working practice so much.

District nursing safe caseload management

I share these observations to show why the improvement resource is important. It’s reassuring to see how its principles will support safe caseload management.

We developed the improvement resource with district nurses and other stakeholders. We want it to be practical, realistic and useful. During the last seven months we attended events and conferences to ask what district nurses and patients/carers wanted us to include. We considered all feedback in line with the literature review’s findings.

Many trusts contacted us: organisations that have maximised the use of existing commercial tools, developed in-house tools or worked with suppliers to adapt an existing tool. We include four case studies with contact details.

We also found a spectrum of safe caseload management similar to Benner’s ‘novice to expert’ descriptors: novice, advanced beginner, competent, proficient and expert. Information about this framework can be found at: http://www.health.nsw.gov.au/nursing/projects/Documents/novice-expert-benner.pdf.

The draft improvement resource is on NHS Improvement’s website at https://improvement.nhs.uk/resources/safe-staffing-district-nursing-services/ . Please let us know what you think about it.

Many thanks to The Queen’s Nursing Institute for arranging my visit, to the DN involved and to the patients who allowed me to observe their care.


Jane Robinson
Clinical Improvement Project Lead
NHS Improvement
February 2017

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