A major new survey of community nurses paints a “troubling” picture of teams lacking enough staff with the right skills and qualifications to deliver care needed by patients.
The research reveals the “huge pressures” on district nursing, at a time when there is renewed focus on providing more care in community settings but nurse recruitment efforts have been mostly focused on hospitals in the wake of the Francis report.
It also highlights a raft of other problems faced by community staff, such as a lack of training opportunities, poor communication with other services, and confusion about who is entitled to call themselves a district nurse.
“We can all work long hours for a period of time but we can’t go on forever”
The Queen’s Nursing Institute survey of 1,035 community nurses found morale was low, with more than 70% of respondents saying it ranged from “quite poor” to “extremely poor”.
Key issues impacting on morale included high workloads, working unpaid hours, fear of letting patients down, poor management, too much paperwork and cuts to services.
The survey findings were published this week in a report titled 2020 Vision – Five Years On: Reassessing the Future of District Nursing (attached, top-right). The report provides an update on a landmark QNI study published in 2009.
QNI chief executive Crystal Oldman told Nursing Times the new report “paints a picture of staff who are stretched and working longer hours”.
“They are hugely committed to the health of their patients and populations and are willing to go that extra mile to stretch their day – working slightly longer hours in the morning and evening to provide a 24/7 service,” she said.
She added: “We can all work long hours for a period of time, and as nurses we always put our patients first, [but] we also have to be mindful that can’t go on forever and there does need to be an additional investment into the workforce.”
The survey found 60% of community nurses believed “unequivocally” that they did not have enough appropriately skilled or qualified staff to deliver the care their patients needed. A further 10% expressed clear reservations about staffing or skill mix.
Only 28% thought their teams were adequate for the job in hand, and many still had concerns about their ability to cope with the workload when people were off sick, on maternity leave or left the service.
Compared with five years ago, 36% said the proportion of qualified nurses on their team had fallen, 54% said it had stayed about the same, while just 10% said it had increased.
This is despite the fact community nurses are now expected to care for patients with increasingly complex care needs. The new chief executive of NHS England, Simon Stevens, also signalled last week that community hospitals should play a bigger role in the NHS, especially in the care of older patients.
About a quarter of nurses surveyed by the QNI said their team had to refuse referrals because capacity issues indicating “a large number of patients – on a national scale – are not receiving the right care”.
Ms Oldman said the message for government was the need for strategic planning and a long-term approach.
“We need strategic workforce planning that underpins the movement of staff – alongside patients – to the community,” she said. “I know we don’t have new money, but it’s about where the money is spent.”
Ms Oldman said she was particularly concerned about poor discharge planning, with 83% of survey respondents saying the situation was not good enough. Many reported communication was variable or non-existent, with some hospitals discharging patients without informing community teams.
“It was an issue in 2009, and for me it feels really disappointing that it is still an issue,” said Ms Oldman, adding that it was vital to learn from organisations that did discharge planning well.
“What the nurses tell us in the survey is where there were nurses in place in the hospital responsible for discharge planning it worked really well. But they’ve seen those posts disappear, which makes it more difficult to have a smooth and safe discharge,” she warned.
Ms Oldman called for all hospital nurses to spend one day shadowing a district nurse, as part of their continuing professional development.
“Actually seeing the reality of somebody being discharged into a home without the services being there, because they can’t instantly be available at five o’clock on a Friday, would have quite an impact,” she suggested.
“We all carry a mobile phone and yet we still have teams that are entirely paper-based”
The report also highlighted that 35% of teams still relied on manual, paper-based systems to allocate work. Meanwhile, just a quarter were using mobile technology, such as palmtops and laptops, to record patient care while working in someone’s home.
“How shocking is it that we all carry round a mobile phone, and that’s how we communicate with each other every day, and yet we still have teams that are entirely paper-based,” said Ms Oldman.
She said the government’s Nursing Technology Fund – set at £30m for 2013-14 and rising to £70m in 2014-15 – was supporting increased use of technology, but the survey highlighted how far behind the NHS was.
A “substantial change” in the way the title district nurse was used had also occurred over the last five years, the survey revealed, with a 9% fall in the number of organisations that only used the title for nurses with a specialist practice qualification.
The report said the “mislabelling” of healthcare assistants had become more widely established and the title district nurse was now used “indiscriminately and colloquially for almost any healthcare employee visiting a patient at home”.
Ms Oldman stressed there were some positive findings from the survey, particularly around partnership working with GPs. “It is still mixed but we got a very positive message coming through,” she said.
The Royal College of Nursing is due to publish a separate report on district nursing in the near future, which is expected to back up many findings in the QNI research.
In addition, Ms Oldman said the QNI would be publishing more stories and case studies from its research later this year to create a “rich picture of the working world of a district nurse”.