National Health Executive - May / June 2021
The needs of district and community nursing
Julie Green 2021-05-17 09:19:58
Professor Julie Green, Dean of Education, Faculty of Medicine and Health Sciences and Director of Postgraduate Programmes, School of Nursing and Midwifery, Keele University
Understanding the overwhelming challenges facing our district and community nursing teams: a call to action for enhanced investment, resourcing and recruitment.
Our district and community nurses (DCN) deliver care to patients within their own homes, but also in care homes, day care centres and ambulatory clinics. The criteria to receive care at home is that the recipient of that care is housebound or where travel for care would impact on the patient’s health or their caring responsibilities. DCN teams deliver a wide range of advanced care to an increasingly ageing population, who often present with multiple long-term conditions. Care can include holistic assessment, multifaceted clinical management, prescribing, admission avoidance interventions, complex wound care, compassionate end of life care, acute infection management, liaison and advocacy with care providers, complex funding assessments, robust support for patients, carers and family members, the promotion of self-care and self-management, where appropriate. Underpinning this is an unremitting commitment to admission avoidance and timely facilitation and support of patient discharge.
Last year, following a number of anecdotal reports of increasing patient acuity and the ensuing system pressures within district and community nursing, the Royal College of Nursing (RCN) DCN Forum developed and circulated an extensive survey in November 2020. Almost 500 forum members completed the survey providing a range of data that delivers a stark insight into the realities of community nursing during a pandemic. This is what they told us:
The pressures within our hospitals have finite limitations, either their physical capacity or the limits of their bed numbers. In the community, there are no such limiting factors and DCN caseloads can grow exponentially without any apparent limit. That is, until we explore the impact on the staff; working days are lengthened, lunch breaks subsumed into clinical care and opportunities to deliver the best quality care are limited. Survey responses indicate that DCN teams are always the team that supports other services, they are the safety net and, even as part of an Integrated Care System, DCNs continue to carry this responsibility to provide care when all others are unable to. Time is being donated to the service on a daily basis, visits are hurried with a plethora of ‘routine’ tasks being required. Multiple visits, alongside high daily mileage, are now the norm and opportunities for additional training and development appear increasingly limited. Vacancies are unfilled and teams are short staffed.
Predominantly female, a quarter of respondents indicated that they are approaching retirement. Role titles were varied, with a rather confusing 32 different titles across services. This plethora of ‘titles’ is complicated for colleagues and patients alike. Clinical grading revealed a predominance of Band 5 and 6 roles, with diminishing numbers at higher grades. This disproportionate predominance of lower grades did not reflect that almost half of respondents that indicated over 15 years’ service and just over half held the District Nursing Specialist Practice qualification, with both advanced health assessment and prescribing skills.
Less than half of respondents indicated that they formally measured the acuity of patients and, when undertaken, the intervals between recording varied widely. Three quarters stated, when acuity was reported, they did not feel this had resulted in any action or additional support. Similarly, in terms of caseload review, respondents commented that this was limited by the pressures of the pandemic. 9 in 10 reported a lack of suitable technology to support patient monitoring, however, 96% stated that patient acuity continued to significantly increase within the community setting.
Respondents told us that on an average day, they would undertake between 6 and 15 patient visits and travel an average 11-30 miles a day. These were the most concentrated responses, however some indicated over 25 visits and over 50 miles. Where visit time was stipulated on allocation, this was almost always insufficient to complete the visit. Respondents reported a range of clinical activities that they felt were of low acuity and, as such, did not require the expertise of the DCN team. Examples included instillation of eye drops, venepuncture, medication prompts, administering prefilled anticoagulant administration, insulin administration for stable diabetics, washing and applying cream to lower legs, applying hosiery, equipment checks and the ordering of equipment. Respondents provided a range of suggestions of who would be better placed to undertake these activities, supported by appropriate education and training. These included the patient, carers or the patient’s family, in some cases the practice nurse, social care staff, a phlebotomist, a GP and residential home care staff. Relocation of such activities to more appropriate services and individuals would substantially reduce pressures on the service.
Only half of respondents reported that they had a mechanism to establish the daily capacity of their team, with most using an e-rostering system. Just over half reported a minimum daily staffing requirement, but only 6% indicated that this was met on every shift. All reported carrying unfilled vacancies, which exacerbated capacity issues. Over half of respondents were not aware of wider pressures on the region’s healthcare system, such as the local emergency department, social services and bed availability.
All stated that teams were required to support other DCN teams when their demand exceeded capacity. In addition, on occasions they were also required to support ‘others’ within the local health and care system; this included GPs, practice nurses, podiatry services, palliative care teams, the local hospital, social services, care agencies, the continence service, intervention teams, tissue viability services, treatment rooms, hospice teams, residential or nursing home staff and the phlebotomy service. All reported that they regularly needed to move planned care to another day due to capacity issues or had needed to refer to another service in order to cope; and for over half, this was a daily occurrence.
When asked what measures would help teams to better support the wider health and care system, over half cited that the most pressing need was for additional qualified staff. Other areas cited included enhancing awareness of the DCN role for colleagues not working in the community, improved direction of patients to be able to self-care, more specific referral criteria, better quality technology, enhanced collaboration with GPs and practice nurses, strong leadership and the referral of only housebound patients. Some mentioned the idea of capping caseloads, accurate dependency tools, prompt recruitment to fill vacancies, accurate acuity monitoring and resultant action, reduced paperwork, minimum staffing, appropriate skill mix and grading reflective of skills to ensure DNs were retained.
Just over half of respondents reported being part of an integrated care service (ICS), alongside other health, GP, social care and mental health colleagues. Positives of being part of an ICS included weekly hub multidisciplinary team (MDT) meetings, improved team working, enhanced communication, optimised patient management with appropriate onward referral and the delivery of a streamlined service. For many, co-location had reaped many benefits. Overall, respondents felt that this approach to healthcare delivery assisted in the management of patient acuity. However, many felt that, when all else failed, it remained the responsibility of the DCN team to deal with urgent or outstanding patient issues.
Training and support were very important to respondents. Over half felt equipped, as a result of the training and supervision they had received, to manage the increasing acuity of patients in your care. Again, over half stated that they would value more opportunity to complete relevant training, alongside the time for supervision whilst practising new skills and consolidating advanced skills. Time and the opportunity for clinical supervision and reflection were important to respondents. Only half reported that their GP practice had a named district nurse who held the specialist practice qualification. Almost all reported providing pre-registration student nurse placements. Over 95% reported actively recruiting newly-qualified staff nurses, however all felt that newly-qualified staff required a period of additional support to be competent to manage the acuity of the patients they would be exposed to.
Shockingly, only 1% of stated that they left work on time every day and, when working over, half of respondents disclosed that they would not be paid or get time back for this extra work. 7 in 10 stated that you did not have time for a lunch break each day. Over half did not feel they worked within a culture where staff wellbeing was valued.
Only 4% of respondents stated that they were always able to deliver your very best care and 3% stated that they were never able to deliver best care. Due to system pressures and time constraints, over half of respondents were unable to include any advice on health promotion or disease prevention in their consultations. A third had received ‘Making Every Contact Count’ (MECC) training but only half of reported having time to implement this intervention during their visits.
The district and community nursing service is key to realising the ambitions of the NHS Long Term Plan, but our survey clearly evidences that this service is under severe pressure. Patient acuity is increasing, and the system is creaking under considerable pressure. Factors that evidence this include only 1% of respondents able to leave work on time, all reporting a need to defer care regularly and only 4% having the opportunity to deliver their best care.
This is not sustainable situation, and this data must serve as a call to action for investment, resourcing and recruitment.
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