Just Another Occupational Hazard?

The RCN surveyed 1,300 community nurses (1) and their results weren’t comfortable reading for me, a community nurse myself.

A half of those community nurses surveyed had been the victim of abuse at work, and one in nine had been physically and verbally attacked. Yet only 13% of them have personal alarms (even though they were widely available in 2009 for lone workers and originally government funded).

Cost-cutting measures are putting community nurses’ safety at risk but it goes further than the lack of personal alarms, it is the increased pressures being put on community services without extra resources. 

Hospitals have to treat more patients for less money (The yearly increase to NHS funding being only 0.9% [2], well below even inflation), so they are discharging patients earlier and earlier, and more and more ill patients are being treated in the community, but there hasn’t been the extra resources put into the community to meet this increasing demand.

Community health services have around 100 million patient contacts each year, and account for about £10 billion of the NHS budget (or 8.3% of all NHS spending) (3). There has been a 15% increase in District Nursing workload between 2011 and 2015 (4) yet the NHS only plans to increase spending on Primary Care as a whole between 4% and 5.5% year-on-year for the next five years (5). There has already been a 15% increase in the workload and it shows no sign of decreasing, this planned increase in spending will be far outstripped by demand. This does not take into account the £2.5 billion cut in Social Care funding, 20% of their funding (6); which also has a severe knock-on effect on District Nurse caseloads.

There has also been a huge fall in the numbers of District Nurses and Community Nurses. Since 2009 there has been a 28% fall in District Nurses numbers and the Community Nurse workforce has shrunk by 8% to 36,600 (4). This alone puts a huge strain on the service.

Patients’ expectations of what can be provided in the community are often unrealistic, measuring it against the very public targets of A&E Departments, and expecting instant access to services. More people want medical input for things that they can manage themselves (“It’s a nurses’ job to give my granny her tablets. The nurses did it in hospital”). The community isn’t an acute service and many patients are reacting with anger and frustration when they are faced with its limitations.

Also, patients in the community are often not aware of shortages of Community Nurses. Sometimes the only time they are aware of it is when they have a visit cancelled. Patients on hospital wards can see how many or how few nurses are on duty and how busy they are. Patients in the community only see a Community Nurse when they visit that patient’s home, they cannot easily see how few nurses are available and how busy they are. Patients are isolated away from the stresses that many Community Nurses are under.

More and more working practices are also putting community nurses at risk, nurses working on their own on late shifts until ten o’clock at night, twilight and night time community nurses working on their own, community nurses working in uniform, poor or unrealistic Lone Worker Politics, staff working without easy access to senior nurse support, working with unrealistically large caseloads and lack of time to do full risk assessments.

Often senior manager’s poor handling of abusive patients makes the situation worse. Senior managers who are reluctant/afraid to confront abusive patients, managers’ fear of generating complaints (“Don’t upset Mrs. ____, because she’s only put in another complaint”), also the pressure to meet targets and numbers of patients treated.

The NHS has always been poor with dealing with abusive patients, but worst so in the community because the argument always comes back, “They’re housebound, who else will see them if community nurses won’t.” A friend of mine, another community nurse, was punched by a patient at work. The same patient had slapped another nurse and been racially abusive to other nurses. Senior management wouldn’t remove treatment from this patient, still requiring nurses to see her. They were only spared further abuse when the patient went into hospital.

NHS Improvement has produced “Safe, sustainable and productive staffing in district nursing services” (7). These draft guidelines are designed to identify “the organisational, managerial and contextual factors that support safe staffing” in the community. But these guidelines do not make any recommendations as to what are safe staffing levels or safe caseloads numbers, instead recommending that that these numbers be agreed “locally”. This fudge could easily lead to poor staffing levels being accepted as the norm, and asks the question what is the point of these guidelines?

Cuts have put community nurses safety at risk but it goes deeper than just lack of personal alarms. We know of the problems caused by under staffing on hospitals wards, no one in the NHS can forget the Mid Staffs scandal (8), why aren’t we more concerned about the same problems in the community?

Drew Payne