The first reading is the first stage of a Bill's passage through the House of Commons, it takes place without debate. The short title of the Bill is read out and is followed by an order for the Bill to be printed. The next stage is second reading, the first opportunity for MPs to debate the general principles and themes of the Bill.

In the first reading of this proposed Bill, Dawn Butler MP made the following points:

• A freedom of information request by Nursing Standard found that across 93% of all NHS trusts, there were more than 8,000 people with the term “nurse” in their job title who in fact had no registered nursing qualifications.
• A route to addressing this issue to would be to amend the Professional Qualifications Act 2022 by adding “nurse” to “registered nurse”, a term that is already regulated by the Nursing and Midwifery Council, so this would not need to be part of regulatory reform.
• The Royal College of Nursing passed a resolution in favour of protecting the “nurse” title at its congress in 2022. 

• RCN's workforce standards set out what must happen to ensure safe and effective care. 
• RCN's levels of nursing show who should be making decisions about emergency care.
• RCN's Raising Concerns Toolkit covers all the essentials to help you sound the alarm.

Related reading on the hub:

• A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift

Demand for health and care is rising, with advances in technology and treatment options growing. Peoples’ individual needs and the support professionals provide for families can be complex. That’s why the NMC has a responsibility to make sure professionals are equipped with the knowledge and skills needed to improve people’s health and wellbeing. Practice learning is a key part of this.

What is practice learning?

Nursing and midwifery education and training takes place at NMC approved educational institutions. Half of the programme consists of academic learning. The other half is practice learning, where academic learning is applied to their developing practice, through supportive, supervised practice with direct contact with people receiving care and their families. This can take place in the community or in hospitals, or care homes for example.

The review

We want to review practice learning for both nursing and midwifery. We want to identify good practice, innovation and collaboration in the UK and internationally. And we want to hear what you think about nursing and midwifery student learning. What support do you think students should receive when they are caring for people or observing the way people are cared for? What is most important to you when thinking about receiving care?

We want to hear from you on these and other questions. So, if you’d like to have a say and help shape the review, please get in touch by Wednesday 15 May 2024.

We’re setting up a public advisory group. It will be made up of people with lived experience of nursing and/or midwifery care, and colleagues from charities, advocacy and patient groups.

Everyone’s voice matters. We’re keen to hear from a range of people from different backgrounds and with diverse health and social care experiences, including people from black and ethnic minority backgrounds, disabled people and people living with long-term conditions.

Please note that places on the advisory group are limited so please get in touch as soon as you can.

Meetings will take place online every six to eight weeks between June and November 2024 during the initial phase of the work. We have an involvement payment policy in place to support your participation.

To find out more, please reply to PracticeLearningReview@nmc-uk.org.

• Technology that is obsolete should be replaced with up-to-date models by employers. The cost of using obsolete devices in terms of lost time and efficiency is likely to far outweigh the cost of purchasing new hardware.
• Nurses should be consulted at an early stage in the choice of hardware for use in community settings to ensure that it is appropriate and safe for its designated use.
• Companies that design mobile devices should be called upon to improve future designs of those used by the community nursing workforce, actively seeking nursing feedback.
• Nurses should be involved at an early stage in the design and development of software programmes that they will use as part of their everyday work.
• Healthcare provider organisations, commissioners and policy makers should undertake national, regional and local reviews of WiFi internet connectivity in all areas where their services are delivered and understand how this is directly impacting on the work of nurses delivering care in people’s homes and communities.
• Healthcare services and supporting organisations could usefully campaign for improved internet connectivity and ask for increased investment by mobile phone operators and government.
• Scheduling tools and related apps should always be designed, developed and used in a manner that is consistent with the nursing process, professional judgement and autonomy, personalised care and patient need.
• All healthcare providers should have a nurse who is appropriately experienced and skilled to lead on the use of digital technology within the organisation.

Caseloads, capacity and time 

An effective District Nursing service should serve the need for nursing care in a defined community. District Nurses understand the needs of their local community but there must also be clear referral criteria for other services.

A growing and ageing population, deprivation, communication issues, social isolation, acuity, multimorbidity, ‘rookie’ factor (number of inexperienced staff), travel time, frailty, cognitive issues, lack of other services and lack of home support systems all affect the demand for healthcare delivery in the community.

Maximum caseloads are not defined in the new Standards, as there is no single definition of a ‘caseload’ used in the community. Currently there is no limit to District Nursing caseloads and this itself is problematic. However, a caseload of over 150 per whole time equivalent (WTE) seems to be a tipping point for more work left undone and deferral. For District Nurses and community staff nurses in the teams, 9-10 visits a day is also associated with the tipping point for people deferring work.

The consensus of professional opinion, borne out by the data, was that a Registered Nurse (RN) visit should be a minimum of 30 minutes to allow for the entire nursing process to be enacted (assess, plan, implement and evaluate). Travel time should be factored into scheduling visits. Route planners and other resource allocation applications should not override the priority of clinical care and professional judgement.

A ‘timed task’ approach to plan work or workforce should not be used: a timed task approached was shown to be a trigger for workforce discontent and even resignation. The safety of timed task approaches has also been called into question. Digital scheduling tools or apps may be used to inform or plan work and workload, but they should not be used to decide the nature and time of the work itself.

Nursing establishment and skill mix 

Skill mix of teams should reflect the demand placed upon them by populations and their needs. Work should be allocated with a focus on risk, unpredictability, complexity and acuity of the situation and not simply competency to carry out a task. Situational awareness is crucial for safe care.

Views regarding an appropriate and realistic skill mix for a District Nursing team were sought as part of the research for the new Standards. Considering the experience, knowledge and skills of the team members, the consensus of views was for a team comprising 60% experienced Registered Nurses; 20% newly Registered Nurses; and 20% Nursing Support Workers, including healthcare assistants and Nursing Associates.

When calculating the nursing workforce, an uplift must be applied that allows for planned and unplanned leave and absence. Underestimation of either or both planned and unplanned leave will result in an establishment that cannot meet day to day staffing requirements, and an overreliance on supplementary staffing, such as bank and agency staff. This will impact on the overall cost and quality of care.

A Registered Nurse (RN) should make the initial assessment and then attend every fourth visit as a minimum to carry out the Nursing Process in full, evaluating care, assess new needs and initiate changes required. Whilst Nursing Support Workers including Nursing Associates can be involved in the Nursing Process and play a vital role in the delivery/implementation of care, the assessment, nursing diagnosis, planning and evaluation of care is the responsibility of the Registered Nurse.

Red flags

• District Nursing services unable to close caseloads, leading to unremitting and unsustainable demand.
• Deferring work every day or most days should be a red flag and escalated.
• Deferring any high priority work at all (for example end of life care, people with blocked catheters) should be escalated as a safety concern.
• High staff turnover and high sickness absence should also be considered a red flag for both patient safety and system resilience.

Commissioners of community healthcare services should work with District Nursing teams to understand patient need in the community, undertake a realistic estimation of demand, and determine a nursing establishment that is wholly appropriate for the needs of individual and population health, now and in the future.

1. NHS bed occupancy rate
2. Sickness absence in nurses working in the NHS and social care
3. NHS nursing workforce vacancy rate
4. High Covid-19 infection rates
5. NHS hospital waiting times
6. NHS elective/community waiting times
7. Social care workforce vacancies
8. International recruitment in the NHS and social care
9. Insufficient domestic NHS and social care nursing supply
10. Increase demand for social care services

• Responsibility and accountability – outlining where the responsibility and accountability lie within an organisation for setting, reviewing, and taking decisions and action on staffing levels and skill mix.
• Clinical leadership and safety – outlining the needs of nurse leaders with professional responsibility for teams, their role in workforce planning and the professional development of staff. 
• Health, safety and wellbeing – outlining what’s needed to support nursing staff to provide the highest quality of care, including safe shift working, the ability to raise concerns and the right to work in a safe environment that prioritises staff wellbeing. 

Download the Nursing Workforce Standards