Managing a district nursing workforce is complex because the workload is not as visible as it is on a hospital ward. The district nurse caseload holder has independent accountability for a caseload of patients, with responsibility for admission to the caseload and care planning including frequency of visits, and patient discharge. Often this caseload management is invisible to the manager of the district nursing service, making it difficult to quantify the workload, allocate the workforce appropriately, determine performance and ultimately provide an equitable service to patients.
In 1994, I became the manager for district nursing in East Belfast, Northern Ireland (NI). At that time, the population was 108,000 people served by 10 district nursing teams. The teams were led by two district nurse caseload holders supported by RGN staff nurses and healthcare assistants. Immediately, I was presented with complaints from the staff about heavy workloads, yet when I tried to understand the issues and manage situation I found I had little or no influence on caseload management practice, which ultimately produced the workload.