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”
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”
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”
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.
“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”.