A triangulated approach to assessing safe workload and safe staffing levels in dietetics

In 2016, the NQB advocated that the capacity and capability of nursing staff were the main determinants of the quality of care experienced by patients (⁶). It is also the case that the capacity and capability of dietetic staff are the main determinants in the quality of nutritional care experienced by patients. Therefore, in addition to considering workload, the approach taken by NICE and NHS England in having ‘the right skills in the right place’ and monitoring safety indicators, is an approach that is likely to be beneficial to dietetics.

Thus, within each dietetic job plan there should be adequate time and hence sufficient capacity for dietetic staff to see patients safely (allowing for appropriate non-IPA direct clinical care) and there should also be adequate time for education and training to ensure the capability of the workforce.

it is recommended that a range of data incorporating capacity, capability and safety indicators are triangulated in order to achieve a more reliable estimate of safe workload and staffing levels. Patient complexity is another factor likely to influence dietetic capacity.

Conflicting priorities and adjusting the balance of workload activities, particularly to address safety concerns, can be a complex task and may require review of service provision, not just workload management. It is important to think holistically and innovatively when addressing workload safety.

Figure 3 from BDA Safe Staffing guidance 2016.png

Figure 3: From BDA Safe Staffing Guidance (2016), now archived

Capacity

Comparing those who perceived their caseload to be safe to those who perceived their caseload to be unsafe, the following differences were found.

As the total number of contacts/month/FTE increased, staff perception of a safe workload diminished. Generally, when the number of contacts was less than 90 per month workload was deemed safe. Once the number of contacts reached 110 or more per month, Dietitians reported that their workload felt unsafe.

77% felt their current workload was excessive. Most of those also stated that their workload was “unsafe” or “undecided”. Hence, the term “excessive workload” is probably a more sensitive marker than the term “unsafe”.

There were differences in the perception of the safe number of contacts in different work place settings; in particular between the acute and community settings. As found in the previous survey, a greater number of patient contacts per full time equivalent took place in the acute setting together with a greater number of new patients seen.

Setting	Number of contacts per month/FTE dietitian		Number of contacts per /FTE dietitian
	Safe/Not*	Excessive *	Safe/Not **	Excessive number dietitian **
Acute	90	120	864	1152
Community	70	100	672	960
* Figures for typical month (does not include any adjustment for absences) **Already includes the 20% absence calculation This assumes the time required for both new and review patients is close to the average (60 minutes and 45 minutes respectively) and that the new: follow ratio is no higher than 1:1.5

EXAMPLE

In the acute setting, if we assume that the N:FU ratio is 1:1.5 and that the total number of patients seen per full working month is 90 (per FTE); then the number of new patients will be 36 and reviews would be 54 patients.

Time taken:

36 NEW requires 36 hours (60 minutes per consultation)54 reviews require 40.5 hours (45 minutes per consultation)

Total time required = 76.5 hours

Total working hours = 162.5 hours

Percentage Direct Clinical Care = 70% or113.75 hours

Remove any non-IPA DCC (on average 10-15% of full-time hours) assume this is 12% = 19.5 hours

Therefore, percentage Direct Clinical Care minus non-IPA activity = 113.75-19.5 or 94.25 hours per full working month

Hence this individual should be able to see this number of patients within the time allocated, provided that there are no absences nor additional time already spent such as travel time, access to medical notes or digital records, waiting to see patients e.g. on wards or in clinics and other duties such as clinical administration.

Capability

Markers of the Capability of Dietetic Workforce include the following: amount and frequency of time spent on CPD, practice supervision, competencies achieved, appraisals, patient experience, outcomes of dietetic interventions and evaluation of training provided to other health care professionals.

The range of CPD activities is extensive and includes work-based learning such as:

BDA Classroom and BDA eLearning via the BDA Learning Zone
reflective practice, clinical audit or Facebook journal club
professional activity including active membership of a specialist group
mentoring or teaching
formal education from short courses to higher degrees

Link: (Continuing Professional Development (bda.uk.com)

From the evidence regarding safe staffing levels for nursing staff, previous dietetic work and the results from the 2023 safe staffing and safe workload questionnaires, it is likely that a variety of factors contribute towards a safe dietetic workload. It is recommended that a range of data that incorporates capacity, capability and safety indicators is used in order to assess the safety of a dietetic workload.

Both the capacity and the capability of an individual dietetic staff member are important to help ensure the provision of a safe and quality service. Below are tables summarising the most relevant information to capture in order to assess the safety of a dietetic workload.

Capacity assessment of Individual staff member

Percentage of time spent in workforce activities (e.g. percentage DCC/SPA)
Number of patient contacts per year per FTE
Referral rate and rate of patient turnover
Ratio of new to follow up contacts
Patient complexity mix
Level of work with MDTs
Referral to treatment time

Capacity assessment of team or department

Percentage of time spent in workplace activities (e.g. DCC/SPA) per individual / team/ pay band
No of patient contacts per year per FTE
Referral rate and rate of patient turnover
Ratio of new to follow up contacts
Referral to treatment time for in and out patients
Patient complexity mix
Skill mix
Time required for new and review patients
Service demands in addition to number of referrals
Overall view of capacity and demand
Benchmarking of activity with other departments
Look at trends within department over time
Look at trends within department over time

Supporting resources

Safe staffing, safe workload questionnaire results
Patient Complexity Tool (once finalised)
Appendix: Workload Activity Split Calculator
BDA Resource:
‘Influencing Action Pack for Dietetics’
Toolkit: calculation to show process for calculating staff requirements
BDA Resource: Caseload Management 2012
BDA Resource: Caseload Management Toolkit

Capability

The following table summarises the key information required in order to assess the safety of a dietetic workload from a capability perspective,

Capability assessment of Individual staff member	Skill set and experience Competencies achieved in specific areas of work Adherence to best practice and latest clinical guidelines Frequency and outcome of practice supervision and peer review Record of training and education received (including mandatory training) Preceptorship completion Audit/ service development work completed Evaluation of training provided to others Feedback from dietetic peers, AHPs and other HCPs Patient experience
Capability assessment of team or department	Adherence to clinical guidelines and latest evidence base Outcomes achieved due to dietetic interventions Patient experience metrics Outcome and frequency of peer review and practice supervision Education and training record and ongoing programme of development opportunities Feedback from students on clinical placements Patient experience
Supporting Resources	BDA Resource: Model and Process for Nutrition and Dietetic Practice BDA Resource: Standardised language terminology BDA Resource Practice Supervision Patient feedback e.g. Friends and Family test

Safety

No data can provide absolute certainty about how safe the care of an individual patient or staff member can be; however, safety indicators can be used to indicate the likelihood of potential problems. NICE described safe nursing indicators and red flags as considerations to indicate unsafe staffing levels. The same system is used here; those indicators with an accompanying red flag should alert dietetic managers that they may need to take immediate action to ensure patient safety.

Patient related indicators	Timeliness of patient care (including referral to treatment time and unmet need) Waiting list metrics Patient experience metrics Outcomes of dietetic intervention
Dietitian or support worker indicator	Being asked to work outside scope of practice Frequency of in date mandatory training Frequency of in date appraisals Frequency of workload concerns Frequency of work-related stress Staff sickness rate Frequency of working above contracted hours in order to complete work Level of working overtime Frequency of practice supervision Amount of time provided for supervision of students on their clinical placements Number of CPD opportunities and number of staff freed up to attend Number of opportunities for service development Frequency of training of other HCPs Level of input to MDT teams
Service-related indicators	Performance data Adequacy of in date nutrition related guidelines and policies Frequency of clinical incidents and near misses Inadequate delegation to support workers Non-dietetic members of MDT provide nutrition advice instead of Dietitian Number of staff vacancies Recruitment and retention rates Ability to recruit appropriate staff Level of reliance on temporary staff, bank and agency staff Departmental level of work-related stress, sickness Level of staff engagement Level of staff morale Frequency of complaints Feedback from students on clinical placements Adherence to adequate auditing schedules Results from peer reviews Benchmarking data

Supplements

Recommended safe staffing levels from BDA specialist groups, members from specialist groups

During the time this project was carried out, the BDA Specialist Groups were asked if they have any staffing guidelines currently in place to help with establishing safe staffing levels. The guidance below was received from those groups who were able to provide information.

Cystic Fibrosis Specialist Group

0.5 FTE/75 patients, 1.0 FTE / 150 patients, 2.0 FTE / 250 patients. For paediatric patients with CF the figures are 0.5 FTE/ 75 patients, 1.0 FTE/150 patients and 1.5 FTE / 250 patients. These recommendations were made in 2011. Travel time not factored in.

Critical Care Specialist Group

Recommend 0.05 - 0.1 FTE RD/ critical care bed

Diabetes Specialist Group

The only guidelines are those produced by Diabetes UK who advise 4 x FTE RDs / population of 250,000. ISPAD guidelines recommend 0.5 FTE RD/100 young adults under the age of 19 with Diabetes.

Food Allergy Specialist Group

No guidelines available

Gastroenterology Specialist Group

The only guidelines in place are for OPD appointment slots of 30 minutes each.

Mental Health Specialist Group

Only guidelines are for 0.5 – 1.0 FTE RD per 10 – 12 inpatient beds for people with eating disorders

Neuroscience Specialist Group

For specialist rehabilitation 0.75 – 1.0 FTE RD per district

For long term neuro conditions 2.0 FTE RDs per district

Stroke services 0.15 FTE RDs per 5 inpatient beds for hyperacute and acute stroke units

Obesity Specialist Group

No guidelines

Older People Specialist Group

No specific guidelines, but a proportion of patients do not require 1:1 consultation e.g. care and nursing home settings.

Paediatric Specialist Group

No guidelines

Primary Care Network Dietitians

Only guideline is 30-minute OPD appointment slots

Renal Nutrition Group

Inpatients: 0.05 FTE RD /bed. 0.06 FTE RD/ Renal HDU bed and 0.15 FTE RD / Renal ICU bed.

Outpatients: 60-minute new appointments and 45-minute review appointments.

Dialysis: 4 hours p.a. / patient.

However, 60% Renal RDs express safety concerns at these levels of service.

NB. No responses were received from the other Specialist groups within the BDA.