Approach

Questionnaire Development

The initial safe staffing questionnaire was developed and circulated in 2015. All dietitians and dietetic support workers employed by the NHS in the UK were invited to complete this questionnaire which was circulated via web link. There were 933 respondents representing 17% of the NHS dietetic profession.

This questionnaire was used as the basis for the 2023 version. As before, it was advertised online by BDA and was available to complete via a web link for 6 weeks between April and May 2023. There have been several updates and additions to the original questionnaire, reflecting recent changes in the NHS such as job planning and current workplace safety concerns. Below are the main changes:

• updated definitions for workplace activities to reflect Job Planning definitions and including new activities e.g. supplementary prescribers

Additional questions on the following:

• average time spent with individual patients
• patient Complexity
• home based and remote working, online working and consultations
• practice supervision
• advancing Roles in Dietetics
• vacancies
• workload safety – including questions on workload stress and vacancy rate and updated wording on workload safety concerns (taken from “workforce burnout in the NHS” (House of Commons report 2021) and “Safe and effective staffing” (RCN 2017and 2022) ^8,9,11,12

Average time spent with individual patients

In order to provide further detail regarding the time required for direct clinical care, it is important to estimate the time required for dietetic consultations as well as the number of contacts. Adding the level of patient complexity is also likely to be helpful to determine the safe number of contacts.

Hence this section was added to provide some data regarding the average (mean) time spent per new (or review) patient for a face-to-face consultation.

The following information was provided in the questionnaire to clarify the aspects of a dietetic consultation to be included when estimating the average time spent per new (or review) face to face dietetic consultation. Separate categories of inpatient, outpatient and home visit were provided. Please note that travel time was not included.

• before seeing the patient - read up relevant previous entries/referral/letter etc.
• dietetic consultation and intervention with patient/carer
• writing up consultation details in all notes (medical/nursing/dietetic etc) and/ or electronic record
• miscellaneous (letters, phone calls, allocation of ONS or enteral feed etc)

*Please note that online or phone consultations were not covered in this question.

Patient Complexity

Questions on patient complexity have been added in order to provide further details regarding individual patients seen in addition to time spent.

For this survey, we have used the ‘Dietetic Complexity Tool’ which was developed at St George’s Hospital, London; it is being piloted in several NHS Trusts in the UK and will be validated for use within all four nations. 

It has ten different domains to calculate an end score for 'very high, high, medium and ’ow' complexity levels and can be used for patients in both acute and community settings. It should be able to help job planning by determining the number of patients who can be safely seen per day and to allocate caseloads within a teams mixed banding of staff. The Tool will also assist in supporting business cases, in education and disseminating understanding of the variety of work undertaken by dietitians.

The Complexity Tool (as used in the 2023 survey) is found in the appendix. Once validated, you should be able to use it in your clinical practice as the final version will be on the BDA website.

Home-based and remote working, online working and consultations

Home-based working is contractual in location. Working from home would be casual with the employee’s base being a hospital site or similar. Remote working can be done anywhere away from the contractual base.

In its long-term plan, the NHS planned to fundamentally redesign outpatient services (Ref NHS Long Term Plan (2019) ¹⁰, stating that the traditional model of service was outdated and unsustainable. The plans included a redesign of services. so that patients would be able to avoid up to a third of face-to-face outpatient visits over the next five years. However, the Covid-19 Pandemic accelerated this change, so this section has been added to provide a baseline for dietitians, rather than to provide any recommendations at this stage.

Practice Supervision

Practice Supervision is a process of professional support and learning and assists Dietitians to meet HCPC standards and the BDA Code of Conduct.  Supervision is defined as a process of professional support and learning, undertaken through a range of activities, which enables individuals to develop knowledge and competence, assume responsibility for their own practice and enhance service-user protection, quality and safety of care, adapted from www.dhsspsni.gov.uk. ¹⁶

Due to the role that practice supervision can play in ensuring patient safety it was deemed essential to include in this piece of work to better understand if there was a relationship between practice supervision and levels of reported stress and overwork.

Advancing Roles in Dietetics

These roles include Advanced Clinical Practitioners, First Contact Practitioners and Consultant Dietitians. Details of these can be found in Chapter 5 of 'Findings'.

Vacancies

Based on BDA intelligence gathering, we recognise that vacancies are a current issue. Questions surrounding vacancies were included in the survey to get an overview of the national situation and consider what impact this has on the dietetic workforce. Many organisations are reporting recruitment issues across a range of bandings.

Workload safety

The NHS Staff Survey has suggested that an unacceptably high proportion of NHS staff experience negative impacts as a result of stress in the workplace and that the proportion of staff suffering from stress is on an upward trend. The 2022 survey found that 45% of respondents (covering AHPs, healthcare scientists and scientific and technical staff) reported feeling unwell as a result of work-related stress in the last 12 months, and this remains above pre-pandemic levels. The Covid-19 pandemic had increased workforce pressures exponentially and 92% of trusts told NHS Providers they had concerns about staff wellbeing, stress and burnout following the pandemic. ¹²

Chronic excessive workload has been identified as a key factor of burnout and staff shortages were identified as “the most important factor in determining chronic excessive workload”. ⁷

As a result of these findings, additional questions on workforce safety were added to the questionnaire. These were asked towards the end of the survey so as not to affect the responses to the previous questions.

They were asked to indicate their level of agreement with the following statements using a Likert scale.

1. I feel that I have enough time to provide the level of care I would like
2. I feel that I am providing the quality of care that I should be providing for patients / service users
3. I am happy with the skill mix within our dietetic team
4. We have sufficient number of staff within our dietetic team
5. I feel that my current workload is safe

They were also asked if their workload was excessive, if they had felt unwell due to work-related stress within the last 12 months and if they felt that their work-related stress was episodic or chronic to reflect those questions in the NHS staff survey. They were also asked if they felt they have the freedom to speak up if you see things going wrong.

Workload concerns

They were asked “if you have any concerns regarding your workload, what are your main concerns?” and were able to select up to 6 main concerns from 20 options given below.

The NICE Safe Staffing Guidance for Nursing in Acute wards described ‘safe nursing indicators’ and ‘red flags’ as considerations to indicate unsafe staffing levels ^13,19. These principles were used when developing the list of dietetic safety concerns for the initial questionnaire. The 2023 survey kept the original list with only minor adjustments to update the wording and the addition of one new category “Insufficient time to spend with students on their clinical placements”.

See updated list below.