New Standards identify red lines to support safe staffing amid growing workforce pressures

The Queen’s Nursing Institute (QNI) has announced the publication of new Workforce Standards for the District Nursing Service

The new Standards were developed by the QNI’s International Community Nursing Observatory (ICNO) over the past eighteen months, led by its Director, Professor Alison Leary MBE.

The Standards were based on modelling using data from several sources including activity analysis (2015-21), NHS benchmarking data, qualitative data on perceptions of workloads and a literature review. The findings were contextualised using data from an analysis of Prevention of Future Deaths reports in England and Wales (2016-2019) which focussed on recurrent concerns from Coroners, the most common of which was missed, delayed or uncoordinated care, lack of care planning and elements of the nursing process.

The Standards should be read alongside the Royal College of Nursing Workforce Standards (2021) and the NHS Staff Council document Welfare Facilities for Healthcare Staff.

This new document sets safety standards for the District Nursing workforce in the UK, setting out areas of risk and giving examples of major ‘red flags’ that require escalation.

Workloads are far exceeding the capacity of services. From the qualitative data we have collected over the last seven years, there appears to have been a shift towards District Nursing teams acting a failsafe for other NHS and social care services, rather than as District Nursing service per se. Patients are being referred to District Nursing simply because other services are short staffed or are not offered as a 24/7 service. District Nursing services rarely refuse patients or close a caseload, leading to unremitting demand and this is a high-risk strategy.  
Nursing is a profession of vigilance not simply one of task delivery. Scheduling of work must be person centred and individualised and the named Registered Nurse must determine the appropriate ‘window’ of time to deliver holistic care. This should not be delegated to scheduling platforms or applications as these are currently unproven.

Professor Alison Leary MBE

Key themes of the Standards

Caseloads, Capacity and Time 

An effective District Nursing service should serve the need for nursing care in a defined community. District Nurses understand the needs of their local community but there must also be clear referral criteria for other services.

A growing and ageing population, deprivation, communication issues, social isolation, acuity, multimorbidity, ‘rookie’ factor (number of inexperienced staff), travel time, frailty, cognitive issues, lack of other services and lack of home support systems all affect the demand for healthcare delivery in the community.

Maximum caseloads are not defined in the new Standards, as there is no single definition of a ‘caseload’ used in the community. Currently there is no limit to District Nursing caseloads and this itself is problematic. However, a caseload of over 150 per whole time equivalent (WTE) seems to be a tipping point for more work left undone and deferral. For District Nurses and community staff nurses in the teams, 9-10 visits a day is also associated with the tipping point for people deferring work.

The consensus of professional opinion, borne out by the data, was that a Registered Nurse (RN) visit should be a minimum of 30 minutes to allow for the entire nursing process to be enacted (assess, plan, implement and evaluate). Travel time should be factored into scheduling visits. Route planners and other resource allocation applications should not override the priority of clinical care and professional judgement.

A ‘timed task’ approach to plan work or workforce should not be used: a timed task approached was shown to be a trigger for workforce discontent and even resignation. The safety of timed task approaches has also been called into question. Digital scheduling tools or apps may be used to inform or plan work and workload, but they should not be used to decide the nature and time of the work itself.

The new standards will be very useful to community service provider organisations, commissioners of services and District Nursing teams themselves. The standards explain the key factors to be taken into consideration when planning workforce to meet demand, and the overriding requirement to always apply the professional judgement of the expert nurse. We would be very interested to hear how these standards are used in practice at all levels, and their utility in supporting the evidence for workforce planning at organisational and system levels.

Dr Crystal Oldman CBE

Nursing Establishment and Skill Mix 

Skill mix of teams should reflect the demand placed upon them by populations and their needs. Work should be allocated with a focus on risk, unpredictability, complexity and acuity of the situation and not simply competency to carry out a task. Situational awareness is crucial for safe care.

Views regarding an appropriate and realistic skill mix for a District Nursing team were sought as part of the research for the new Standards. Considering the experience, knowledge and skills of the team members, the consensus of views was for a team comprising 60% experienced Registered Nurses; 20% newly Registered Nurses; and 20% Nursing Support Workers, including healthcare assistants and Nursing Associates.

When calculating the nursing workforce, an uplift must be applied that allows for planned and unplanned leave and absence. Underestimation of either or both planned and unplanned leave will result in an establishment that cannot meet day to day staffing requirements, and an overreliance on supplementary staffing, such as bank and agency staff. This will impact on the overall cost and quality of care.

A Registered Nurse (RN) should make the initial assessment and then attend every fourth visit as a minimum to carry out the Nursing Process in full, evaluating care, assess new needs and initiate changes required. Whilst Nursing Support Workers including Nursing Associates can be involved in the Nursing Process and play a vital role in the delivery/implementation of care, the assessment, nursing diagnosis, planning and evaluation of care is the responsibility of the Registered Nurse.

Red Flags

  • District Nursing services unable to close caseloads, leading to unremitting and unsustainable demand.
  • Deferring work every day or most days should be a red flag and escalated.
  • Deferring any high priority work at all (for example end of life care, people with blocked catheters) should be escalated as a safety concern.
  • High staff turnover and high sickness absence should also be considered a red flag for both patient safety and system resilience.

Commissioners of community healthcare services should work with District Nursing teams to understand patient need in the community, undertake a realistic estimation of demand, and determine a nursing establishment that is wholly appropriate for the needs of individual and population health, now and in the future.

Read the Standards here: Workforce Standards for the District Nursing Service



QNI/ICNO Workforce Standards for the District Nursing Service

RCN Workforce Standards (2021)

NHS Welfare Facilities for Healthcare Staff https://www.nhsemployers.org/publications/welfare-facilities-healthcare-staff

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