Reflecting international trends, in all corners of the UK, changing demographics of the ageing population have resulted in a shifting pattern of disease, from acute illness to complex and multiple long-term conditions (Royal College of Nursing (RCN), 2014). Resultant policy drivers have shifted the balance of care to the community, with avoiding hospital admission being an international priority (World Health Organization (WHO), 2010; Northern Ireland Assembly, 2016; Scottish Government, 2016; Department of Health and Social Care, 2018; National Assembly for Wales, 2019). District nurses (DNs) are viewed as being ideally placed to deliver the policy agenda due to their position as the largest group of providers of nursing in the community (RCN, 2014).
These changes in demographics and political focus challenge district nursing at a time of increasing caseload size and complexity, with an ageing and dwindling DN workforce (RCN, 2014). This is further exacerbated by scarce additional resources to meet the demands, with district nursing caseloads described as a ‘ward without walls', where the caseload has no physical boundaries or limitations (Haycock-Stuart et al, 2008). These challenges have resulted in increasing pressure for active management, monitoring and evidencing of DN caseloads (Baldwin, 2006). However district nursing and the delivery of care has always been a difficult activity to quantify, with no ideal universal method available. Further confusion is evident in practice due to a plethora of methods, with interchangeable use of terminology and applications. The literature suggests that the principles of caseload management provide a range of methods to support DNs to manage caseloads (Bain and Baguley, 2012). Of these, two methods specifically focus on monitoring, managing and evidencing of caseloads-workload analysis and caseload profiling (Table 1) (Ervin, 2008).
Table 1. Defining caseload profiling and workload analysis
| Caseload profiling | Workload analysis |
|---|---|
| An analysis describing the total caseload managed by the district nurse, in terms of a number of variables, in an attempt to articulate the complexity of the caseload, with an aim of helping effective management and equitable resourcing of caseloads | A process that compares patient's dependency from simple counting of caseload numbers to more complex measures, used to determine nursing time required, that is then compared with available nursing time, to establish if there is a deficiency or surplus of time (based on time and motion principles) |
In practice, some literature supports adopting workload analysis methods (Grafen and Mackenzie, 2015; Jackson et al., 2015). However, this is contested by others, with suggestions on the use of a mixed approach, encompassing workload analysis and caseload profiling (Reid et al, 2008) or caseload profiling being argued as the most robust single method (Baldwin, 2006; Thomas et al, 2006; Harper-McDonald and Baguley, 2018). Regardless of the methods applied, DNs and their managers need a method to measure, monitor and resource caseloads. Understanding on the application of these methods is heavily based on the expert opinion of those with managerial or educational roles, and there is a need for more qualitative work on the direct experiences of caseload measurement from DNs' perspectives (Harper-McDonald and Baguley, 2018). This article seeks to report a service evaluation that was conducted on the experiences of DNs implementing caseload profiling to their caseloads to address the gap in knowledge.
Service evaluation on caseload profiling
Within the Scottish context, the method to measure, monitor and resource DN caseloads is based on the principles of workload analysis, and workload is measured on the basis of subjective self-reporting by professionals, time spent on tasks compared with hours worked, completed over 10 days, once annually (a time and motion study) (Scottish Government, 2013; Grafen and Mackenzie, 2015). While this provides some data on DN activity, within Aberdeen City Health and Social Care Partnership, the method failed to adequately provide DNs and managers with sufficient caseload data to manage and resource the service. However, locally, the possible benefits of caseload-profiling were considered a more suitable alternative, and a working group was established to create and pilot a caseload profiling tool. This tool was based on the variables advocated in the literature (Box 1) (Audit Commission, 1999; Bain and Baguley, 2012). Additionally, data collection categories were standardised with NHS Scotland datasets (Scottish Government, 2013). The caseload data were entered into Microsoft Excel and provided a detailed monthly caseload-profiling report.
Box 1.Variables of the caseload profiling design
| Demographic detail (gender and age profiles) |
| Geographic detail (linked to the multiple areas of deprivation) |
| Primary diagnoses |
| Interventions (broad categories and sub-categories) |
| Patient dependency/weighting on caseload |
| Caseload throughput (admissions, discharges and changing interventions and dependency) |
Aims and objectives
The service evaluation aimed to explore the working group's experiences of implementing a caseload-profiling tool to caseloads in district nursing in one community setting. To achieve the aim, the following objectives were considered:
- Explore DNs' experiences on the barriers to using a caseload-profiling tool
- Explore DNs' experiences on the facilitators of using the caseload-profiling tool
- Explore DNs' perceptions on the significance of data collected when using the caseload-profiling tool.
Methods
A service evaluation is defined as an applied research method with a distinctive purpose to assess the value or worth of an intervention, and a range of different data collection methods can be applied from either a qualitative or quantitative paradigm (Robson, 2011). As this service evaluation aimed to explore DNs' experiences, a qualitative approach was most appropriate (Robson, 2011). To identify the qualitative method, the Cambridge method decision tree was applied (Marsh and Glendenning, 2005), identifying semi-structured interviews as the most appropriate method for service evaluation (Figure 1).
Figure 1. Cambridge methods decision tree
A total of three semi-structured interviews were conducted during meetings of the working group during the pilot implementation of the caseload-profiling tool from January 2016 until March 2016. The purposive sample comprised working group members, including two DN caseload holders and a senior administrator. The caseloads were representative of the local area, covering areas with a range of socio-economic statuses and both city centre and suburban areas. Inclusion of an administrator was particularly relevant due to their extensive knowledge of and involvement in data collection in district nursing. The semi-structured interviews were guided by an interview schedule, and notes were taken and transcribed following the interviews. To ensure accuracy and credibility, transcriptions were checked with participants (respondent validation) and, while any dispute would be resolved in favour of the participant, no dispute occurred during the service evaluation.
Following the semi-structured interviews, thematic analysis was applied to analyse the data collected. Braun and Clarke (2013) defined thematic analysis as an analytical method of data analysis in qualitative research, identifying, analysing and establishing patterns (themes). These themes can either be identified from data (inductive approach) or driven by the interest of the project (theoretical thematic analysis) (Braun and Clarke, 2013). A theoretical approach supported data analysis in this service evaluation, which saw themes and sub-themes established, correlating with the service evaluation objectives. Permission to conduct the service evaluation was granted by the lead nurse, and informed consent was gained from colleagues in the working group. As a service evaluation is not classified as research, NHS Research and Development ethics permission was not required, although ethics approval was granted by the ethical review panel of the author's university.
Results and discussion
Findings from the service evaluation will be discussed under the three themes-barriers, facilitators and significance of data collected in caseload profiling-and they were compared with the available literature and policy contexts (Figure 2).
Figure 2. Results—themes and subthemes identified from implementing caseload profiling to caseloads in district nursing
Time
A major barrier to caseload profiling is the time required (Audit Commission, 1999; Ervin, 2008; Queen's Nursing Institute (QNI), 2014). This was evident in the service evaluation, with 10% of codes generated in the thematic analysis process attributed to this barrier. More specifically, there was recognition that the impact of time was more prominently attributed to the initial population of the caseload-profiling tool and that ongoing profiling of caseloads would have less impact on time.
‘The amount of time is the initial getting your caseload on the caseload-profiling tool. Keeping it up-to-date is not going to be time consuming.’
Additionally, it was identified that use of administrative staff could help overcome this barrier. However, this identified another barrier acknowledged by all members of the working group:
‘The district nursing service has been starved of admin. Because they have all gone to the health visitors, this needs to improve with fairer distribution.’
Evidently, reflecting the literature, time is a significant barrier to implementing caseload profiling, mainly at the initial stages. Despite recognition that increased administrative support may solve this problem, this is challenged by limited and competing demands on administrative resources within DN and health visiting services that are under the same management structure.
Caseload profiling and management
In the literature, there is interchangeable reference to the terminology on caseload profiling and caseload management, with no agreed definitions, which has resulted in confusion in practice (Harper-McDonald and Baguley, 2018). This was evident when exploring the working group's understanding of caseload profiling:
‘I think knowing what is available in the community like support groups, incorporated with knowing what type of patients you have got are all part of caseload profiling.’
Despite aiming to define caseload profiling, this definition aligns with the definition of community profiling (Jack and Holt, 2008). At this stage, the working group was provided key defining terms; nonetheless, in subsequent interviews, the confusion over the terminology persisted:
‘Caseload profiling, well, everyone gets confused. There are so many interchangeable terms that surround it.’
Reflecting the literature, there is certainly confusion in practice over terminology. Consequently, this could be one contributory factor to why caseload profiling is seldom conducted in practice (Thomas et al, 2006; Bain and Baguley, 2012). Supporting this, Ervin (2008) advocated a need to raise awareness and education of caseload profiling in practice. Additionally, this subtheme highlights the need for standardised language and clearer definitions on key terms surrounding caseload management.
Workload analysis
As described earlier, workload analysis is the data collection method used nationally in Scotland. There was a strong consensus disputing the application of this method by all members of the working group:
‘We need a tool that goes beyond the current National Workload Tool. We know we are all busy and all the workload tool does is confirm this, with no way of quantifying why. This does not help identify what would help.’
‘I agree, it is an inadequate and unreliable tool failing to demonstrate the complexity of nursing care in the community or help you to manage your caseload.’
In contrast, one member of the working group commented:
‘Caseload profiling is much more representative than the terrible workload tool that tells you nothing. However, it will be double work having to complete both.’
Albeit a strong stance, it does articulate the viewpoint of the working group on the workload analysis method employed in the Scottish context. This aligns with suggestions discussed above, that caseload profiling is a more reliable method than workload analysis, as it provides a more accurate measurement, and supports caseload management (Thomas et al, 2006; Brady et al, 2007; Reid et al, 2008; Harper-McDonald and Baguley, 2018).
Accuracy of data collected
Another suggested barrier to caseload profiling is that DNs are protective, subjective and guarded about disclosing information on their caseloads, making it challenging to collect accurate caseload data (Kane, 2008; Bain and Baguley, 2012). This barrier was identified by the working group:
‘Inaccuracies in reporting on caseloads are likely to happen. Historically, it has always happened. If we use caseload profiling, we rely on the district nurse to accurately report.’
Additionally, Kane (2008) reported that DNs may have incentives to falsify caseload data when completing a caseload profile. This was expressed as a concern by the working group:
‘If people are worried about what the caseload profile may show, like a smaller caseload, they may, rather than discharge a patient, keep them on, to keep their caseloads looking busy.’
When Kane (2008; 2009; 2014) implemented caseload profiling, it resulted in redistribution of staffing and resources, and the findings highlighted one reason why DNs may attempt to maximise their caseload size. This concern was identified by the working group:
‘Don't we need to be open and transparent that applying caseload profiling may alter staffing?’
‘People need to stop being so protective of their own little area, it is a citywide service.’
Despite the working group's concern over the accuracy of data reporting, it was acknowledged that future inaccuracies will become more apparent, due to the ability to compare caseload profiles collectively. Comparing caseload profiles to identify inaccuracies and variations in practice is defined as caseload analysis (Kane, 2014). This method of caseload analysis was articulated by the working group:
‘If everyone is doing caseload profiling, differences in the profiles would become more apparent, and it would be easier to detect variation.’
The working group identified that variation in practice may highlight the need for discussion with the DN in a supportive capacity, as opposed to a disciplinary capacity:
‘It informs a critical discussion, where that manager can go to that district nurse to have a discussion. It is not getting that person into trouble, it is identifying variations in practice or problems that exist within that area.’
Practice culture
Although caseload profiling may benefit the DN service, its application can be hampered by a resistance to change (QNI, 2014). This was evident in the service evaluation, and resistance to change was identified as a significant barrier hampering the implementation of caseload profiling and highlighting the need for effective leadership and change management skills:
‘We need to challenge this constant resistance to change in practice.’
‘Everyone in practice always sees everything as a criticism. I do get it to a point, but there is a mind-set that just needs to change.’
This theme has discussed barriers to caseload profiling comparing the literature with the findings of the service evaluation summarised in Table 2.
Table 2. Barriers to caseload profiling: available knowledge and new insights
| Barriers identified in the literature | Strategies identified to overcome these barriers | Barriers identified in the service evaluation | Strategies identified to overcome these barriers | |
|---|---|---|---|---|
| Lack of awareness and training on caseload profiling and caseload management | Confusion in practice on defining the terms ‘caseload profiling’ and ‘caseload management’ | |||
| Lack of time exacerbated by lack of caseload-profiling tools and information technology to support data collection | Lack of time to undertake a caseload profile | Administrative support | ||
| Lack of administrative support in district nursing service | Explore distribution of administrative support with district nursing service | |||
| Workload analysis fails to provide a strategy to measure, manage and monitor district nursing caseloads | Application of caseload profiling as an alternative | Duplication of work with having to complete existing data collection methods based on workload analysis | Caseload profiling viewed as a more reliable and representative tool | |
| Protective, guarding and subjective nature of data collection affecting accuracy | Caseload analysis | Accuracy of data collection (an issue regardless of caseload measurement strategy) | Compare caseload profiles collectively to identify variations (referred to as caseload analysis) | Supportive discussions with caseload holders where variation is detected |
| Resistance to change | Resistance to change due to practice culture | Effective change management and clinical leadership skills | ||
| Key | ||||
| Represents findings from the literature and findings of the service evaluation where comparable relationships were evident | ||||
| Represents where new insights have been identified from the service evaluation | ||||
Facilitators to caseload profiling
Complexity of care
As discussed earlier in the article, measurements focusing on workload analysis (quantitative in nature) are inadequate in illustrating the complexity of the DN caseload (Brady et al, 2007; Kane, 2014). This viewpoint was supported by the working group:
‘Just having a number doesn't tell you anything. You could have 50 patients with multiple needs on one caseload, compared with a caseload of 150 with one need, and the smaller caseload is more complex.’
Alternatively, it has been suggested that caseload profiling could provide a strategy to overcome limitations in historical workload analysis methods and illustrate the complexity of care using more qualitative measures (Baldwin, 2006; Thomas et al, 2006). Within the service evaluation, a consensus supporting the above claim was observed:
‘Caseload profiling for me is looking in a more analytical way-quantity and quality-not just how many patients you have, but what is involved with those patients in much more detail.’
Promoting effective caseload management
It has been suggested that applying caseload profiling to practice results in improved performance of the DN (Audit Commission, 1999; Kane, 2008; Reid et al, 2008). This was supported in the discussions of the working group:
‘Before caseload profiling, I would perhaps see that patient as a patient with a wound, but now I see their diagnosis … have I looked into that? Have I cared for that? You can anticipate future care needs.’
‘For me, caseload profiling may open up opportunities to match resource and skills to patients' needs, as well as identifying training needs of the team.’
These comments illustrate a facilitator of caseload profiling, in that it supports the DN to lead their team effectively to meet and anticipate patients' needs. Additionally, mirroring the literature, these comments also suggest that caseload profiling enabled the DNs to ensure more equitable distribution of resources to those in the greatest need and help reduce inequalities in healthcare delivery (Audit Commission, 1999; Bain and Baguley, 2012).
Integration and policy agenda
The introduction of the caseload-profiling tool occurs at a time of significant change, redesign and blurring of roles, as policy agendas advance across the UK. This is specifically in the Scottish context, where the integration of health and social care has become a reality (Scottish Government, 2016). The working group identified that the information gathered from the caseload-profiling tool is vital to evidence the work and contribution of district nurses:
‘We have not mentioned integration yet. This is going to be critical information for integration.’
This highlights the importance of the district nursing service being able to articulate and evidence its caseloads and the remit of services it delivers as the policy agenda, service and roles change.
Public health aspect of district nurses' role
The literature suggested that one weakness of caseload profiling is its failure to acknowledge the public health aspect of the district nurse's role (Harper-McDonald and Baguley, 2018). Due to awareness of this weakness, when the caseload profiling design was created locally, it encompassed a method to categorise patients in relation to the Scottish Index of Multiple Deprivation, whereby patients were classified according to affluence or deprivation (Scottish Neighbourhood Statistics, 2012). This was viewed as a facilitator of caseload profiling by the working group:
‘It is pertinent to categorise my patients as affluent or deprived, because their lifestyle choices can have an effect on their health, that is, wound healing. These patients need more support. And with easy recognition, I can target the support and help reduce inequalities.’
This quote would indicate how application of simple measures within the caseload-profiling tool has contributed to the acknowledgement of the district nurse's role in public health and helping to meet Government aims of reducing inequalities in healthcare. It could be suggested that it is important to consider these measures and others potential measures in future caseload-profiling designs.
The findings of the service evaluation in relation to the facilitators of caseload profiling are summarised in Table 3.
Table 3. Facilitators of caseload profiling: available knowledge and new insights
| Facilitators identified in the literature | Facilitators identified in the service evaluation |
|---|---|
| Powerful strategy to comprehensively articulate caseload composition | Articulates the complexity of care being delivered by district nursing teams |
| Strategy to promote reflection on and analysis of caseloads | Increased analytical and reflective approach toward caseload management |
| Increased performance of the caseload holder | More proactive patient-focused management of the caseload |
| More equitable distribution of resources due to caseload profiling providing a strategy to set priorities and co-ordination of caseloads | Caseload profiling provides information to match resources and skills to patient needs |
| Caseload profiling provides detailed information and evidence on caseloads and the remit of district nursing services, of particular importance moving forward into integrated care | |
| Simple methods can be included in caseload-profiling designs to aid integration of the public health aspect of district nursing | |
| *All these facilitators are suggested to result in a reduction in caseload numbers | |
| Key | |
| Represents findings from the literature and findings of the service evaluation where comparable relationships were evident Represents where new insights have been identified from the service evaluation | |
Significance of data collected in caseload profiling
Recognising multimorbidity
One negative aspect of applying the caseload-profiling tool identified by the working group was its failure to capture data from patients with multimorbidity:
‘I don't like the primary diagnosis on the tool. It only has one. It fails to recognise multimorbidity. All my patients, or most, have multimorbidity. I have an issue with this. It doesn't represent my caseload.’
Although the above quote articulates a failure of the caseload-profiling tool, in fact, it exposes a failure on the data collection requirements of the Government (Scottish Government, 2013), where there is no requirement to report more than one long-term condition. Locally, the caseload-profiling tool was adapted so all patient conditions could be recorded, enabling a more accurate reflection of complexity of care being delivered by DN teams. Although it was beyond the scope of this service evaluation to address concerns in Government data reporting requirements, this issue is noteworthy.
Identifying service delivery priorities
One significant factor identified by the working group regarding data collection in caseload profiling is related to how this can help identify issues in service delivery and highlight service delivery priorities.
‘I think the information that can be gained is immense with caseload profiling, and it helps explain what we are doing.’
‘We want our managers to see our profiles and what we do. We are busy but it's not always easy to explain why.’
These quotes contradict the literature, which suggests a protective and guarding attitude is adopted toward reporting caseload data (Kane, 2008; Bain and Baguley, 2012), and, in fact, the main issue is challenges in district nurses articulating their work. Importantly, this viewpoint is that of authors in management or educational roles rather than those in practice. Therefore, new insights have emerged from district nurses, indicating they want transparency of their caseloads, and they have said that sharing caseload-profiling results with management could articulate problems faced by the nurses and the DN service:
‘It can highlight to service managers problems that are happening, and this gives them the evidence that means they have to do something about it …’
‘The service managers are excited with the data the caseload-profiling tool captures. This is data we have never had before.’
These quotes from the experiences of the working group support the literature, where not only is caseload profiling viewed as a tool to ensure even distribution of resources, but it also provides evidence when seeking additional resources or competing to maintain funding (Kane, 2008). This was further evidenced by the following comment:
‘At the moment, when our managers are trying to source additional resource, they have no evidence, they can only say we are busy. That's not enough.’
Simplicity of caseload profiling
A significant observation from the data collected was the simplicity of applying caseload-profiling principles to DN caseloads, despite it returning complex and informative data:
‘So simple and usable, yet such effective and useful results.’
This subtheme challenges the literature, where it is argued that the lack of a suitable tool and investment in IT solutions have contributed to difficulties in conducting caseload-profiling (Audit Commission, 1999; Thomas et al, 2006). New insights have been gained during the service evaluation, which indicate that, when the working group applied a caseload profiling tool, using a simple self-created Excel program, caseload profiling was simple and effective and provided rich and informative caseload data.
This theme highlights the findings of the service evaluation on the significance of data collected as a result of caseload profiling, as summarised below:
- Caseload profiling is a simple process returning complex and informative data
- It aids in identification of issues within service delivery, enabling service delivery priorities to be identified.
Study limitations
One limitation of using semi-structured interviews was the effect the researcher can have on the participant (Robson, 2011). This is more apparent in small-scale projects, such as this service evaluation, where participants are generally known to the researcher. The researcher effect became apparent at the start of the service evaluation, when one participant stated ‘Well, what I think your vision is …’, indicating that, because the participant knew the author, their response aimed to reflect the author's viewpoint and not their direct experiences. In order to address this limitation, the working group was consistently reminded that the aim of the service evaluation was to gain their experiences. Additionally, to ensure an accurate account and interpretation of participants' viewpoints, the transcriptions were checked with participants (respondent validation).
Conclusions
This article described a working group's experiences of introducing a caseload-profiling tool to their caseloads and compared their observations with the literature to gain new insights. One important observation was that no barriers related to caseload profiling were identified, and any barriers discussed were related to external factors, which would be evident on the application of any new process in practice. It should be kept in mind that there are issues around the lack of standardised definitions or terminology and terms are used interchangeably in the literature, causing confusion in practice.
During this service evaluation, it became evident that district nurses struggle to evidence their work and the complexity of their caseloads. However, caseload profiling provided a method to help them evidence their work and use this information to more proactively manage their caseloads and support the public health aspects of the role. While there were issues with the time required to apply caseload profiling to practice, it was clearly identified that caseload profiling is a simple process, providing complex data to support district nurses in managing a caseload and helping identify service delivery priorities. These insights may benefit both district nurses and managers in understanding benefits, barriers and factors for implementing caseload profiling or similar workload tools to DN.
Following this service evaluation, it is recommended that, in practice, the caseload-profiling tool be further implemented, and a full evaluation should be conducted thereafter. Specifically, this evaluation should explore the impact of the identified strategies to overcome barriers to caseload profiling. In addition to practice recommendations, further research would be valuable to explore the work and contribution of district nurses that they identified as being difficult to articulate.
KEY POINTS
- Caseload profiling is a more robust method to measure, manage and monitor district nursing caseloads, compared with workload analysis
- Caseload profiling is an easy process, providing a return of complex data to support caseload management and help identify service delivery priorities in district nursing
- Caseload profiling provides information supporting more proactive caseload management and strengthening the public health aspect of the district nursing role
- Any barriers to the use of caseload profiling relate to external factors that would be evident in the use of any workload measurement tool.
CPD REFLECTIVE QUESTIONS
- What methods are used in your practice to measure, manage and evidence caseloads, and what are the strengths and weaknesses to the approaches used in your practice?
- Considering the methods available, do they help you with caseload management and resource allocation?
- What is the potential impact of applying caseload profiling to your practice?