District Nursing Today: The Views of Team Leaders Revealed in QNI Report

The Queen’s Nursing Institute (QNI) has launched a major national survey of District Nurse Team Leaders. The new report was launched by the QNI’s chief executive, Dr Crystal Oldman CBE, at the National District Nursing Network (NDNN) meeting held in London today.

Over 1500 District Nurse team leaders from all countries of the UK contributed to the report, through an online survey undertaken in 2023. The survey makes extensive comparison with data gathered in 2019, illustrating trends in the workforce since the Covid-19 pandemic. The report focuses on the demographic profile of the workforce, working practices and technology, education and professional development, and capacity in nursing teams. The analysis of the survey was overseen by Professor Alison Leary MBE, Director of the QNI’s International Community Nursing Observatory (ICNO).

The report shows that District Nurse team leaders are carrying more responsibility than ever before, and this is increasingly reflected in the role being paid at Band 7 on the Agenda for Change scale.

It also reveals that team leaders are responding to the increased complexity of their work by developing their knowledge, skills and qualifications when they have the opportunity. Team leaders are becoming more experienced and developing more advanced nursing skills in response to the greater level of complexity in the people they serve. . More nurses now have the District Nurse Specialist Practitioner Qualification, a prescribing qualification, and an Advanced Clinical Assessment qualification.

However, the report shows that District Nursing services remain critically under-resourced, with multiple indicators that teams are struggling with capacity.

Dr Crystal Oldman commented, “We have a growing and ageing population and this is having a profound impact on how health and social care must be planned and delivered: District Nurses are increasingly responsible for people living with very complex healthcare needs. The next government must work to boost the District Nursing services that deliver essential individual and population health in communities everywhere.

“It is a testament to the District Nursing profession that many nurses are taking their education to the next level to address increasingly complex needs in the people they serve, but frustrating to see the barriers to accessing this. Without better access to the DNSPQ, this makes it difficult for nurses to plan their career paths. In 2023, the QNI launched its Field Specific Standards for District Nursing and these are now being used to develop courses that reflect an advanced level of practice. These courses reflect the real environment of District Nursing practice today, with all its challenges and opportunities.”

Report Highlights

Educational achievement and remuneration

• There are more team leaders with the District Nurse Specialist Practitioner Qualification (DNSPQ) than when the survey was last carried out in 2019. However, only half of respondents’ employers required them to have a DNSPQ qualification.
• The number of team leaders without prescribing qualifications is falling; almost a third of team leaders (27.9%) in 2023 had a V300 qualification, compared to 18.5% in 2019.
• The proportion of respondents who had completed an advanced clinical assessment course/module increased from 38.2% in 2019 to 43.4% in 2023.
• The number of respondents paid at Band 7 on AFC scales has increased since 2019, while the number of those on Band 5 and 6 has decreased.

Capacity Challenges

• More teams are carrying bigger caseloads. Caseloads in the 101 to 200 range have fallen (20% in 2023, 24.8% in 2019) while those of 600 plus have gone up (16.2% in 2023, 11.5% in 2019). This may indicate that there are more large teams and fewer small ones than in 2019, as services have been reconfigured. It may also show that individual nurses have a bigger caseload.
• 31.9% of respondents had to delay or defer visits every day, 32.6% most days, 25.8% once a week, 8% less than once a week and only for 1.7% of nurses, never.
• 56.6% of respondents in the 2023 survey did not have to refuse referrals because of capacity or workload issues, compared to 61.7% in the 2019 survey, so those who did have to refuse referrals has increased.
• The most common aspects of care not done or not undertaken to professional satisfaction due to capacity/workload issues were psychological care/support (43.3% of respondents), assessment (38.6% of respondents) and managing continence (30.8% of respondents).

Workforce and conditions

• Virtual wards and remote monitoring are having a growing impact: 46.2% stated that they had made no difference to workload, but almost a third (28%) stated that they had increased it. Only 4.5% believed that they had decreased workload.
• Unpaid overtime was common. 43% of respondents are carrying out 4 to 7 hours unpaid overtime per week, 33.3% 1 to 3 hours, 15% 7 to 10 hours and 8.7% more than 10 hours per week.
• There appear to be more band 3 and 4 staff including Nursing Associates in DN teams than in 2019. 52.4% had no Nursing Associates on their team, compared to 73.9% in 2019.
• More respondents in 2023 had access to parking permits. 39.8% of respondents had access to a car parking permit in the 2023, survey compared to 30.7% in the 2019 survey. However, 39.4% of respondents were not fully reimbursed for fuel costs.

Recommendations

• A sustainable financial investment in the District Nursing current and future workforce, combined with the removal of barriers that make staff recruitment and retention more difficult.
• Clear support for the District Nursing Specialist Practitioner Qualification (DNSPQ), including financial support for those who wish to take the qualification and a more clearly defined career path.
• Coordinated efforts to address issues that make District Nursing less effective, particularly poor IT systems, out of date technology, and disjointed communication and referral.
• Fairness of reward and management of the costs of delivering care – too many nurses work unpaid overtime and are subsidising their employers in other ways, for example vehicle expenses.
• A greater stated recognition for the essential value of the core District Nursing service within the National Health Service and the strategy to deliver more care in or closer to people’s homes.
• Valuing the skills and experience of District Nurses. Consideration should be given to a national strategy and campaign to raise the profile of District Nurses and the essential role they play in the NHS and the health of all communities in the UK.

Many though not all of the concerns raised by District Nurse Team Leaders included in this report could be addressed by greater central government funding. Despite the numerous challenges described, district nurses remain absolutely committed to providing high-quality care to their patients. It is crucially important that the NHS and its constituent bodies continue to invest in district nursing services to ensure they have the resources required to meet the profound changes in individual and population need that are emerging in the 21st century.

Notes to Editors

The Queen’s Nursing Institute (QNI) serves as an independent professional organisation and national advocate for all community nurses in England, Wales and Northern Ireland. The QNI has undertaken regular surveys of District Nurse team leaders in the UK since 2009. These surveys seek to provide a snapshot of the issues affecting the workforce, highlighting challenges and opportunities that are faced on a national level. Since 2019, these District Nurse surveys have been carried out by the QNI’s International Community Nursing Observatory (ICNO). The ICNO exemplifies our core belief that the design and activity of healthcare services should be based on independent evidence.