District nursing services: survey reveals ‘relentless’ pressures

RCN’s shocking survey shows pressure on district and community nurses goes even beyond challenges of pandemic
Nurses under pressure

RCN’s shocking survey shows pressure on district and community nurses goes even beyond challenges of pandemic

  • Many nurses are working unpaid hours beyond the end of their shifts and have no time for meal breaks while on duty
  • Multiple demands on nurses’ time mean there are reduced opportunities to deliver the best care
  • RCN District and Community Nursing Forum has drawn up urgent recommendations for community commissioners and managers
Nurses are under intense pressure
Picture: iStock

District and community nurses play a pivotal role in the nation’s health. From multifaceted clinical management, prescribing and end of life care to liaison and advocacy with care providers, complex funding assessments and so much more, the district and community nursing role is complex.

Yet it is a role under unprecedented pressure, even beyond the challenges brought by the COVID-19 pandemic.

The RCN District and Community Nursing (DCN) Forum, of which I am chair, has been hearing anecdotal reports of rising patient acuity.

Half of nurses feel they work in a culture where staff well-being is undervalued

That is why we commissioned a survey to gauge the current pressures on nurses working in the community.

Our shocking findings reveal a DCN service at breaking point. Only 1% of district and community nurses left work on time at the end of their shifts, according to responses from 492 nurses.

Always a clock ticking in your head – high demands on district nurses

Team manager Gail Goddard says district nursing has always been hard work but the findings of the RCN survey highlight how much harder things have become in the service.

Gail Goddard, Queen's Nurse and team manager
Gail Goddard

‘Now the word I would use to describe it is “relentless”. Each visit you try to give off a vibe to the patient that you are there for them and have got all the time in the world, but you have always got a clock ticking in your head.’

Ms Goddard, who is a Queen’s Nurse and a member of the RCN District and Community Nursing steering group, says she has not left work on time in the past 15 years and is unsurprised to hear 99% of those surveyed were similarly unable to do so.

Increase in complexity of care required

‘It was an issue before COVID-19 but it is even more of one now. It is not so much the number of patients we are seeing – although caseloads have increased significantly – but more the complexity of care required.’

Ms Goddard says community nurses are seeing many more older people, often with frailty, who require complex care that takes time, especially given the need for changes in and out of personal protective equipment.

On a typical day, care nurses’ caseloads include palliative and end of life care, disconnecting chemotherapy pumps, supporting insulin-dependent diabetic patients, dealing with falls, long-term condition support, pressure areas or wound care, plus catheter care and IV antibiotics

‘There’s no other service like it,’ Ms Goddard says, describing how patient profiles have changed during the pandemic. In her service, nurses are seeing a lot of patients who are COVID-positive, but they are not dying of the virus.

Other patients have been too afraid of contracting COVID-19 to engage with healthcare services, and after a period of trying to manage on their own their health has deteriorated, leading to hospital admissions.

Many people who have spent time in hospital have since become deconditioned or deskilled in the self-care they were previously practising. Yet others with cancer or life-limiting diagnoses may have been seen in hospital but are new to community services.

Pressures on time have filtered into rotas

‘The complexity of care has increased,’ she says. ‘Our patients often need to be visited every day rather than a couple of times a week.’ The pressures on time have filtered into rotas.

When Ms Goddard first started as a district nurse 30 years ago she worked Monday to Friday from 8:30am to 4:30pm and one weekend a month. Now her team covers a 7am to 7pm shift rota, and until recently she was working every other weekend.

A recent typical day began for her at 7:30am, included ten patient visits, and ended at 10pm once she had finished a raft of documentation.

Some of these visits can be emotionally draining, especially in the context of COVID-19, when nurses’ own external support from family and friends, or fun events such as weddings and holidays, have been taken away. ‘I often sit in my car and cry, but that is part of the job we do,’ she says.

‘Everyone is finding it difficult at the moment and work is only one part of our day – a lot of people are also finding their own lives difficult and we have lost the balance a little bit. Because of COVID it can be harder to keep perspective, which is why peer support and clinical supervision is vital at the moment.

‘We give a good service and are highly skilled – community nurses are amazing.’

Worryingly, half the nurses said they would not be paid for their extra work, while a similar number did not feel they worked in a culture where staff well-being was valued. Around two thirds had no time for a daily lunch break.

One of the problems nurses are contending with is the way DCN teams often pick up the slack from other services.

While hospitals have limits to their capacity and bed numbers, in the community there are no apparent limiting factors and DCN caseloads can grow exponentially.

However, there is a limit to what DCN teams can deliver without adequate investment. Already our nurses are working beyond their timetabled shifts, lunch breaks are being subsumed into clinical care and opportunities to deliver the best quality care reduced.

Skills and experience deserve recognition

There is a predominance of band 5-6 roles (71%) among district and community nurses, which does not reflect the fact that 51% of respondents hold the specialist practice qualification, with advanced assessment and prescribing skills.

The RCN District and Community Nursing Forum survey found that over one third (39%) of respondents have more than 15 years’ service.

Nurse respondents said they would value more opportunities to complete relevant training, along with time for supervision while practising new skills and consolidating advanced skills.

Over 95% reported actively recruiting newly qualified staff nurses, but all felt that newly qualified staff required a period of additional support to be competent to manage the acuity of the patients to whom they would be exposed.

District and community nursing is the safety net that supports other services

Multiple patient visits, alongside high daily mileage, are now the norm for nurses, and opportunities for additional training and development appear to be increasingly limited.

Our feedback indicates that the DCN team is always the team that supports other services, it is the safety net and continues to carry this responsibility to provide care when all others are unable to do so.

Time is being donated to the service from nurses on a daily basis, visits are hurried and many routine tasks are being required of DCN teams that could arguably be carried out by others.

Offload some services to ease pressure

The district and community nursing (DCN) service is key to realising the ambitions of the NHS Long Term Plan, but the service is under severe pressure.

Nearly all of the nurses responding to the survey (96%) said patient acuity continued to significantly increase in the community setting. However:

  • High numbers (83%) of nurses reported a lack of suitable technology to support better management of this acuity
  • Nearly two thirds (61%) of nurses do not formally measure patient acuity
  • Three quarters (75%) said that when acuity was reported it had not resulted in any action or additional support

Against the backdrop of this increasing patient acuity, survey respondents say there are many activities that do not require their expertise and which could be carried out by others with the right education and training.

This would help reduce pressure on the DCN service. Suggestions for substitutes include the patient, their family or in some cases practice nurses, social care staff, a phlebotomist, the continence service or a GP.

Suggestions of activities that could be transferred to more appropriate services include eye drops, venepuncture, catheter care, continence assessments, simple dressings, medication prompts, hosiery application, annual reviews and equipment checks.

Vacancies are unfilled and teams are short-staffed, making DCN staffing one of the most pressing issues to solve, with 86% of nurses reporting vacancies in their team.

Nurses tell us they regularly need to move planned care to another day due to capacity and that they in turn are required to support other DCN teams when their demand exceeds capacity.

Despite this, only half of nurses have a mechanism to establish the daily capacity of their teams, with most using an electronic rostering system.

Around 90% of care is delivered outside of hospital

Many call for better progress on self-care, more specific referral criteria – such as housebound-only patients – improved technology, enhanced collaboration with GPs and practice nurses, and strong leadership.

Around 90% of the country’s care is delivered outside of hospital – in people’s homes, care homes, daycare centres and ambulatory clinics – to an increasingly ageing population, often with multiple long-term conditions.

Around 90% of the country’s care is delivered outside of hospital – in people’s homes, care homes, daycare centres and ambulatory clinics
Picture: iStock

We must ensure that funding for community services reflect this.

A call to action for community service providers

The pressures are only increasing. Add to this the impact of post-COVID recovery, as well as the rising numbers of long-COVID patients, and this vital service will simply will not be able to cope.

Our DCN forum survey feedback must now serve as a call to action for community service providers.

DCN requires investment, resourcing, effective technology and strong leadership to ensure the ability to deliver consistent, excellent care can be restored, at every visit.

What must be done: priorities for commissioners and managers

The RCN District and Community Nursing (DCN) Forum has made a number of recommendations for community commissioners and managers, including:

  • Daily minimum nurse staffing with sufficient staff on duty and optimal recruitment with vacancies filled promptly
  • Accurate patient acuity and caseload review tools
  • Define appropriate DCN activity, for example defining the remit of the role of the DCN service including the range of visits covered by it
  • Put electronic rostering systems in place where missing
  • Appropriate technology
  • Enhance services for mental health, drug and alcohol abuse, and homelessness to ease pressure on DCN teams
  • Investment in social care
  • Provide better access to specialist practitioner qualification programmes for nurses who lead caseloads
  • Having meal breaks and leaving work on time should be the norm rather than the exception
  • A culture of prioritising staff well-being

Infographic on district nurses' pressures


With thanks to RCN professional lead for community and end of life care Carolyn Doyle, and RCN District and Community Nursing (DCN) Forum Steering Group members Sarah Hayes, Wendy Newnham, Sue Hill, Irene Zeller, Marysia Graffin and Gail Goddard for their work on the DCN survey, which collected responses from 16 November to 7 December 2020