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District nurse staffing levels should be based on caseloads, not ratios, says QNI


Staffing levels for district nursing should be based around caseloads rather than nurse-to-patient ratios, according to a leading association for community nursing.

This strategy should be used to reflect the more “comprehensive and inclusive” approach required for workforce planning and deployment in community settings, said the Queen’s Nursing Institute.

“[It is] vital to understand what constitutes a safe caseload for district nursing team members [to] ensure that community nursing services are safe”

QNI report 

In a report published today, the QNI noted the growing focus on shifting care away from acute settings and into the community. However, it said there was currently a lack of robust data about safe staffing for nursing in community settings.

It also noted that district nursing services often absorbed additional workloads that were not restricted by a set number of beds.

Official nurse staffing guidelines for acute settings by the National Institute for Health and Care Excellence state the nurse-to-patient ratio at which there is an increased risk of harm for patients.

But the QNI said that for community settings it was “vital to understand what constitutes a safe caseload for district nursing team members” to ”ensure that community nursing services are safe, effective and provide a high quality of patient experience”.

It laid out a number of factors that should be taken into consideration when looking at caseloads – which it defined as the patients served by district nurses and all the activities involved in supporting them during a specified period in a specified locality.

“District nursing teams are operating in a high pressure environment in which resources are scarce and there is a risk that care may be left undone”

QNI report

These factors include population demographics, the complexity of care now delivered in homes and the community, patient acuity and dependency and whether the service is covering rural or urban areas.

In addition, the ratio of district nurses to registered and unregulated staff should be considered, rates of recruitment and retention, and the amount of time spent with patients face-to-face, said the report, called Understanding safe caseloads in the District Nursing service.

“Relying on staff to work increasing hours of unpaid overtime in order to complete their work must be avoided,” said the QNI’s report.

The number and size of care homes and nursing homes in the local area and the extent to which they depend on district nursing services, as well as the capacity of practice nurses and GP services also needs to be taken into account, it said.

Additionally, the use of technology – such as video calling between healthcare professionals, as well as remote consultations with patients – as well as education and training needs for staff must be taken into consideration.

“Relying on staff to work increasing hours of unpaid overtime in order to complete their work must be avoided”

QNI report 

However, the QNI warned that in areas where staff were working unpaid overtime, the use of technology may only stop this from happening rather than increase their capacity to take on higher numbers of caseloads.

“The health and care sectors, and the district nursing service in particular, are facing significant challenges,” concluded the institute in its report.

“The ageing population raises concerns around both recruitment and retention of the workforce, as well as growth in the level and complexity of patient need,” it said. “District nursing teams are operating in a high pressure environment in which resources are scarce and there is a risk that care may be left undone.”

The QNI said it hoped its report would stimulate debate about how to determine safe caseloads for workforce planning in district nursing teams.

In addition, it hoped the report would be used to inform work being carried out on safe staffing for district nursing by regulator NHS Improvement, which has now taken over the national safe staffing programme after NHS England asked NICE not to continue this activity.

QNI chief executive Dr Crystal Oldman said: “The issue of safe caseloads is one that has been of growing concern to district nurses in recent years and we receive more questions on this subject than almost any other.

Crystal Oldman

Crystal Oldman

Crystal Oldman

“This is against a background of overstretched services that are struggling to cope with the number of patients being referred to them for the expert care that they provide,” she said.

“Frequently these are patients with complex long term conditions, who need specialist healthcare in the community for them to be able to live with dignity in their own homes,” she added.

“There is now general recognition among policy makers, commissioners and service planners that we need a stronger framework of principles and measures in order to meet individual and population need,” said Dr Oldman.

The report follows warnings last week by the King’s Fund that district nursing services were now at breaking point due to an increase in the number of patients and complexity of care they require.

In its investigation into district nursing for older people, the think-tank said pressures on services were leaving staff “broken”, “exhausted” and “on their knees”.


Readers' comments (9)

  • michael stone

    'Ratios' are 'easy to measure' but the things you really need to get at (how resource-intensive is the patient care needed, etc) are much harder to 'audit'. Even with 'ratios' current metrics typically over-simplify the situation - good luck with this one.

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  • M. Stone, There are more suitable chat columns you can post on such as Facebook. I would like to encourage more nurses and senior colleagues back to these pages to share their meaningful clinical experiences which are important in informing practice. As long as you monopolise these pages there is no question.

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  • michael stone

    ANONYMOUS 6 SEPTEMBER, 2016 12:01 PM

    My comment above was not 'chat'.

    And I am not stopping anyone from commenting on NT - if your 'nurses and senior colleagues' are put-off from posting, simply because I post, then shame on them.

    By the way, just for your information. if you go to the SCIE's webpage at:

    then you will find a picture (a bit out-of-date) of me. And a link to a 'blog piece' I wrote. And a side pane, of 'News'. As well as being highlighted (because it is the most recent) my 'blog' is currently sitting at the top of the news pane. Next down, is a blog by Rachel Grififths, the MCA Lead for the CQC. Three further down, is a 'blog piece' by Baroness Finlay, who is leading for the 'better MCA implementation group'.

    Do you honestly think, that I could get the Social Care Institute for Excellence, to include on its pages one of my pieces, if all I do is to 'chat and intrude' ?

    I'm not expecting an answer from you - past experience, suggests I will not get one.

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  • I do not see 'ratios' and 'caseloads' as either/or. Each involves establishing the care needs of patients, determining how many hours of care are required to meet them, and who should meet them. That information will provide the information needed to determine how many patients and clients any one nurse or care worler can look after and also how many nurses and care workers are needed to ensure that number and those grasdes of staff are available.

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  • michael stone

    JENNIFER HUNT - what you've described, is definitely what should happen. But it isn't what seems to actually happen - 'staffing measures' seem to be much more simplistic than your eloquent comment, even with respect to staffing mix, let alone with respect to 'patient complexity'.

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  • @stone

    'And I am not stopping anyone from commenting on NT - if your 'nurses and senior colleagues' are put-off from posting, simply because I post, then shame on them.'

    The typical remarks of a bully, online in this case, who lacks finesse and insight into their own behaviour attempting to project their shortcomings and shift the blame onto others.

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  • michael stone

    ANONYMOUS 10 SEPTEMBER, 2016 11:33 AM

    I will report that one to NT - I prefer not to, but I promised the NT team I would.

    If I were 'an online bully' then I wouldn't post things with my own name, would I ?

    And you seem to fail to understand the difference between arguing and bullying - claiming that somebody else is wrong, does not amount to bullying.

    If there is no inherent worth in my comments, then you and your colleagues should counter-comment and 'prove' where I am wrong: hence my 'And I am not stopping anyone from commenting on NT - if your 'nurses and senior colleagues' are put-off from posting, simply because I post, then shame on them.'

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  • Sadly no one wants to be a district nurse anymore due to the ever increasing caseloads but no more staff. So how can they continue to perform tasks under such impossible situations . So I do hope something helps the situation as patient care is suffering all ready.

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  • Nursing in general is becoming more and more difficult. District Nursing is a daily challenge as no one is refused care, but some days your seeing a larger volume of patients meaning your limiting the time you can spend with each individual. Managers want a high face to face patient contact time, which we would love to give but as a reactive service we don't always have capacity to do this. The NHS runs on goodwill a lot of time, staying late due to ill patients needs etc etc but this is unsustainable. The NHS is being run into the ground and staff are overwhelmed, demoralised with morale being lower than its ever been.
    Mobile devices are great but on a lot of occasions they don't work and you waste time trying to get them to work. Saying they are freeing up time to care is simply not always true! Managers need to get out from behind their desks and spend time doing the job to remind themselves of the complexity of looking after more and more people at home with fewer nurses and more complex conditions and care being given at home.

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