Historically in England, the district nursing service was developed by the Queens’ Nursing Institute (QNI) (2022). Initially founded by William Rathbone, there was a need for nurses to care for people in their own homes. The title of district nurse (DN) is often used interchangeably with ‘community nurse’, which is a collective term for a nurse (qualified or not) who cares for patients outside of the hospital setting. This collective term now encompasses areas from nursing care homes, general practitioner (GP) surgeries, hospices, prisons and in more recent times, a focus on those who nurse the homeless (QNI, 2022). Nursing and Midwifery Council (NMC) standards (2022) for the proficiency of community nursing specialist practitioner qualifications acknowledge this variety of roles and the ever changing context of community nursing to which further specialist qualifications may be needed. For this article, the role of the DN will largely refer to a registered adult nurse who has completed an additional year of the professional body NMC-approved training in this specialist field. The qualified DN is registered and regulated with the NMC (2022), and thus, district nursing is established as a profession in its own right (Allsop and Saks, 2003). In response to a 21-year gap, the proficiencies for specialist practitioner qualifications are now under review (NMC, 2022). It is highly appropriate that these are reviewed, when considering that the DN often is a lone worker, making autonomous decisions, diagnoses and directing the holistic care for their patients. As a profession, district nursing upholds the provision of high-quality care to the local community of patients, both in their own homes and part of local community clinics and GP practices.
DNs are not employed by GP practices; however, they are required to fulfil contractual agreements made by NHS Trusts offering community services. They are experts in patient and wider family management, local community services, promoting patient confidence and independence, as well as prioritising care and safety of the patients at home. Specialist qualifications for DNs, health visitors and school nurses, among others, requiring this additional year of training are considered vital for providing quality care in the community (Maybin et al, 2016; QNI, 2015). The NMC (2022) acknowledges that this specialist role pertains largely to autonomy and progression in management, research and education. Community district nursing teams have a unique mix of skills, owing to the different qualifications of their staff. However, there is a disproportion in the ratio when comparing other team members to a qualified DN; this has been highlighted as a concern given that specialist nurse commissioned places for the DN qualification have been reduced (QNI, 2015). The quality of care that the district nursing profession provides can be underestimated at times, to the extent that suggestions have been made to remove this qualification (Mitchell, 2020). Along with recent coverage about the role of DNs in the COVID-19 pandemic, the specialism in itself can be unseen and thus, a target for misrepresentation (ITV news, 2020).
Primary care centres, such as GP practices, deliver community care and are the first point of contact for individuals who may seek help or support. Here, individuals may receive a diagnosis of their health condition, which can refer to ‘first’ or ‘primary’ diagnosis. DNs are often the first people to receive such referrals to assess whether a patient's condition can be managed successfully at home and avoid hospitalisation. There has been significant progress in healthcare since the 1950s, including developments in therapies and general anaesthesia. Additionally, over these years, plans to shift care from hospital to the community began. This had a visible impact on hospitals, with several of these institutions shutting down, acknowledging that care for people at home over institutional care was more person-centred and cost-effective. Consequently, there has been further funding to develop community services (NHS England and NHS Improvement, 2019). In addition to this, institutions and funding sources have also recognised the need to support community nurse education (Willis, 2015). Willis (2015) recommended that community education should be further integrated into the pre-registration nursing curriculum, where students attend university and placement education to achieve a degree in nursing. Willis (2015) went as far as to suggest that community nursing should have a field of its own, in addition to the current four fields: adult, child, mental health and learning disabilities. However, the specialist community field of nursing was not formalised, but instead, community care was integrated more recognisably into the nursing curriculum (NMC, 2018).
As a senior lecturer with a DN qualification, and therefore, a background in community nursing, the author has had the opportunity to interact with many student nurses. Through such interactions, the author has heard ‘murmurs’ across the nursing community, whose general perception is that community nursing seems less valued by those that nurse in a hospital. This can be aligned to the five myths of district nursing (White, 2019), none of which are complementary, such as: needing a year on an acute ward before becoming a DN; working in the community deskills you; district nursing is where you go to retire; career progression is difficult and that district nursing is not real nursing. As such, the author has noticed that in pre-registration education, district nursing in particular appears to be fighting to establish its promotion and identity (van Iersel et al, 2016; 2019). This appears to be reinforced in several ways: historically, through media, via public perceptions and through education.
Some of these troubling perceptions include:
- The media's portrayal of nurses being ‘frontline’ and therefore working in a hospital and predominantly lifesavers in the emergency
- Deskilling comments — students are being advised by hospital staff that they might be ‘deskilled’ if they go into the community (van Iersel et al, 2016).
Exploring the murmurs: media portrayal and the term ‘frontline’
When new to the lecturing role, the author was perturbed by feelings of imposter syndrome at the thought of teaching hospital-based care. Referring back to their initial training, they felt unsure as to why, having gone from a specialist role, they now needed to relearn things to teach students in the expected way. This impacted on the loss of autonomy they once had. The skill of aseptic technique is one such example—teaching about the precise cleaning of the trolley as opposed to finding a suitable surface in a patient's home on which to lay the dressing pack. Other research methods include using visual ethnography, such as pictures. For example, on initial observation of the sketched image (Figure 1) there is a nurse staging a blood pressure check with a patient dressed in his own clothes rather than a hospital gown. However, this woman is a real DN asked to pose with a patient for a Christmas card. This particular patient was chosen because a rapport was established and therefore the DN knew he would enjoy the participation. In the first instance, this DN helped this patient by identifying and diagnosing a condition he had, managing his symptoms, through referral, appropriate treatment and self-care optimisation. If they did not have the skills needed to diagnose his concerns, he would have had displayed symptoms for a lot longer and had a poorer quality of life.
Compare this with the normative assumption of nurses saving lives and this image is not the expected one. Nurses saving lives appears to conjure up the technical medical image of the emergency, monitors and resuscitation. Amid a pandemic, nurses are needed to attend to critical care beds, to be on the ‘frontline’ caring for people in hospital and to ‘save lives’. Little is advertised about nurses equally being needed to take care of people in the community and ultimately, saving lives too. This can be further supported by the fact that initially during the COVID-19 pandemic in the UK, only hospital deaths were recorded in national figures and only later was there a recognition that many deaths had also occurred in the community, including care homes (Higham, 2020). The term ‘frontline’ ignores what goes on in the background—the infrastructure and supportive network required to ensure the smooth running of operations. Foucault (1972;86-87) recognised that language and power in the production of truth finds a way of defining itself socially, giving status and manifesting it. However, this can also be seen as negatively impacting DNs’ profiles. For example, DNs have been interpreted to not be caring when they have prioritised workload, protected their health and their safety, as well as the safety of their patients by limiting contact (ITV news, 2020).
Murmurs from the field: deskilling comments
It has been noted within pre-registration education that nursing students and hospital staff have assumed that being a DN means you become deskilled. In this context, it is important to explore what being deskilled is and what the skills to which these students and staff refer to. Paralleled with capital theory (Bourdieu, 2003) hospital nursing appears to have dominated nursing overall in terms of significance and place in history. Cultural language has taken the focus of student placements being ward-based, and the perception that nursing is predominantly acute-focused is still prevalent (Lewis et al, 2019). Furthermore, nursing skills represented on practical application with simulation manikins, and with equipment such as passing a nasogastric tube, are at the marketing forefront of university open days, as opposed to the non-visible and less technical skills of assessment, communication, and health promotion.
In addition to the above, more issues were highlighted when being required to teach a core skill of counting respiratory breaths to students in the context of a National Early Warning Score 2 (NEWS). A NEWS score determines the need for critical care which in itself is specific to acute hospital care, as opposed to visiting patients who are largely independent and at home. This again could be attributed to needing to show what nurses do in the context of a critical emergency. This vital acute skill of counting respiratory breaths does need to be taught; however, the learning framework could be on holistic breathing assessment involving quality and quantity of breaths in the context of acute or long-term conditions and presentations. A notion of temporality is identified, where short-term learning of a skill is differentiated from a specialist skill that takes a lot of experience (long-term learning) and no equipment to master. The rhythms of time (Lefebvre, 2004) are different, and moreover, the selling of the ‘instantaneous’ measurable factor (Ball, 2018) are identified and capitalised upon. This is appropriate and appealing in terms of immediate access to information, gadgets and the time ‘squeeze’ (Atkinson, 2019). However, it minimises the knowledge, purpose and understanding for students’ learning in terms of patient care and responsibility. How smoothly a student nurse or nurse performs a task should not be the only defining and perceived factor of how good a nurse is, despite this being a visible and measurable function. Furthermore, patient-centred care is defined by paying attention to psychological and emotional support and meeting basic needs such as pain relief, and not just the treatment of specific health conditions (National Institute for Health and Care Excellence (NICE), 2021). This is fundamental to the professional standards of practice and behaviour for nurses, midwives and nursing associates (NMC, 2018).
In exploring students’ perception of nursing skills, it is expected that these skills are task-oriented, such as taking blood pressure, blood sugar, dressings, medication, and more recently, venepuncture and cannulation. These task-oriented skills are all seen as more important or exciting areas to be proficient in than skills that could be characterised as less technical, specialist and occurring out of the experience of the practitioner. These include communication, assessment and interpersonal skills, as well as promoting health and the ability to plan care effectively. Meerabeau (2004) agreed with this observation that some associate technical expertise and the treatment of patients (or what we do to them) with autonomy and competence in nursing, and that this is regarded as a higher status than expertise in managing care, and providing person-centred care. Students are known to rate a placement more highly where they have more task-oriented opportunities (Henderson et al, 2012), and because of this, hospital placements are possibly the favourite choice for students (van Iersel et al, 2020).
When a student clinical placement is largely observational, the appreciation of specialist skills such as assessment, care planning and autonomous practice that lack the involvement of students can result in students losing interest which can, in turn, be interpreted by mentors as disengagement (Baillie, 1993; Reynolds and Fell, 2011). As a student placement manager in a community trust, the author would frequently be contacted by students who were concerned that ‘they could not learn their skills’ in a community placement. What they meant was that they felt that the hospital-based technical skills they expected to achieve could not be applied in the community; hence, they would not learn as much as when they had a hospital placement. This could also be due to the fact that community patients are more independent and less acutely ill, which can be confusing for students who have defined nursing as what they do for patients when they are unwell and unable to care for themselves. This can make them more physically distant from the patient and therefore, unsure about their role, unless specifically guided by the community practice supervisor. Hayes (2012) also noted that the focus on technical competence in nursing can be promoted because of the institution placing a high value upon it. Despite innovative approaches being developed in community care placements (Cahalane et al, 2018), it is still hospitals that provide the majority of student placements. Consequently, they have the capital power to influence educational establishments and professional bodies, what is required for competence and the employment of post-registration nurses. This further aligns with Lefebvre's (2004) insights of capitalism killing social richness and risking the loss of essential aspects of nursing care but leaving the functioning of the ‘thing’ (nursing tasks and technical competence over knowledge development) to persist. In light of COVID-19 and its media coverage, the identification of a shortage of critical care beds has highlighted the need for this important speciality of nursing, appearing to further strengthen the importance of acute hospital care over community care (BBC News, 2021).
Community placement experiences
Placement experiences influence a student's likelihood of employment (van Iersel et al, 2016), and the length of placement representation within a curriculum has been associated with learning interest, that is, the longer the placement, the higher the students’ interest (Bjørk et al, 2014). However, when longer and more participatory experiences within community nursing for students were introduced in alignment with university-based training, there was an initial reluctance to this change owing to many factors. One-to-one student support required from DNs to take them to each home visit meant more time spent. Although students contribute to care in hospitals, in the community they add to the workload, requiring additional multi-tasking skills for the DNs, reducing administration time and the balance of student and patient needs (Kenyon and Peckover, 2008; Brooks and Rojahn, 2011). This, in turn, leads to difficulty in achieving independence for the DN and contributes to low morale, particularly if the workload is high (Betony, 2012-).
Contributing to the lack of capacity for student placements was the fact that mentors were initially not always adequately trained, nor was the space in offices considered (Baillie, 1993; Betony, 2012). Despite this, it is widely reported that students highly evaluate community placements and this does positively influence their perception and influence their decision to work there post-qualification (van Iersel et al, 2020), and that one-to-one support is viewed as extremely beneficial (Murphy et al, 2012).
Possible solutions
The development of increasingly innovative community placements, such as those by Cahalane et al (2018) and Clark et al (2020) would ensure students have more opportunity and more exposure to the richness of the community setting. However, developing these areas can still be a challenge due to the balance of cost and resources discussed. Over recent years more GP nurse placements have been developed (Lewis et al, 2019) and this has helped raise the profile of community nursing further. It has also been noted that even if curricula are designed to incorporate a more community-orientated approach, this does not necessarily result in a higher interest (van Iersel et al, 2020). More simulation of the community experience is an option for educational settings. For example, setting live simulation scenarios within a community setting rather than the hospital ward or theatre has the benefits of raising awareness of district and community nursing and poses a challenge, particularly to students who have not had an opportunity for any kind of community placement (Reynolds et al, 2018). Simulation of this nature raises the profile of communication and assessment skills over technical skills. This type of simulation evaluates highly in terms of enjoyment and learning opportunities. Exposure to simulated district nursing for students raises awareness of the autonomy required and the importance and expertise of the role, making it an exciting place to work rather than one to go when you want to retire (White, 2019).
Conclusion
There is a concern that the specialism of district nursing is and could further become more hidden among other community healthcare developments, such as advanced clinical practice, physician's associates and enhanced practitioners. In general, the language and reporting focus used by the media during the COVID-19 pandemic in terms of ‘frontline’ and saving lives, centres only on the emergency and not nursing. The media has also appeared to ignore community care in nursing and care homes in initial reporting. Historically, community placements have not been met with the same enthusiasm from students as hospital placements have, due to several reasons such as what defines a nursing skill, or a high-quality learning experience on placement. Within education, this is reinforced by capitalist re-marketing of the instant reward of learning a technical skill over an acquired long-term experiential and knowledgeable one, that is at its heart a good experience for patient care. In addition to incorporating more DN recognition and community care integration within the theory element, education settings can further improve community interest and employability by offering more community simulation experiences.