The World Health Organization (WHO) (2006) encouraged governments worldwide to explore better ways of delivering healthcare to ensure the sustainability of healthcare services. Government strategies concluded that people's care needs could be best managed in primary care, specifically the home setting, using a ‘shift left’ approach (Department of Health, Social Services and Public Safety (DHSSPS), 2011a; 2011b; 2014; 2015; 2016a; 2016b; 2018; 2020; Department of Health and Social Care (DHSC), 2013; Bengoa, 2016). The NHS (NHS England, 2017) acknowledged that an ever-ageing population and related comorbidity, together with widening health inequalities, intensify the complexity of health and social care that is required, especially within primary care services (Ryder and Bain, 2013; Bengoa, 2016). With people living longer and care needs increasing, it is expected that the shift in services will weigh heavily on district nursing. As a result, the demand capacity gap will inevitably increase, leaving district nursing services to face expected difficulties in how to meet client demand and expectation (Royal College of Nursing (RCN), 2013; Chalk and Legg, 2017; McComiskey, 2017).
The district nursing caseload is often referred to as the ‘ward without walls’ (Stewart et al, 2008). District nursing may be the only profession that has no limitations to workload (Oldman, 2017; Chilton and Bain, 2018). This exposes the profession to being viewed as a ‘catch all’ by other services (Ball et al, 2014; Queen's Nursing Institute (QNI), 2014). Elements that generate the district nursing working caseload cannot be defined as fixed; thus, it is challenging to outline a threshold of patients or workload capacity due to its unpredictability (National Quality Board (NQB), 2018). District nursing contacts reach over 100 million per year in the UK (Addicott et al, 2015). Additionally, Norther Ireland has seen a 10% increase of 120 000 district nursing contacts between 2010/11 and 2014/15 (DHSSPS, 2017).
The referral process ensures that care is distributed and delivered by the most appropriate professional, providing a starting point to initiate assessment for service appropriateness. Similarly, it has been considered that evidence-based, clear referral criteria are likely to be the most cost effective and clinically effective way to use services, as they ensure that the right individual is referred to the most suitable service (Imison and Naylor, 2010). Commonality in district nursing referral criteria can be seen throughout the UK and Ireland (Jarvis et al, 2006; Bowers and Cook, 2012; Western Health and Social Care Trust (WHSCT), 2017; Health Service Executive (HSE), 2020). Themes in policy indicate that district nursing services accept referrals for individuals who have a clear need for a complex health assessment and/or nursing intervention, the individual consents to the referral and the individual is aged 17 years old or is within their transitional year to adult services. Additionally, nursing interventions that are deemed more appropriate to be carried out within the home setting also play a factor in meeting the referral criteria (Jarvis et al, 2006; Bowers and Cook, 2012; WHSCT, 2017; HSE, 2020). The main criterion to be met is that the individual is housebound. Being housebound is generally described as being unable to leave the home environment due to a physical or psychological illness, but the description is open to interpretation (Bowers and Cook, 2012).
To the authors' knowledge, there are no studies that investigate the lived experience of community nurses' implementation of referral criteria within their day-to-day role. This study aimed to explore district nursing students' perceptions and experiences of district nursing referral criteria in Northern Ireland.
Methods
Design
A qualitative phenomenological approach was adopted to explore district nursing referral criteria from the students' perspective, experience and interpretation (Astin and Long, 2014).
Sampling and recruitment
A non-probability purposive convenience sampling strategy was used. Specialist Practice Qualification (SPQ) district nursing students (n=55) registered at one higher education institution (HEI) in Northern Ireland were invited by the researcher (CY) to attend a virtual information session about the nature and purpose of the study. Potential participants were subsequently contacted via the HEI's email gatekeeper with an invitation to participate in the study. Consent to participate was communicated directly to the researcher by individual students via email. In total, 10 of the 55 students consented to participate in the study.
Data collection
In view of the COVID-19 pandemic, data were collected using online focus group interviews hosted on Microsoft Teams using a semi-structured interview guide. The interview guide focused on four main areas: understanding of referral criteria, experience of referral criteria, strengths and limitations of referral criteria and recommendations for the future. Two online focus group interviews were conducted with five students in each group. Each focus group lasted 90–120 minutes. To reduce participant reticence, they were permitted a choice of having the video camera on or off during the online focus group interviews, although audio recording was essential. The online focus group interviews were recorded with participants' written and verbal consent.
Data analysis
Data collected through digital online recordings was entered manually into the computer-assisted qualitative data analysis software (CAQDAS) NVivo 12 Pro. Data saturation was achieved during the two focus groups with emergent themes captured by the researcher during analysis (Doody et al, 2013). Miles and Huberman's (1994) thematic data analysis framework was applied through data collection, data condensation, data display and conclusion drawing/verification. Study findings were confirmed by the themes being member checked by all participants.
Ethics considerations
The study was granted ethics approval from the HEI's research governance filter committee. Participation in the study was entirely voluntary, and participants were free to withdraw at any stage of the study. In addition to written consent, verbal consent was also sought prior to the digital recording of the online focus group interviews. As all participants were registered with the Nursing and Midwifery Council (NMC), they were advised that the NMC code of conduct would be adhered to for any professional concerns that might have arisen (NMC, 2018).
Findings
Participant demographics are summarised in Table 1. Data analysis yielded four emergent themes: referral criteria: insight and inconsistency, task versus patient-centred care, role transparency and service provision awareness. Overall, participants valued referral criteria in enabling district nursing teams to provide care and sustain future district nursing services.
Table 1. Demographic characteristics of the participants
| Gender | |
| Female | n=9 (90%) |
| Male | n=1 (10%) |
| Age | |
| 20–29 years | n=2 (20%) |
| 30–39 years | n=5 (50%) |
| 40–49 years | n=2 (20%) |
| 50–59 years | n=1 (10%) |
| District nursing experience | |
| 0–4 years | n=5 (50%) |
| 5–9 years | n=5 (50%) |
| District nursing team setting | |
| Urban | n=3 (30%) |
| City | n=2 (20%) |
| Rural | n=5 (50%) |
Referral criteria: insight and inconsistency
District nursing students demonstrated a lack of awareness and insight regarding the existence of district nursing referral criteria:
‘I have heard reference to a policy, but no one has ever been able to show it to us. The policy was often referred to but no, it was never seen. That's just what the manager said.’
(participant 2, focus group 1)
Some participants explained that knowledge of referral criteria was gained through word of mouth and day-to-day experience within their district nursing teams. Others were provided an informal information page they believed to be generated by their manager:
‘I have a sheet that I was given by the sister on the caseload, but there is no trust logo or anything.’
(participant 3, focus group 1)
Participants described how there was a lack of a defined regional district nursing referral criteria. They emphasised how clear regional referral criteria would provide support when challenging inappropriate referrals, thus justifying district nurses' professional decision-making with respect to triaging referrals. They expressed concern surrounding variations in referral criteria leading to subjective triaging, which, in turn, leads to a divergent interpretation of those persons who do and do not meet the referral criteria. Differing electronic allocation tools and referral systems further contributed to inconsistency throughout the region. Staffing and resource issues, such as lack of administration staff, lack of technology and staff vacancies, were considered to contribute to failings in quality triaging of referrals.
Participants highlighted challenges with respect to the varying locality and team definitions of ‘housebound’:
‘Our criteria (for service provision) is housebound patients, and housebound was described as somebody who requires an ambulance to leave the house and palliative care.’
(participant 2, focus group 1)
Participants reported feelings of worry and guilt if a person was not considered as housebound, but declined to attend the treatment room for nursing care:
‘It's quite difficult to know that you would be leaving that patient untreated. I know, it's their choice, but it's a difficult decision ethically to think you're leaving someone with an open sore out there in the community untreated.’
(participant 1, focus group 1)
Some participants also expressed concern about referrals to district nursing services based on age rather than nursing need.
Task-oriented versus patient-centred care
Participants emphasised the importance of holistic person-centred assessment as integral to their district nursing role. However, referrals to the service were considered to be predominately task oriented. Participants described referrals as lacking essential information, thus resulting a task-driven response:
‘What you get is a list of bloods. You know it is task oriented.’
(participant 3, focus group 2)
Another participant stated:
‘Yeah, like, they tell us not to be task oriented, but our referrals always are like a dressing. You get no build-up, you get no history or anything else; all you get is a task usually. When you go out, you realise there is so much more going on.’
(participant 2, focus group 1)
Misunderstanding the service
All participants perceived a lack of knowledge among those making referrals to the service about the role of the district nurse:
‘I once spoke to a GP. I couldn't believe the perception they had of our role … what we did was just go out and check blood pressures, you know. There is a lot more to it.’
(participant 2, focus group 2)
The importance of the initial visit was described ‘as vital to setting the tone for the patient's journey with the district nursing service’ (participant 4, focus group 1). Misleading service expectation from patients' perspective was recounted by participants, accompanied by the perception that such misleading expectation was instilled by the source of referral.
‘Today, we had a referral for a man with a toothache. I don't think they realise what we do, because often people would think community is a lovely wee number. I think it is just a case of, if in doubt send the district nurse to go.’
(participant 2, focus group 1)
Participants also described how other disciplines would initiate care, and then refer into district nursing to ‘pick up’ and to continue care. There was a consensus among participants as to how the role of district nursing teams was promoted with overall feelings of being ‘invisible’ and ‘dismissed’ compared with acute staff within the hospital setting, and they were dissatisfied with this outlook. The need to develop greater reciprocal understanding of professional roles was emphasised:
‘I really believe hospital staff need [to be] educated but vice versa, the community staff need [to be] educated, too. The two teams are so separated, they need to be brought together. They really underestimate the role of the district nurse.’
(participant 3, focus group 2)
It was noted by some participants that there was a lack of knowledge with regard to the urgency of referrals and the required response time. Some participants considered their 4-hour urgent referral response time as being unrealistic and commented on how most referrals were deemed as urgent by the referrer. From a district nursing team perspective and the time given to triage appropriately, most referrals could be deemed as non-urgent when properly triaged and further information was obtained from the referring agent.
‘I don't think the nurses are trained in what makes an appropriate referral. So, for example, a referral came through this week for perineal sinus. The patient was 30 years old, but the criteria were written that her boyfriend works through the week [so] he cannot take her to the treatment room. So the district nurse just rang the hospital and said, “I am sorry, she is not housebound, we cannot take her”.’
(participant 3, focus group 1)
Referral quality
Poor communication and lack of detailed information on referrals were reported as ‘frustrating’ by all participants. It was highlighted that resources including, for example, dressings and prescription authorisation, were not always provided following a hospital discharge, resulting in delayed patient care and increased workload for the district nursing teams. Consequently, lengthy periods of time were spent following up referrals to obtain more comprehensive information.
‘It stresses you, because it is so inappropriate, and you haven't got the staff to cover it.’
(participant 2, focus group 2)
Participants mentioned difficulties in accessing the primary referrer, patients not being referred in a timely manner, limited information on referrals and inconsistencies with respect to response times across health and social care trusts:
‘It's very hard to get information on hand; to get back to the source or person who sent the referral can be time consuming. You just go out blind a lot of the time; you just don't know you're going into.’
(participant 2, focus group 1)
A few participants pointed to existing enhancements to the organisation of health and social care that contributed to more comprehensive and appropriate referrals:
‘What works well for us is that we obviously work out of a GP building, and the social workers are sharing our office, so it is, like, easy to get essential information from the social worker, where you can say that's not for us without rejecting a referral. That's multidisciplinary working; we are all in an office together. I think it works better.’
(participant 1, focus group 1)
Discussion
This study aimed to explore district nursing referral criteria from the perspective of district nursing students in Northern Ireland. Lack of consistency and awareness of existing referral criteria were discernible among study participants, which led district nursing teams to foster their own notion of what was deemed an appropriate or inappropriate referral. District nursing is viewed as a demand-led service, rarely refusing referrals, as workload capacity is not limited in the community as it might be due to limited bed capacity in a hospital (Roberson, 2016; Oldman, 2017). Additionally, district nursing services are the initial point of contact for all community services rather than for their specialised nursing skills (QNI, 2019). Hence, the lack of agreed referral criteria places district nursing teams under pressure to accept all referrals to the service (Bain, 2012; QNI, 2019b; McKinless, 2020). The QNI (2009) concluded that strict referral criteria would reduce demand and ensure a nursing need was identified prior to referral. Although this would encourage high-quality referrals, Maybin et al (2016) remarked on the risk of delaying patient care. Moreover, there appears to be of a lack of transparency surrounding the role of what district nursing teams offer and referrer awareness of eligibility in meeting the referral criteria (Bowers and Cook, 2012).
Inopportunely, misdirected and inappropriate referrals waste time to redirect within a service already working above capacity (Ball et al, 2014). With variations in criteria being based on localised historic custom and practice rather than based on assessment of patient need, it may be contended that unless district nursing teams collectively uphold the true ethos surrounding district nursing services, the service will continue to be mistreated (Gould, 2018). The lack of consistency in approaches to referral criteria and referral processes has led to confusion among referrers and other health professionals, as well as patients, carers and district nursing teams about what the service offers (Jarvis et al, 2006; Drew, 2011; Nordmark et al, 2015; Leary et al, 2017, McKinless, 2020). The DHSSPS (2018) recommended standardisation of referrals, admissions, assessments and discharges to promote an equitable district nursing service throughout Northern Ireland. The implementation of this recommendation is still awaited and, thus, difficulties are likely to continue, permitting referrers to generate inappropriate referrals and allowing for a false expectation of what the service will provide and when it will be provided (Pye, 2020). Implementation of a more robust district nursing referral criteria will undoubtedly increase the workload demand on those services that have historically been supported by district nursing (Bowers and Cook, 2012). Equally, this will allow referrers to better identify what service is best skilled and equipped to support the patient.
This study highlighted the challenge of task-oriented referrals contradicting the holistic nature of district nursing. District nursing is a multi-skilled professional service that provides highly specialised, clinically holistic nursing care to individuals in their own homes and local communities (QNI, 2016; 2019a; 2019b; DHSSPS, 2018). They play an integral role within primary care not only by providing direct care but by also engaging in health promotion, patient education and promotion of self-management (DHSSPS, 2018; QNI, 2019a). In addition, district nursing teams support the patient, as well as their family and carers, through a multidisciplinary, collaborative approach referring patients and carers to other disciplines and incorporating a holistic approach to person-centred care (QNI, 2016). Visits from district nursing teams are usually initiated by a referral for a physical, hands-on clinical nursing need or task (McKinless, 2020). Offen (2015) argued that district nurses view physical tasks as a preliminary step to undertaking richer assessments and building a therapeutic nurse-patient relationship. However, district nursing faces the challenge of being stereotyped, where home visits are classified as task oriented and a ‘pop-in service’, disregarding the vast knowledge base, complexity of clinical skills and complex assessment skills that are held by the profession (Drew, 2011). Further, the task-focused culture of district nursing has been acknowledged, indicating that the decrease in capacity to meet demand and chronic understaffing have affected a population health approach, thus inhibiting district nurses' ability to be proactive in anticipatory care and disregarding caseload profiling as an approach to health promotion (Bain and Baguley, 2012; Maybin et al, 2016; Chalk and Legg, 2017; Harper-McDonald and Baguley, 2018; McKinless, 2020). Barriers to referrals include:
- Inadequate information and detail on referrals
- Untimely referrals
- Poor communication
- Lack of awareness of the district nursing role resulting in inappropriate referrals w Differing IT systems
- Absence of a structured discharge proforma to community services w Lack of time for multidisciplinary team collaboration prior to discharge impact significantly on the referral process (McHugh et al, 2003; Ball et al, 2014; Nordmark et al, 2014; 2015; 2016; Pellett, 2016).
Nordmark et al (2016) reported that verbal information exchange is perceived as more beneficial than electronic information exchange, and they recommended one shared electronic system rather than multiple systems to ensure a smooth streamlined information flow. This highlights the importance of verbal conversations following electronic referrals, as the latter are limited in the detail that can be provided during information exchange. Barriers in discharge planning and information exchange can fragment the smooth transition from hospital to home, resulting in the breakdown of continuity of care, delayed discharges, re-admissions and negatives affects regarding quality of life (Nordmark et al, 2016). Nordmark et al (2015) reported that there is a higher prevalence of information sharing from the district nursing perspective (74%), but only 46% staff nurses shared information with district nursing during discharge planning. Additionally, the National Institute for Health and Care Excellence (NICE) (2015) proposed that discharge information must be handed over from the hospital team to the community team to facilitate informed care planning.
Reinstating colocation of district nursing teams in GP surgeries would permit closer team working, which would benefit both patients and carers in primary care through enhanced communication, up-to-date documentation and the monitoring of patient progress, which can be a means of safeguarding patient care (QNI, 2016). Further, GPs value having faster access to district nursing teams as this prevents unnecessary admissions to hospital and allows patients' end-of-life care needs to be met at home (Bowers and Cook, 2012). Nonetheless, district nursing teams often share large office locations, which can provide an opportunity for reflection, peer support and sharing of best practice (QNI, 2019a). This can impair continuity of care through a lack of consistency in staff delivering and reviewing care, and this can affect patient outcomes and patient satisfaction (Drew, 2011; QNI, 2019a).
Study limitations
This small qualitative study has some limitations. It would have been preferable to conduct the study with established SPQ district nurses, but this was not possible due to restrictions placed on the conduct of research by the COVID-19 pandemic. Another limitation is the use of a self-selected sample from one geographical region. Therefore, the study findings may not be transferable to other district nursing settings. A larger study including district nurses from different regions is recommended.
Conclusion
This is the first study to explore district nursing specialist practice students' perceptions and experiences in regard to district nursing referral criteria. The findings highlighted how the lack of standardised referral criteria in Northern Ireland has contributed to inconsistencies and discrepancies in how individual district nursing teams manage referrals. Lack of a standardised approach to referral criteria not only undermines the specialist knowledge and skills held by district nurses but also leads to a task-oriented referral culture that negates the holistic nature of person-centred care. Standardised regional referral guidelines offer a pragmatic starting point towards making optimal use of district nursing services, thereby ensuring that patients receive clinically appropriate, safe and sustainable quality care.
Recommendations
- Education programmes for health professionals may enhance awareness of the district nursing role
- Communication, collaboration and co-ordination of multidisciplinary teams to improve discharge planning to district nursing services should be encouraged
- Clear referral criteria to support health staff when making referrals to district nursing services should be developed and piloted
- Quality referral audits to identify areas for improvement should be considered
- Further research regarding district nursing referral criteria involving other health professionals should be conducted.
KEY POINTS
- The care that is now delivered within community settings by district nurses is becoming increasingly complex
- Referral criteria help ensure efficient and service provision to district nursing clients
- There appears to be a lack of consensus with respect to referral criteria in district nursing, contributing to inappropriate and poor-quality referrals
- Task-oriented referrals currently being used contradict the holistic nature of district nursing
- Standardised referral criteria urgently need to be established and disseminated.
CPD REFLECTIVE QUESTIONS
- What are the benefits of referral criteria?
- What challenges are faced when implementing district nursing criteria and how may such challenges be overcome?
- What can district nursing teams do to raise the awareness of referral criteria for those who use their services?