District nurses under pressure

Workloads are massively increasing at a time when staffing numbers are falling

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By Sarah Ward

Northamptonshire’s community nursing team is under severe pressure as the pandemic is having an impact on workload and staffing levels.

During the pandemic the county’s health system has tried to avoid admitting people to hospital as well as discharging patients quickly in order to free up bed capacity and keep people safe from the virus - a move that is putting pressure on the district nursing team.

But at a time when workload is increasing, staff numbers are falling, with some community nursing teams down by as much as 30 per cent as a mixture of Covid absence, sickness, vacancies and annual leave are all taking their toll.

NN Journal spoke to a Northamptonshire district nurse who after many years working in the community decided to leave. She said most of her former colleagues are also feeling the strain.

“In recent years the job has become more and more stressful. But then Covid came along.

“There was a mass discharge from the hospitals so a lot of really ill people came home into the community and so we had a lot of palliative care. 

"The amount of palliative care went up by about 300 per cent so we were looking after a lot of dying people. That is obviously more complex and it takes its toll on you emotionally.”

The workload could be as much as 17 visits a day, as well as travelling between jobs. There would be no proper breaks - with food eaten on the go - and many staff are having to input their assessments out of hours in their own time.

The nurse said:

“District nursing has been happening for 160 years, but many people don’t even know we exist unless they have experienced our care. We are the Cinderella service and in many ways have been forgotten about during the pandemic.”

Northamptonshire Healthcare NHS Foundation Trust (NHFT) has the contract with the Northamptonshire clinical commissioning group to provide the community nurses across the county. There are a number of teams spread across the county based at centres across the major town.

The role of a district nurse is huge. They deliver services outside of hospital to those living in the community and their duties include wound management, continence care, catheter care and also end of life care.

The workforce problem is so severe that the organisation is having to use expensive agency staff from off-framework (unapproved) agencies in order to plug the gap.

But those taken on have not stayed and cited overly heavy workloads as the issue.

At a board meeting in January NHFT’s nursing director Julie Shepherd laid bare the problems to other board members and said the problems within district nursing were being seen as a priority within the organisation.

She said:

“We did bring in some staff on long-term agency contacts,some of those stayed for a short-while and found the workforce pressures quite high and so ended their contract with us.”

Her report gave more detail on the issues being faced by district nursing staff and noted the team was under ‘considerable pressure’: 

“There are significant increased pressures from; rising complexity of palliative care patients which can take up to two hours and include syringe driver and wound care; diabetes cases that often involve bi-daily visits; community nursing teams providing reactive and complex care to care homes with quality and safety concerns and increased visits due to early hospital discharge and admission avoidance. 

There is a significant increase in patients who wish to remain at home rather than be admitted to a hospice or hospital, therefore, the patients are more complex and unwell.” 

Julie Shepherd told the board there was some work going on around governance of the service and the workforce was being looked at closely.

NHFT’s chief executive Angela Hilary says the issue is a nationwide one and Northamptonshire is not alone in its predicament.

Pre Covid concerns

Concerns about district nursing levels across the UK were being flagged before the pandemic hit.

In May 2019 the Royal College of Nursing called for urgent investment into district nursing and said the district nurse workforce number had dropped by 43 per cent in the previous decade. It said there were only 4,000 UK nurses caring for a population of 55.8m people - a ratio of one district nurse for every 14,000 people. In comparison there was one GP to every 1,600 people.

The RCN stated district nurses were working to capacity and to at times unsafe working levels. It also said there was an ageing workforce with new qualified staff not joining the service as fast as experienced district nurses were retiring.

In November of the same year the Queen’s Nursing Institute also released a report led heavily by surveying those in the job who pointed to increased targets and less resources. A quarter of respondents said they were regularly doing unpaid overtime in order to see all the patients they needed to.

Serious incidents and CQC concerns

In Northamptonshire there has been a rise in serious incidents (SIs) within the community nursing team in the past year. A serious incident can include omissions of care which result in death, avoidable injury or serious harm. They have to be investigated and the lessons learned shared.

There were five SIs within the community nursing team between April 2019 and March 2020. Between April and November 2020 there were already seven serious incidents and the rise has led to regulator the Care Quality Commission raising concerns with bosses. 

It has asked for further information about an SI in 2019 involving referrals to the diabetic high risk foot service and a similar serious incident that is currently under investigation.

There were also 15 complaints made to the patient advisory service (PALS) about the community nursing service in the third quarter of the current financial year. The CQC and NHFT met earlier this month in a private meeting to discuss the current transformation plan for the district nursing service which will see it working with the organisation’s Intermediate Care Team.

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