The development of the district nursing workforce has become a priority for policymakers seeking to address evolving health needs and changing population demographics (While, 2024). As with any nursing workforce, a focus on recruitment, development and retention is necessary (World Health Organization, 2016; NHS England, 2023). Nurse retention remains a critical concern across the NHS in all four countries that make up the UK. The increasing shortage of nurses, coupled with high turnover rates, negatively impacts the quality of patient care and the experiences of other staff members (NHS Employers, 2023). In 2023, 76% of nurse team leaders in district nursing services reported unfilled vacancies or frozen posts within their teams (Bushe et al, 2024).
As a result, nurse retention, including that of nursing associates, has become central to the sustainability of district nursing services. This article presents preliminary work as part of a study funded by the General Nursing Council Trust, which investigated effective retention strategies for district nursing services. The study included a scoping review, surveys and interviews (publications are currently in progress). When applying for research funding, the authors argued that district nursing has distinctive features that set it apart from other settings. Reports from district nurses (DNs) during the pandemic, for example, were notably different from those of hospital nurses (Green et al, 2020). Effective retention strategies for nurses in hospitals or other settings may not apply directly to district nursing, as the role's unique characteristics must be considered. The aim of this article is to validate these ideas with a broader group of expert nurses in district nursing services and refine them where necessary.
Distinctive features of district nursing
The authors began their study with a set of three key features of district nursing, identified through focus group interviews with nurses and senior managers across England. These interviews were part of a previous study exploring how best to support experienced hospital nurses transitioning into community matron roles (Drennan et al, 2005). This initial set served as a foundation for discussions with the study's advisory group and DN forums that supported the work and helped to distribute the survey. Through these discussions, the initial set of three features was expanded to five proposed distinctive features of district nursing (Figure 1).
1. Patient-controlled and negotiated decisions in the home
In district nursing, the patient is often in control of decisions affecting their health and wellbeing, especially in the context of their home environment. Person-centred care requires ongoing negotiation between the nurse, patient and family carers or informal support network. Positive outcomes depend on the nurse's ability to establish and maintain a relationship with the patient.
2. Lone working
DNs typically work alone, making clinical and professional decisions under time constraints, often in less-than-ideal circumstances and without immediate support from colleagues.
3. Multiple, location-specific systems and networks
DNs must navigate multiple health and social care systems, which can vary across local areas. This necessitates building diverse networks with other health and social care providers, as different systems support individual patient care.
4. Travel and transport between patients
DNs usually require transport to move between a dispersed group of patients, as most areas are not densely populated enough for nurses to walk.
5. Unlimited patient numbers
Unlike hospitals or care homes, district nursing services in England are expected to accommodate all patients referred under the block contract commissioning system (ie for a total population), without set limits on the number of patients.
The authors invite DNs to share whether these features resonate with their experiences, to assess if these statements are accurate and relevant, and to refine them based on their expertise and experience in district nursing services.
Further exploration
The following sections provide further details of the different characteristics of district nursing.
The following two points are perhaps more contentious in terms of NHS policies and distinctive features of the occupation of district nursing.
Conclusions
Several distinctive features set district nursing apart from nursing in other settings. Recognising these unique aspects is essential for developing effective retention strategies for DNs. By presenting five key features, the authors invite feedback from experienced DNs to confirm, refine or challenge these statements. Such input is crucial in ensuring the accuracy and relevance of these features based on real-world experience. Clarifying these distinctions may also support research, inform business cases for resources, aid in retention strategies and bolster recruitment efforts.