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'We need more health visitors AND more district nurses' 

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14 May, 2012

The recent report on community nursing released at RCN Congress highlights the pressure that community nursing is currently under.

Falling district nurse numbers, social care cuts, and an ever growing number of increasingly complex patients. It’s a frightening mix and with a significant number of district nurses set to retire in the coming decade, it’s hard to see that others will be rushing to step into their shoes.

It’s already a tough job without all the increasing pressure currently being loaded on. Working in a ‘hospital without walls’ is a challenging role. Making decisions about frail and elderly patients with multiple co-morbidities in their own home takes skill and training. There is no second opinion readily at hand – you are on your own with limited resources. While nursing support workers do a great job in working alongside registered nurses in the community, the complexity of the work means that the ratio of registered nurses and support workers must not swing too far in the wrong direction.

The push to increase the numbers of health visitors is welcome. However this campaign is more likely to recruit from the community nurse workforce as those already working in the community are more likely to apply. For those working in hospitals, it can be a leap of faith to take that step to work outside the hospital environment that they are used to.

Also the increase in health visitor numbers must not be used as a panacea for the fall in district nursing numbers. I was struck  by how Andrew Lansley answered a question about declining nos of district nurses at RCN Congress by talking about the increasing number of HVs. A good initiative but it’s not the same thing.

The RCN report makes clear for the urgent need  for more district nurse numbers and support for this crucial arm of the profession. Lack of support and care of patients in the community will inevitably lead to more hospital admissions. It feels like we are just going around in circles. Policy makers need to wake up to the fact that all the money comes out of the same pot so cuts in the community will lead to increased costs in hospitals.

Readers' comments (9)

  • Thanks it's nice to at last have some publicity surrounding the problems in District Nursing. I just hope that something is done before it is too late.

    It is all part of a much wider problem relating to the kind of management that exists in the NHS and the constant knee jerk changes that are instigated at the whim of successive governments.

    The health visitor crisis would not have occurred if health visitors had been listened to. We can take no satisfaction from being proved right in our criticism of changes.

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  • After taking a pounding, they want more HVs. This is likely to be experienced nurses cross training over. So this in turn would increase shortage of skilled nurses.

    They also did this with social workers, by criticising and bashing all of them after numerous high profile cases like the Baby Peter and Victoria Climbie. Years later, wondering why there's a lack of good social workers.

    Would you like to work in a profession where you're not appreciated, criticised, poor paying and worsening terms + conditions.

    Its time main stream media start to highlight all the excellent work being done out there by dedicated and caring staff, and time government start putting more resources into improving our health and social care services They can start by improving health promotion + prevention of illnesses, encouraging people to be more responsible for their own health by improving their own lifestyle (possibly by nudging people in the right direction). This I feel would save much more money in the longer term and improve everyone's health and wellbeing.

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  • Hear hear to all comments above. I've worked in the community for quite a few years now and find that poor discharge planning (make that none in some cases!) leads to more pressure on community nursing staff. For example, a patient discharged home following head injury, with request for observations to be done. The info came through at 7pm at night! Oh and patient discharged who needed IV drugs, with no advance warning of this need.

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  • If they need more DN's then they need to start treating the ones they have with respect and stop bullying the ones they have first and that might just keep a few good nurses working. But my experience of working as a DN and as a teamleader, was endless, wide spread bullying which eventually made it impossible to go on being a DN.

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  • As the master plan is to try and keep elderly people at home and out of hospital, it seems pretty likely that more, not less, DNs will be needed. Unless I have made an error somewhere in the logic.

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  • Anonymous | 14-Jun-2012 2:45 pm

    like the rest of us your computational skills must be a little out. just ask the government c/o office of Mr. Lansley, they will put you right on the facts and figures although I know it should be the other way round and from the front line experts!

    Hopefully the problem will be resolved so that the elderly will receive better care and support in their homes (with a higher nurse/patient ratio providing 24/24 services) as well as their families looking after them, with enough places in welcoming care homes with appropriate high quality facilities and excellent standards of care for those who choose this preference or circumstances force them to go there.

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  • Tiger Girl

    Anonymous | 14-Jun-2012 10:30 am

    'If they need more DN's then they need to start treating the ones they have with respect and stop bullying the ones they have first and that might just keep a few good nurses working. But my experience of working as a DN and as a teamleader, was endless, wide spread bullying which eventually made it impossible to go on being a DN.'

    Is this because DN Services tend to be quite small and fragmented, so that DNs do not speak with the weight of unified numbers behind them ? I don't know, I am asking the question.

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  • re Tiger Girl:| 15-Jun-2012 10:49

    I agree that there is disunity across the services, but I think there was more to it than that.

    I can tell you of my experience, but actually other DN's in other parts of the same District in which I worked were also being bullied by other Managers' so it was probably an endemic thing and something which has not been dealt with even now. Which is a shame because it wrecks lives and destroys careers.

    1. Our manager( a HV) bullied 5 nurses in the group, probably because she had always managed in a bullying way and no one stopped her.

    2.Management were to weak to deal with her because they didn't "want trouble" until it became so big and her behavior had become so florid that that she was asked to leave... which didn't deal with the problem at all anyway. So I have no doubt she went off to disrupt life and happiness elsewhere.( But i had left by then)

    3. She thought she knew it all, but being a HV ,she had no empathy for DN's work, ethics and problems; and she thought with a bit more close supervision and the imposition of "her way of doing things" which was better than the way DN's did things anyway, we DN's would be as good as HV's, which though funny in retrospect, wasn't at the time.

    (I know there are nice HV's who don't think like this, but some still do just the same.)

    4. I think one of the problems with the system is that much of the bullying in the District, can be done in almost secret because we go out alone and do our work alone, have "one to ones" with the Manager alone and so it is possible for the Manager to pick at our practice without others necessarily being particularly aware of it. And probably the other staff are grateful it isn't them who are being picked on and so just lie low and hope the flack stops with me( and the 4 others). One of whom committed suicide, 2 left and one stuck it out.

    I think, certainly when I was working, DN's were not half as cocksure of themselves as HV's were and so assertiveness was not one of our key skills. We were everyone's dumping ground and although i never told patients what the person I referred the patient to, would do for them. No other professional seemed to have the same reticence to dictate what they thought my job was, even if it had no relevance to my role. That also made us vulnerable, because I was always the meat in the sandwich.Saying no, that is not my role, what i do is... and I am an autonamous practitioner so it is not for the GP etc to tell me what to do etc. They do not understand their professional boundaries.

    It was a quirk of the District I was working in, that the DN's and Com RGN's, and Auxiliaries had been working there for years and years, and so had their "set ways of doing things" and saw any newcomer regardless of how long she had been qualified for, as "trouble" and to be put in her place before they got put in their place.... deep joy to try to work long side these people, there. So there was lots of " telling tales, misinterpretations of what was said and stirring of problems" by the Auxiliaries, in particular to this manager who just loved having some more grist for her mill. There were a lot of staff with personality problems and failure to grow up... to adult behavior.


    I was glad to leave them, but sorry to leave my patients who were lovely on, the whole.

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  • The BSc public health practice in specialist community nursing (or community nursing degree as it is sometimes know) is a one year course for healthcare professionals who want to move their career forward. It is only open to registered nurses and midwives and places are dependent on obtaining sponsorship from the National Health Service. This programme is designed to develop your knowledge and skills; helping you to provide evidence-based public health practice to several different groups.

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