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District nursing pressure leaving staff 'on their knees'


Pressure on district nursing services is leaving staff “broken”, “exhausted” and “on their knees”, and is compromising the quality of care they are able to provide to patients, according to an influential think-tank.

The problems are being driven by an increase in the number of patients and the complexity of care they require, in addition to a reduction in the number of community nurses in recent years, said the King’s Fund in a new report investigating district nursing for older people.

It was “common” for district nursing staff to have unmanageable caseloads and, as a result, some were leaving the service, warned the report.

“Providing more care in the community cannot be achieved when district nursing is at breaking point”

Anna Charles

Because this type of nursing care is provided in people’s homes, there was also a “real danger that serious failures in care could go undetected because they are invisible,” it warned.

In addition, it said the shortage of district nursing staff was having an impact on caseloads in general practice and social care. There was a risk the shortage could mean more older people require hospital admission and that there is an increase in delayed transfers of care for older people in hospital, said the report.

Researchers conducted interviews with 50 patients, carers and staff at three case study sites – in London, a rural area in South East England and a city in North East England.

At one site, staff numbers had halved in the past three years due to a combination of cuts to posts and difficulties with recruitment and retention. This had led to the Care Quality Commission giving the site a poor rating for safety.

“A number of people receiving care commented on reduced frequency of visits and delays to wound care”

King’s Fund report

At another site, one interviewee said they were using an escalation process for staff shortages on a weekly basis. Managers at the third site said they only had a full team for around three months a year due to staff turnover.

Concerns were raised about a lack of training places for nurses wanting to become district nurses and the shortage of experienced staff members with this specialist qualification.

The think-tank noted that these problems were not unique to these regions, as recent reports by NHS England and the Royal College of Nursing had indicated district nursing shortages were widespread.

It said that, although national data was not available on the exact number of nurses working in district nursing due to many services now being run by non-NHS providers, official figures from the Health and Social Care Information Centre did show a 48% drop in NHS district nurses between 2000 and 2014.

At the three sites researchers looked at, staff shortages were often dealt with by employees working longer hours, very intensely and often without breaks.

“To let the decline [in district nurse staffing] continue would be to knowingly deprive patients of care which makes a proven difference”

Kathryn Yates

But despite this, researchers found district nurses sometimes were unable to visit patients as often as they should do and that there were resulting delays to care.

“A number of people receiving care commented on reduced frequency of visits and delays to wound care: one person was confined to her bedroom for several days following a postponed visit as the leakage from her wound was so severe,” said the think-tank.

In its report – called Understanding quality in district nursing services: Learning from patients, carers and staff – the King’s Fund noted it had originally set out to compile evidence for a framework for quality district nursing care.

But after finding the gap between demand and capacity within district nursing had worsened in recent years, it has set out a series of immediate actions to address this problem as well.

It called for action to be taken to reverse the declining number of district nurses by raising the profile of the profession and developing it as an attractive career option.

Robust mechanisms for monitoring resources, activity and workforce must also be developed, it said.

In addition, it urged health and care leaders to recognise the vital importance of community health services in helping to transform the way the whole health and care system was run in the future.

“It’s two years since the RCN warned that the district nurse role was in danger of extinction, yet the situation is at least as bad today”

Anna Charles

Anna Charles, policy researcher at the King’s Fund, said: “At its best, district nursing offers an ideal model of person centred, preventive, community-based care.

“For years, health service leaders have talked about the importance of providing more care in the community, but this objective cannot be achieved when district nursing is at breaking point and a poverty of national data means the quality of services is not properly monitored.”

Responding to the report, the RCN said it showed problems with district nurse staffing must be tackled immediately.

Dr Crystal Oldman, chief executive of the Queen’s Nursing Institute, welcomed the report’s findings, which she said “closely reflect information gathered from nurses by the QNI in recent years”.

Crystal Oldman

Crystal Oldman

Crystal Oldman

“Nurses, patients and their families, and policy makers all want more care to be delivered closer to home,” she said. “But this will never be a reality while we have growing patient demand, and falling capacity in the workforce.

“Overstretched District Nursing teams lead to staff burnout, exacerbating recruitment and retention problems, which in turn make staffing problems even worse,” said Dr Oldman.

“Therefore, we strongly welcome the key recommendations of the report, and the opportunity to work with all stakeholders at the system and service levels to address these issues urgently and in a sustainable way, to protect patient care now and in the future,” she added.

Kathryn Yates, professional lead for primary and community care for the RCN, said: “District nurses are an essential lifeline to many people…They are highly qualified, skilled and experienced nurses with expertise which includes palliative care, medication and wound management.

“It’s two years since the RCN warned that the district nurse role was in danger of extinction, yet the situation is at least as bad today,” she said.

“There is much to take away from this report. However, the main message is that to meet the level of need for high quality care, the long term problem of staffing has to be tackled now. To let the decline continue would be to knowingly deprive patients of care which makes a proven difference,” she added.

Ruth May

Ruth May

Ruth May

Ruth May, executive director of nursing at NHS Improvement, said: “District nurses play an essential role in delivering community services and we want to support them to make sure they can continue to deliver quality care to patients in their homes across England.

“Today’s report is helpful in defining what good quality care provided by district nurses looks like and NHS Improvement has already been working closely with nursing leaders, royal colleges and our partners to understand what kind of support district nurses need,” she said.

“Alongside our wider safe staffing work, NHS Improvement have commissioned a working group at the Queen’s Nursing Institute to understand what more can be done to improve the quality of community nursing care and ensure consistently safe caseload management,” she added.




Readers' comments (10)

  • michael stone

    'Because this type of nursing care is provided in people’s homes, there was also a “real danger that serious failures in care could go undetected because they are invisible,” it warned.'

    The rise in demand is down to an increase in the number of elderly patients, and at some point the care of elderly patients in the community turns into care of 'end-of-life/dying' patients in the community. I am also of the opinion that 'failures in EoL home care' tend to be 'even more invisible' than the failures in 'elderly home care'.

    It is ABSURD to have a strategy based on more care in the community, and less care in hospitals, IN COMBINATION WITH inadequate numbers of District Nurses !

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  • I worked in a DN team for 6yrs, Everything in this article rings true impossibly long lists of patients to see, no time for adequate follow up, reduced and missed visits due to short staffing, The dream of patient centred care, reduced to daily fire fighting and task based care as you rush from one patient to the next, No support from Trust management. High levels of burnout and stress leading to high turnover of staff, Saw 4 managers in six years and over 30 staff of all grades come and go in the same period, team running on 40 percent agency when I left. Loved the job but had to get out to keep myself sane. There is a widespread crisis in District Nursing and it won't be fixed until the service is properly funded, planned, resourced and managed,

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  • I can see the end of DN careers in 3 years time. All because of poor budgeting and poor governance.
    Solution: Let all the "pen pushers" come out of their offices and get back to hands on patient care. I'm sure this will motivate junior Nurses.....and a pay rise is needed as well!!!!

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  • The one thing not mentioned is those who have taken early retirement because of the pressure and the waste of their years of experience to support those new to the working in the community.

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  • It would be helpful if you had distinguished between District Nursing and community nursing, as these two terms have been used within the same article without clarity it makes it harder to see whether you are suggesting the DN's have a greater burden than before, or whether you really meant the Community Nursing team as a whole.

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  • michael stone

    Anonymous1 September, 2016 8:37 pm

    I'm sure there is a difference - understood by clinicians - but so far as I am concerned [from the service user perspective] the 'label' is irrelevant: if the nursing is done inside the patient's own home, then it is included in this debate. So in essence it is about 'the nursing provided' however you care to sub-divide 'the team as a whole': are there enough resources, and is the competence 'of the team' adequate ?

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  • If you are a Community or District Nurse check and see if your patient is officially on Residential or self-funded care, or Nurse Funded care or Continuing health care (CHC).

    As I understand it, it is not impossible that some authorities are officially classifying some patients as needing and GETTING Nurse Funded Care which would allow the nurses employed by nursing care homes to give the care required, but these authorities may not actually be giving that funding to the homes who then have no authority to provide the care needed. And if that was the case then the extra work burden would fall upon visiting District Nurses.

    If you should discover this I would recommend that you anonymously contact the CQC about it but do not discuss it elsewhere. If an authority was doing this, it would indicate the lack of a moral compass and they might well persecute a whistleblower. Caution required.

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  • And anonymously contact your MP about it.

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  • It is so telling that the majority of comments posted here are done so anonymously, including mine.
    I once forgot to click the anonymous button . I contributed to the conversation from my own experience offering what I thought was constructive comment.
    I was surprised and dismayed by the abusive response that I got.
    This does not happen on the medical sites all are proud and able to contribute and allowed to have an opinion. Maybe this is what is wrong with the culture in nursing and why we have such shortages of skilled staff.

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  • The fact is that the nation is facing challenges in health and social care in the community that are now at breaking point, in fact has broken, there is no quick solution, the future of the nations health service depends on being able to decentralize and localize, more patients will be cared for in their homes and communities. District Nurses, Community nurses, and all the other specialist community nursing professionals are needed, and they require support from Nursing associations,policy makers, educators, to take on these challenges.
    All community nursing specialists clinicians need acknowledgement through regulatory bodies, a clear structure to their roles, and adequate staffing in each specialty to meet the demands of the nation.

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