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Major survey: Lack of district nurses hitting community care

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”

Crystal Oldman

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.

Crystal Oldman

Crystal Oldman

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”

Crystal Oldman

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”.

Readers' comments (12)

  • No surprises here. Community services have been ignored for 10+ years and stripped down to consist largely of care assistants.

    These unregistered staff have FAR too much 'delegated' work, without having any of the knowledge and skills to make any safe or effective clinical judgements. It means that sick and disabled older people with complex health needs get a service that is hardly better informed than social care.

    It's similar to care homes, but with all the fundamental responsibility left to family carers.

    The only difference from social care is that it's not means tested, but it is rationed and seldom available out of office hours.

    We should be ashamed at what district nursing has become.

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  • I trust that you mean "hardly better informed ON MEDICAL MATTERS than social care", otherwise this is offensive.

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  • Well said, this is indeed an offensive comment. Sounds a bit like you are disrespecting 'care assistants', when in actuality it is the nurses' responsibility to delegate effectively. The nurse must only do so, knowing that the delegatee is capable of performing the task. I am quite proud of nursing in the community and if people voice their opinions more often, instead of just moaning, healthcare can be revolutionised. Well I like to think so anyway!

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  • The CQC LOVE paper and this is probably why District Nurses are using paperwork based services. If it's not recorded on a piece of paper it never happened!
    The CQC need to come out of the dark ages.

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  • Forester you are spot on! not offensive in any way!

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  • I am surprised at the defensive reactions. It's not offensive to speak the truth, unless you are averse to hearing it.

    The abuse and exploitation of HCAs is a shameful aspect of modern care. Nurses do sometimes delegate care unwisely, even recklessly. I don't deny some professional culpability. But they are under pressure with diluted skill mixes imposed by management cuts in establishments and failures to train & employ enough specialist community nurses, midwives and health visitors.

    Some managers have so little insight into the advantages of having a knowledgeable & skilled nurse at every bedside that they just regard us as pairs of hands. From this perspective, one pair of hands is much the same as another, so if you can get more staff numbers by having many fewer registered nurses, so much the better.

    HCAs who object to arguments for a properly qualified community nursing workforce seem to suffer from much the same blindness as these 'bean counting' managers. They think they're as clinically effective as a registered nurse and react badly to suggestions that this mightn't be the case.

    Unfortunately, the evidence from successive research studies since Carr-Hill in the 1990s demonstrates that registered nurses produce better patient outcomes. I don't think I could dismiss this evidence so easily, even if some readers don't like it.

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  • To Anonymous | 2-Jun-2014 7:37 pm

    Actually, this is function of our adversarial legal system. if you'd ever found yourself in court or at an inquest, you'd realise that lawyers see a failure to record what was done and how the patient responded as omissions of care.

    Good record keeping is an essential communication tool as well as a legal requirement.

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  • I work as a HCA in a DN team & agree that the skill mix is sometimes to dilute ,
    For a DN team to operate effectively it needs to be properly staffed, funded & organised: and have effective communication with partners such as GP's Hospitals, Social care & managers within the Trust all are poor/ lacking in my 15yr experience of community work. In my team we have a patient dependency score of over 1000 & a staff baseline of 600 ish, of course with holidays, sickness & training etc the staff baseline often drops to 500 & something. Is it any wonder we have near misses, incidents, virtually no handovers & care plans that are not fit for purpose. We end up giving rushed task focused care to our mainly elderly vulnerable patients. NOT GOOD ENOUGH For them or US who are FED UP & BURNT OUT !!!!

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  • PS we have been protesting about lack of Staff & support in my team for at Least 4yrs - WHATS Happened on the Ground Nothing !!!! just a load of ineffectual management talk & no action WHATS NEW !!!

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  • Change and improvements definitely needed - well done to those remaining who are working with near-impossible workloads with no sign of official recognition that many more, appropriately qualified district nurses are needed. Good idea of QNI to have hospital nurses shadow DN one day a week - but I suspect many would need a careful reflection or guided de-brief to actually see the amount of need. Poor discharge planning has been a feature for decades.

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  • I note from HSJ that staff mileage payments (already ridiculously low given the real costs of fuel!) are now to be reduced by 20%.

    Whoever in DH had this bright idea clearly wanted to complete the undermining of understaffed, under skilled and under resourced community nursing services by forcing poorly paid staff to subside their visits even more than we already do.

    I'm so angry about the effects of this on services, I probably shouldn't be allowed anywhere near a computer right now!

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  • Forester.......... don't get me started........

    We are sitting ducks with no defence, with all the changes the AFC brought in, then no pay rises, stoping regular usesrs allowance,
    being paid low milage for years, changes to milage last year introducing 67p per mile for first 3500 miles, then reducing to 24p per mile thereafter. Increased visits due to caring for more patients in the community, working in a rural team means the 3500 miles is eaten up within the first few months of the year,.................. I could go on, and on just to equate my sister came back from Dubai two years ago after not worked for 18 yrs walked into a job that pays the same as me a year gross and takes home more than me net.... blinking crazy... some say change your job.. I love my job .......... eks...............ranting again

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