Determining the safe number of Individual Patient Contacts
a) Workload and time spent with Individual Patients
433 people answered these questions. Those questions regarding how much time respondents were allocated per new and review contact in the different workplace settings, and how much time is spent per contact in relation to whether or not the respondent feels their workload is excessive or not, produced surprisingly similar results.
Regarding whether or not respondents felt that their workloads were excessive, 97 (23%) felt their workloads were safe and 324 (77%) felt their workloads were excessive.
Regarding the time spent per patient, there was no consistent pattern to indicate that dietitians spent less time, on average, per patient seen for those who considered their workloads to be excessive from the others, see appendix 14.1 and 14.2 for more details.
Outpatient Clinics
There was also a question relating to the outpatient clinic time allocated for individual appointments in outpatients/ community which was “Do you feel that the time allocated for dietetic assessment, treatment and related admin is sufficient?”
369 people answered this question, of which 43% responded that they felt the clinic time allocated was sufficient while a greater proportion, 57% felt the time allocated was insufficient.
Discussion
Dietitians appear generally to spend an appropriate amount of time per patient for new and review consultations unrelated to their workload. The difficulty appears to be when asked to take on a greater number of patients than they can see safely. This additional work which many undertake often means working overtime.
b) Workload and number of individual patient contacts
As discussed earlier, respondents answered questions regarding the mean number of new and review individual patient attributable contacts that they had in a typical working month. This was further analysed in relation to their responses to questions regarding whether their workloads were deemed to be safe, excessive and if it was excessive, was this episodic or chronic and if they had felt unwell due to work related stress within the last 12 months
As stated previously, the total number of respondents to these questions was 308. Most respondents worked in the acute sector with a significant number working in the community. The greatest proportion of respondents were specialist dietitians, working at band 6 or band 7 level.
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 (see appendix 14.3 for more details)
Dietitians who reported that workload was manageable had an average of 82 contacts/month/FTE and those who stated their workloads were excessive had an average of 115 contacts per month. The number of contacts per month/FTE are clearly closely linked in terms of manageable and safe workloads (82 – 90 contacts/month/FTE) and likewise the excessive and unsafe workloads (110 – 115 contacts/month/FTE)[1]. See appendix 14.4 and 14.5 for more details.
Clearly, those respondents with fewer total contacts (average 82/ month/FTE) felt that their workload was not deemed to be excessive.
Those respondents with an excessive workload but not unwell due to work related stress reported an average of 106 contacts / month / FTE.
Those respondents with an excessive workload which resulted in feeling unwell due to work related stress had an average of 120 contacts / month / FTE[2].
For those dietitians that work in the acute sector
A caseload requiring up to 90 contacts /month/FTE would indicate a safe caseload with the staff member unlikely to be suffering work related stress.
On average, higher caseloads requiring approximately 100-110 contacts / month / FTE mean that the Dietitian is more likely to be feeling that their workload is excessive, but this may not have a detrimental effect on their health.
Once caseloads are on average 120 contacts / month / FTE then there is a higher probability of the Dietitian reporting ill health due to work related stress.[3]
For those that work in the community, the corresponding figures are
A safe caseload would be likely to be on average 70 contacts per month per FTE
Higher caseloads requiring on average approximately 85 contacts / month / FTE mean that the Dietitian is more likely to be feeling that their workload is excessive
An excessive caseload is likely to be more than 100 contacts per month/FTE. [4]
For those that work in Mental Health
The mean number of new patient contacts per month per FTE was 12 and 47 reviews, giving a total of 59 contacts per month. There were 20 respondents to this question and unsurprisingly there was no significant difference between a safe and an excessive workload with these low numbers.
For those that work in primary care
Again, numbers were low; 19 respondents. However, there was a difference between a safe and an excessive workload – the safe number is likely to be similar to that for community dietitians.
For those that work in Paediatrics
This survey was not designed to provide specific guidance for specialist groups, but it is of interest to note that the mean number of monthly contacts was 106 for those who stated that their workload was excessive and 78 contacts if it was not excessive, which is similar to the data for both community and primary care dietitians.
In Summary[5]
|
Setting |
Mean Safe number of contacts/ month/FTE |
Mean Excessive number of contacts/month/FTE |
|
Acute |
90 |
120 |
|
Community/primary care |
70 |
100 |
|
Paediatrics |
70 |
100 |
Additional factors to consider
Lower monthly contacts would also be expected in the following scenarios:
- for those staff where the New to follow up ratio is higher than 1:1.5
- where travel time is high e.g. staff undertaking home visits
- where caseload contains a high proportion of high or very highly complex patients
- where caseload contains patients requiring a significant additional time commitment e.g. education on carbohydrate counting in diabetes
- where the job plan contains a significantly high proportion of SPAs relative to time allocated for DCC such as band 8as with a clinical caseload
- for those newly qualified or new to post
Calculating safe contact numbers for your workplace setting
See calculation for estimating the number of contacts using job planning information and the data from this survey. (see separate document/link)
Practice supervision
Practice supervision is 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 (BDA: adapted from www.dhsspsni.gov.uk) 16
Practice supervision should be included within working practices and is important for all bands. It is a key component to supporting dietitians to meet HCPC standards.
There were 426 respondents to these questions. 269 (63%) received practice supervision but 157 did not (37%). For those who had practice supervision, the most frequent time interval was 6 – 8 weeks (42%), followed by monthly (34%) and three monthly (9%), see appendix 15.1 for more details.
Those who stated that they did not currently receive any practice supervision were asked for their comments. A selection of their comments that reflect common themes include:
- due to service pressures, clinical supervision is often cancelled or moved
- no time for any supervision in the day due to staff shortages
- not in job plan
- often cancelled due to hospital pressures
- specialist area no other RD understands it
- rarely happens unless I ask
The survey also looked at supervision and stress levels amongst respondents to try and ascertain whether having regular supervision helped to manage work place stress and ill health.
For those who reported no work-related stress leading to ill health, 65% had supervision and 35% did not. Of those who reported ill health due to work related stress a smaller number, 60%, had supervision and larger number, 40%, did not receive supervision. This could indicate that regular supervision may have a beneficial role in helping to reduce workplace stress induced ill health as this supervision may help in identifying and rectifying stressful work conditions.
From the responses obtained, 35% had a supervisor in the same dietetic clinical area, another 35% had their Dietetic line manager as supervisor and 30% had another HCP as their clinical/practice supervisor. This is indicative of the fact that some band 7s and a significant number of Band 8s report upwards to another HCP rather than a dietitian.
Regarding the dietetic line manager as practice supervisor, the BDA recommends that a practice supervisor should ideally not be their line manager if the workforce can accommodate it.
[1] Please note, the vast majority of respondents were band 6 and above and many were specialist dietitians working in the acute setting. The safe number of contacts was found to be lower in the community setting than in the acute setting.
[2] Please note: these figures are for dietitians only as there were insufficient responses from support workers to obtain sufficient data. Most responses were for band 6 dietitians, so safe contact numbers may well be lower for newly qualified band 5 dietitians. By far, the largest response was from the acute hospital sector and hence, these recommendations are likely to be the most robust.
[3] Please note, as a high proportion of respondents worked in the acute sector, these figures are likely to be lower in other workplace settings.
[4] Please note: there will be variables in the working environment which will affect the safe numbers of patients that can be seen.
[5] Please note that these figures are based on a full working month and do not include any time for absences such as annual leave, training or sick leave. An average of 20% absence is often used. Hence an annual expected number of contacts would be (Xx12) x0.8 where X is the monthly number of contacts.