Protecting district nurse numbers

District nursing leaders have called for the Royal College of Nursing (RCN) to ensure that it focuses on safe staffing levels in the community as well as in hospitals.

This follows the RCN releasing its European election manifesto (see box), and calling for MEPs to support its priorities.

Safe staffing levels has been a focus for the media and the profession, catalysed by the Francis Report, released on 6 February last year. However the majority of the debate, recommendations and media coverage have been focused on staffing levels for hospital nurses.

Yet there is clear evidence that the numbers of district nurses and community nurses are decreasing while their caseloads are increasing. The Frontline First Report conducted by the RCN found that there had been a decrease of 5.06 per cent of community nurses since 2010.1

Speaking at the launch of the manifesto, Peter Carter, the general secretary and chief executive of the RCN, said that the healthcare system still focused too much on secondary care and that there needed to be proper investment in primary care to meet the population's needs.

How could this be done?

Kate McCandlish, clinical lead for district nursing in Kensington and Chelsea, London, believes that measuring the district nursing workforce could be done with an evidence-based tool, which would measure the workforce and their requirements in the local area.

'What we need is a well-evidenced systematic tool which would allow us to manage our workload, assess the needs of the population and work out what [staff] we will need in the future as the population needs change, so that we could match our staffing and training to meet the needs of the local population. We need something practical that we can apply to caseloads and workforce so we could match the demand to our capacity.

'I understand [the RCN] is doing high-level strategy stuff but I would like to see something more operational. That's what's missing.

'The RCN could help to bring together best practice from the four countries in the UK and carry out a systematic or literature review of what best practice means, in terms of matching workforce demand. I know there are little pieces of work happening out there but it is really hard to pull it altogether and I wonder if that is something the RCN could help with,' Ms McCandlish adds.

Defining safe staffing levels

In order to calculate safe staffing levels for the district nursing workforce, the caseload a district nurse is realistically able to manage needs to be defined, says Crystal Oldman, chief executive of the Queen's Nursing Institute (QNI)

However, Ms Oldman stresses that it is a lot easier to define the number of nurses needed on a ward to produce an ideal staffing ratio, than it is to ascertain the number of cases a district nurses can take on.

'It is important that the number of district nurses meets the demand of patients. However, community care is a lot more complex and cannot be defined by a ratio.'

'Caseloads are less bounded in community care and there is no limit to the number of referrals that a district nurse can have.'

To define safe staffing levels in the community, it will be necessary to understand how district nurses manage their workloads, says Kay Kane, an independent consultant in community nursing, based in Northern Ireland. Ms Kane believes that the most important thing is for managers to have contemporaneous knowledge of the nursing caseloads, in terms of dependency, and the visiting patterns, which directly impacts upon the workload of the district nursing team.

'In this way the manager will be able to allocate the workforce better and the needs of the patients will be met more effectively. Therefore, transparency is vital in district nursing and a system of measuring caseloads to benchmark across a group of caseload holders can help,' she says.

'There would need to be a robust system for caseload analysis to understand the way the district nursing workforce works and to ensure optimum performance.'

The QNI has been working with NHS England to develop a document that focuses on the numbers of and workload of district and practice nurses, Ms Oldman says. 'The Community Nursing Strategy programme will identify the key criteria required for caseload management. It is due to be released within the next few months.'

Universal concern

In terms of the RCN's EU manifesto, Ms McCandlish believes it is important for nurses to engage and support it because it offers an opportunity to share best practice which will lead to changes for patients. 'The more efficient and effective we can be, the more time we free up to spend with our patients. That goes for both practice nursing and district nursing.

'I get concerned that the RCN and the political arena focus on hospital care and how many nurses are needed on the wards, when there is so much care that goes on in the community,' she says. Hospital care is obviously very important but so is district nursing. If we can get some really good tools in place now, that will help set us up for the future when more care moves into the community.'

Ms Oldman says that the issues affecting district and community nursing here are often the same things nurses struggle with elsewhere, and suggests there might be things that can be learnt from them. 'Sometimes we are so focused on what is happening at home …. perhaps we lose sight of the way that other countries in Europe are managing their nursing numbers.'

Matthew Hamilton, EU/International advisor for the RCN, says: 'These priorities extend to all areas of nursing and we will ensure that MEPs engage with this. The EU has published figures that there will be a shortage of nurses across the EU by 2020, which will affect the level of care given to patients, and this applies just as much to community nurses as it does to hospital nurses.'