The profile of community nursing is often hidden to the public. Subsequently, the profile of community nursing is often hidden to student nurses entering pre-registration education. This can be influenced by the media’s representation of nurses being the forefront of hospital care, as seen in TV dramas such as ‘Casualty’ and ‘Holby City’ (Lavery and Henshall, 2022). During the COVID-19 pandemic, narratives such as ‘frontline’ were used to imply that only those working in critical care wards were saving lives, while disregarding those staff working in the community, whose roles and routines were also challenged (Green et al, 2020). These assumptions are further strengthened prior to commencing a pre-registration adult nursing degree, where university marketing promotes visibly technical and practical skills associated with acute nursing on open days for adult courses, such as: passing a nasogastric tube or resuscitation of a manikin. However, skills such as health promotion, that are less easy to display, which require more expertise and are associated with community nursing, are considered to be of lower value (Warner et al, 2010; Cooper et al, 2014). Other areas that suggest the community nursing profile is hidden are the emergence of myths (White, 2019; Queen’s Nursing Institute (QNI), 2022) such as: choosing to work in the community setting after qualification might ‘deskill’ a student or qualified nurse; that one needs at least a year’s experience in hospital before going into district nursing; there are a limited amount of community placements compared to hospital (Byfield et al, 2019; Arnold et al, 2021). Hence, students have limited comparable experience to challenge assumptions regarding nursing in the community setting.
Current pre-registration education requires registrants to complete a 3-year programme of 4 600 hours, of which 50% should be in placement and the other half should be theoretical content learning at university (Nursing and Midwifery Council (NMC), 2018). The contents of the curricula are noted to be largely acute-focused (Byfield, 2019; Meeley, 2021). Furthermore, compared to hospital clinical placements, expanding and developing community placement opportunities are known to be complex (Betony, 2012). For example, on a hospital clinical placement, whilst students are supernumerary, they are physical additional numbers that add to staff capacity on a ward or unit. This is different when compared to the community clinical placement, where they have one-on-one support from a practice supervisor or assessor with whom they travel from home-to-home or clinic observing and supporting one patient at a time. This is more intense for the individual practice supervisor, whose main priority is the safe delivery of care to their patients, which is challenged by teaching students full-time (Dean, 2010). This is a difficult cycle to change, despite national drivers calling for more community care (NHS England and NHS Improvement, 2019), more community nurse curriculum content (NMC, 2018) and suggestions that community nursing should be a field of its own (Willis, 2015).
Method
Building upon the author’s personal reflections about teaching community nursing to pre-registration students (Reynolds, 2022), a phenomenological study explored the experiences of other community nurses’ subsequently pursuing a career in pre-registration nurse education. Phenomenology is appropriate to this research in order to understand the hidden ‘phenomena’ that is community nursing and how it is perceived within education (Holloway and Galvin, 2017). A collection of rich qualitative data, including stories and making sense of memory recollection was achieved by a method of self-interviewing (Keightley et al, 2012). Self-interviewing provides a participant with the opportunity to respond to questions themselves and in their own way. This method allowed participants the freedom to ponder and reflect on their experiences to three questions. Allowing participants to self-direct disinhibits the flow of their stories (Mishler, 1986), as opposed to a researcher interviewing, who may lead or distract away due to time constraints or subconscious bias. Self-interviewing was also a practical method of data collection during the pandemic, where participants were asked to audio record their responses during social contact restrictions. The recordings also made the story telling more realistic; for example, a verbal conversation as opposed to writing was conducive to participants sharing true unedited stories, again, allowing for rich data collection. These recordings were then transcribed and a thematic analysis was conducted.
Sampling and recruitment
Convenience sampling was conducted by recruiting identified, willing participants who met the criteria: to have a background in community nursing and be currently working as an academic in pre-registration education (Table 1). Ethical approval was obtained through the university’s ethical review committee: ‘Reynolds/#7834/sub/R(A)/2020/Nov/HELS FAEC-The lived experience of community nurse lecturers in pre-registration nurse education contexts’. Each potential participant was provided with an information form and the opportunity to ask any questions prior to making a decision, or to not participate at all. Once agreeing to participate, they provided informed consent through signing a consent form. Prior to data collection, the participants were reminded that participation was voluntary, and they could withdraw their data any time before completing the data analysis.
Table 1. Recruitment criteria of participants
| Participants | Job title | Gender | Participant background |
|---|---|---|---|
| Research Participant 1 (RP1) | Community nurse lecturer | Male–University employer 1 | Went into community straight from qualification |
| Research Participant 2 (RP2) | Community nurse lecturer | Female–University employer 2 | Worked in hospital 18 months post-qualifying before community nursing |
| Research Participant 3 (RP3) | Community nurse lecturer | Female–University employer 2 | Worked in hospital 8 years post-qualification before working in the community |
The questions asked required the respondents to recall and think about the following points:
- Tell me about your first introduction to community nursing. As a qualified nurse, how did it feel?
- Tell me about your first year working as a lecturer in university. How did it feel as a nurse with a community background?
- Explore your current position. Thinking about recent experiences has anything changed and how do you feel now?
Data analysis
Data analysis commenced with the transcription of the audio recordings by the researcher, which supported familiarisation of the stories and the development of common themes between the participants. Sub-themes were also identified. The themes were returned to the participants, to ensure both parties agreed to the interpretation of the stories being recorded, which was crucial to the investigation. If not, amendments were made accordingly. The themes were presented to each participant via an online meeting and feedback included participants’ visual agreement of nodding, smiling and recognition of the clarity presented by the themes. Referring to the researcher’s personal murmurs (Reynolds, 2022) that prompted the pilot inquiry and their involvement in the research, helped develop relationships in bridging the interpretations of the dialogue and provided further triangulation of the data (Tighe et al, 2013).
Findings and discussion
Two overarching themes were identified; each theme had subthemes. The first overarching theme was the recognition of how different community nursing is to hospital nursing, and within this theme, sub-themes included the recognition of accountability and lone working, and experience needed to be competent in the role. The second theme identified how acute-focused the pre-registration nursing curriculum is with sub-themes noting particular tensions with critical care nursing, feeling a loss of identity and value as pre-registration lecturers, and how they embraced conflicts. Both themes will now be discussed in more depth.
Theme 1: community nursing is vastly different to hospital working
All three participants had different, yet positive, community experiences. Research Participant (RP) 1 said:
‘had a team that was lovely and supportive.’
According to RP2:
‘…felt free from routine and institution, good to get out and about in the car and give proper quality nursing care, knowing that you had done the best you could for a patient rather than being rushed and limited in providing care.’
RP3 felt:
‘joyful, and a welcome break from hosepital.’
Both RP2 and RP3 identified the difference between acute hospital nursing and community nursing. RP2 experienced a complete loss of confidence in their role and what it meant to be a qualified nurse in the community.
RP3 found the reality of community nursing as:
‘another culture of caring’
and
‘if anyone thinks any other way than learning and contextualising the skills you’ve learned for a new area then they are very much mistaken if they don’t think that you are almost learning another job.’
RP2 felt the role:
‘invited relationship and rapport building with patients for it to work.’
Not unlike hospital nursing where you still need to establish a rapport, RP3 notes that the kind of rapport building was different in that,
‘you had to gain trust because patients will be very quick to decide whether to engage in your support or not. You don’t have any dominance like you would in hospital, you have a relationship where you invite rapport, you knock on the door of their houses, you sit where they direct you to and you ask permission to speak about certain things…so that routine you have in hospital…you can throw that out of the window!’
Subtheme 1: heightened sense of accountability/lone working
RP1 recalled a story when they were fairly new to the role; during this time, they were asked to see a diabetic patient. Having been introduced to the patient the day before, RP1 was to visit the next day; however, on arrival, was unable to get a response from the patient to be let in, which heightened their sense of accountability.
‘I looked through the letterbox. Lights were on but no one was responding, I called down to the warden because it was sheltered accommodation and eventually found the woman slumped behind the kitchen door in a hyperglycaemic attack. I’m nervous as hell about this! Fortunately, the education had kicked in, and I knew what to do.’
Similarly, RP2 recalled a story of visiting a male patient with diabetes:
‘…patient’s blood sugar that evening was quite high, he was on medication, but he didn’t speak English and when explaining to him about taking his medication and avoiding sugary foods and drinks he just kept smiling and nodding but I was unsure he understood. I let the general practitioner know but was concerned about leaving him alone in case he had a hyperglycaemic attack. It would be inappropriate at this stage to send him to hospital and I was unsure what to do. Fortunately, a family member arrived and said they would be staying there with him. I still worried that evening that he would be okay and went to see him in the morning. His blood sugar thankfully had lowered at that point.’
RP3 recalls similar stories and makes particular note of not having emergency equipment, and furthermore, this accountability and lone working awareness seems to be captured by stories from the 3 participants of lone medication administration as well.
Subtheme 2: recognition of experience needed to be competent in the role
All 3 participants recognise the journey of learning that separates knowledge from experience. RP1 and RP3 discussed a,
‘self-confidence that comes with practice’
and RP2 explored how their feelings about community nursing improved with experience and knowledge.
‘I was able to see leg ulcers being healed because I had the knowledge and I was able to apply it, it was working! I was more autonomous. I wonder now whether I was really properly prepared for community nursing. A lot of my training centred on hospital care, I even lived in there! I had had community experience as a student, but it wasn’t hands-on, it was observational, so I wonder whether I had fully embraced what community nursing was about and what it meant as a qualified nurse being in the community.’
This further raises concerns about the preparedness of students to work in the community following qualification further strengthening the need for a specific community pathway or field.
Theme 2: the pre-registration nursing curriculum is very acute-focussed
When considering the results of the first theme, generating examples of the vast differences between community care and acute/hospital care, a pre-registration curriculum that is very acute-focused will undoubtedly manifest frustrations with community nurse lecturers and the following sub-themes demonstrate these.
Subtheme 1: tensions between community care and critical care
When outlining this anomaly, it seems that there are tensions between community and critical care as a speciality. RP1 highlights that many of their superiors were from a critical care background and notes an additional sense of tension regarding teaching with a community background.
RP3 states:
‘You know, there were lots of critical care nurse lecturers and it really did feel like…the critical care was… ‘the prize possession’.’
‘We deal with much more complex issues, medication and technology-you of course just drink tea and go out!’….it was disappointing.’
‘All of the lecturers who were there either seemed to come from intensive care and they wore it almost like a badge of honour that it was their background…it didn’t intimidate me particularly, but I do have to say it rather, made me a bit sad that that seemed to be what the focus was.’
Furthermore RP3, when thinking about learning and technical skills, believes there is a great focus on critical care skills.
Subtheme 2: loss of identity, self-esteem, value and autonomy
RP1 and RP3 both spoke of the initial expectations they had of the lecturing role. RP1 recollected being excited to ‘share their knowledge and experience for the student’s benefit’, and RP3 made the assumption they would be able to provide ‘a reflection of the diversity of their role’. Both quickly realised this was not the case when they actually began. Along with RP2, experiencing a loss of confidence, RP1 reflected upon having an identity crisis, feeling alone and felt the pressure, as with the researcher’s murmurs, to teach things that did not align with the community background.
‘I had to teach myself things, teach a subject I didn’t want to teach…they didn’t respect my skills.’
Building upon this, all three participants reflected on how they perceived students felt about their community teaching:
‘I very much felt this sort of, resistance, almost from students when I was teaching that they…they didn’t like community, it was completely different, they didn’t get it, they didn’t understand what I was saying half the time, they couldn’t understand that you didn’t do an A-E assessment on every patient you had, because it wasn’t an emergency.’
RP2
‘And the students don’t seem to (nervous laugh) like how I am teaching. I thought – is it me? Is it the subject? Is it community? Because it just seemed second rate compared to everything else.’
RP1
‘So I feel quite discouraged, I think I’m going to have a huge uphill battle to be heard.’
RP3
Subtheme 3: embracing the conflicts
RP1 had experienced several educational institutions in an attempt to settle in a role where their experience and value was recognised, but appeared to hit the same barriers of being unable to teach community nursing to willing students within an institution that acknowledged this value. The concluding factor was that this experience has now made them feel ‘embolden to change things’ but continues to feel there is not enough community representation in the pre-registration curriculum. Conversely, RP3, having only been in post 8 months as a lecturer, recognised the need to try and find a way of being true to oneself in the role:
‘whether you close doors in your mind or whether you get to a place where you don’t endure the kind of, sort of painful stuff that, stresses you out or damages your passion but you find another way to redirect your energy and kind of, perhaps indulge the things that you think are really, really important.’
RP2 discussed how they had redirected their energy by focusing on the things in community that make it unique:
‘the promotion of independence, the individualised care planning, and health promotion…I have felt very much that students really need to experience community nursing to really understand it. When you think that I was teaching some of them that hadn’t even had a community experience or placement at all, I can imagine that it was a hard concept to follow really.’
Discussion
The findings have captured the vast differences between community and acute nursing. Within education, these differences have manifested for community nurses as a loss of identity and awareness of being in a different culture where acute nursing seems to be the focus. Current national focus seems to promote amalgamation of all nursing environments, with transferable skills. Yet, the capitalisation of acute nursing does not provide an effective means for this amalgamation within education in the current climate.
Theme 1: community nursing is vastly different from hospital nursing
This theme highlights particular differences in accountability and lone working and recognition of experience needed to be competent in the role. This could be where the myth (White, 2019, QNI, 2022) needing a year’s hospital experience before going into the community has come from. RP1, having gone straight from qualification, while experiencing a normal, anxious transition from student to staff nurse, appeared to not experience the same anxiety or effect of community nursing being entirely different from that of hospital nursing. This may support the option of having a specific community field suggested by Willis (2015) or at the very least, a community pathway or elective for those interested in community employment following qualification (Cooper et al, 2014; Cahalane et al, 2018).
Stories of accountability within lone working noted in this theme are nursing skills that go visibly unnoticed to nursing students and could be likened to previously referred to health promotion skills that can be perceived by nursing students to offer little value (Warner et al 2010; Cooper et al 2014). These skills are difficult to instantly teach as they require experience and practice and there is a need to ‘feel’ this kind of responsibility in order to consider this as a transferrable nursing skill. If students are not practising these skills, it can appear that the community skill-set requires a lot of talking and not visibly doing, as perceived by some students (QNI, 2022). Furthermore, within acute care, lone working skills are not readily available in an environment where there are always more senior and medically trained professionals to ask. These skills lend themselves to simulated practice for students and more opportunity should be made available in the pre-registration curriculum for these. It also suggests that the term ‘deskill’ (White, 2019) is irrelevant, depending on the setting, as the skills required for hospital can be quite different to the skills required for the community. When acute nurses suggest the term ‘deskill’ they are adding to the underlying narrative that to be a nurse, you must work in the hospital.
Theme 2: the pre-registration curriculum is very acute-focused
These findings correlate with student expectations of the curriculum. Student perceptions regarding community care and the curriculum can be categorised into two elements within literature: lecturer views on pre-registration curriculums and nursing, and primary care or community clinical placements and potential employability. With regard to lecturer views, it is reported that nursing students have insufficient classroom time to prepare them for the challenges of working in primary care, due to a focus on acute care (Ali et al, 2011; Albutt et al, 2013). This has been echoed internationally (Van Iersel et al, 2016; Byfield, 2019; Murray-Parahi et al, 2020). However, investigating whether an intentional primary focused curriculum influenced students’ perceptions showed that it actually did not (Van Iersel 2019). In order to change student perceptions regarding community nursing, it must be acknowledged that there is a need to combine an overall positive experience of community nursing in both placement and academic redesign (Byfield, 2019; Van Iersel et al, 2019), as isolated positive experiences are not having an effective, overall impact in raising the community nursing profile.
With regard to the second element: community clinical placements and potential employability, evaluations of community placements show that students appreciate more active participation (hands-on) rather than observation and this increases their satisfaction of learning, positive experience and likelihood of potential employability. Opportunities for students to have active participation on a community placement are very supervisor-dependent (Baillie, 1993; Murphy et al, 2012; Bloomfield, 2018; Meeley, 2021). Therefore, student experiences of community nursing can be very different and rely on having a proactive supervisor in order to have a positive experience. More consistency nationally regarding students and indirect supervision, or independent visits for final year students in clinical placement (Watkinson et al, 2009; Brown, 2013) would ensure even more student involvement. This would, once again, provide the opportunity to feel professional autonomy in the community as, currently, nursing student perception is that primary healthcare offers have limited autonomy (Byfield, 2019). Yet, professional autonomy is noted as being highly valued in terms of nursing and job satisfaction (Dilig-Ruiz et al, 2018).
An acute-focused pre-registration nursing curriculum is difficult to change without national drivers supporting a balanced, academic curriculum and placement opportunity. There have been isolated areas of innovation regarding promoting the community nursing profile from innovative community placements, simulation and community enhanced curricula. However, a whole standard approach needs to be taken from a national level in order to change perceptions and attitudes that currently prevail with nursing students. However, it has been acknowledged that a combined focus on community within curriculum and community placement within the community has been successful at the University of Roehampton (QNI, 2022). More community nurse lecturers are required to influence nursing curriculums, owing to much more acute nurse lecturers teaching from the premise of their background. The amount of acute technical skills needing to be taught (NMC, 2018) could be reduced so that the task-based nature is also not the focus of the future student nurse, who furthermore regards the acute setting as the best place to achieve these (Byfield, 2019). Another factor that appears to be difficult to change is the expectation of students prior to commencing nurse education. Lavery and Henshall (2022) concluded that students were unsure about community roles, both in terms of what the role was and the many different types and titles of community nursing leading to more ambiguity about significance and employability.
Conclusion
The purpose of this study has collectively uncovered how current pre-registration nurse education can reinforce already established misconceptions of nursing and where care is primarily delivered. It has provided a good insight into the conflicts that community nurses face within pre-registration nurse education, as there are vast differences in expected taught content that is acute-focused. This is highlighted by the differences in the skill set required for the different settings. It demonstrates difficulties that can be faced when entering employment into community nursing, following a lack of preparation from current pre-registration education, as well as the conflicts faced when teaching community nursing when the current curriculum and student expectation appears to value visibly noticed task-based skills over holistic skills that are less visible.
Owing to national drivers to needing more nurses in community care and subsequent nursing student preparedness for employment in the community, community nurses need to have a larger presence in pre-registration academia to ensure the focus is balanced across all care sectors. This includes a higher curriculum content, considering even more positive ways to further expand and fund community placement capacity and having a standardised national drive to ensure consistency across curricula. The heightened sense of accountability and experience shared by the participants demonstrate community nursing needs to either be valued as a specialism by having a field of its own or at least incorporated in a much more intended way into the curriculum.
Current curriculum may require less attention on task-focused technical skills and more empowerment for students so that they are able to be confident in decision-making and more holistic skills, such as lone working and the ability to manage care without always having equipment at hand and still prevent hospital admission. Simulation may provide an opportunity for this, so the student can experience this risk free, rather than merely observe (Reynolds et al, 2018, Arnold et al, 2021). Furthermore, more placement opportunities that allow students to experience lone independent working need to be expanded and risk-assessed.