The district nurse has often been described as central to the care of patients in the community, delivering high quality, holistic care to meet the needs of an ever-ageing population with complex health needs (Queen's Nursing Institute (QNI), 2015a,b; NHS England, 2019a). Recognising the burden on community services over the years led to NHS England committing to invest in primary medical and community health services and spend more than £4.5 billion on services within 5 years (NHS England, 2019b). It has been acknowledged that despite best efforts, district nursing services face staffing challenges in the form of recruitment and retention, which compromise policy objectives and threaten the delivery of safe care (QNI, 2016; Drennan et al, 2018).
This paper presents the qualitative ndings from a study that explored students' perceptions and barriers to joining employment at a partner NHS community trust.
In 2020, 29 740 students accepted places onto pre-registration nursing courses in England; this represented a 25% rise compared to 2019, and signalled an increase of over 6000 students in a year (The King's Fund, 2021). It is di cult to quantify how many students join the district nursing workforce directly after qualifying, but it is known that the number of district nurses has declined by 45% since 2009 (The King's Fund, 2018). Data from NHS Digital (2022) in England showed 226 677 full-time equivalent hospital and community health service vacancies as of March 2022—a 2.4% increase—the previous year, indicating the workforce crisis continues. The King's Fund (2018) pre-empted and supported strategies to shape a sustainable workforce, as outlined in the NHS long-term plan (2019). The plan aims to boost out-of-hospital care and seeks to dissolve a historic division between primary and community services to provide an integrated and collaborative workforce. Health Education England (HEE) now has lead responsibility for the NHS workforce and a part in shaping roles and pathways for the future (NHS England, 2019). The plan includes higher educational institutions in its vision of providing enough people, with the correct skills and experience for clinical roles. Nevertheless, global student nurse attrition rates are concerning, and other potential solutions point to the redesign of undergraduate nursing programmes as a way of increasing student engagement and the nursing workforce (Chan et al, 2019). Speci c to district nursing, making the role more attractive to undergraduates and challenging misconceptions about the breadth and depth of career options has been highlighted as an urgent measure (QNI, 2015a; NHS England, 2019; NHS England, 2022a).
The goal of undergraduate nursing education is the development of confident, empathic and competent healthcare professionals (van der Riet et al, 2018), who meet the standard for registration. Programmes and practice placements should prepare student nurses to practise effectively in any area of the nursing workforce, and students should feel supported and ready to achieve this upon registration. The purpose of the study reported here was to explore barriers to joining the district nursing workforce from the perspective of undergraduate nurses, to establish robust recommendations and to develop changes in practice.
Objectives
The objectives of the study were to understand the perceived challenges and barriers that pre-registration BSc (Hons) nursing students faced to moving into a career in district nursing. The research aimed to gain an understanding of these barriers to improve opportunities and experiences for student nurses who wish to join the pathway of a district nursing career. The research would enable the programme and practice partner team to analyse and develop support strategies, to improve awareness of student difficulties and enhance collaborative engagement with community practice partners.
Methods
As background, search strategy included databases: CINAHL, ProQuest Health Research Premium, Medline, Pubmed and EBSCOhost. Key terms were searched within the library catalogue and databases to gain information to base this study on and interpret results. Peer reviewed articles which were published 10 years ago or less were included. The subject was refined to nursing and nurse education, initially using the terms, ‘district nurse’ AND ‘employment’ AND ‘undergraduate nurse’. Of the 6 results, no articles were suitable. Further truncated search terms included ‘undergraduate nurse’ AND ‘employment’ AND ‘community nursing’, which yielded 31 articles. None directly related to district nursing, but rather, community nursing. Further search terms were used narrowing this down to 12 articles, of which 2 articles directly referred to district nursing. ‘Student nurse and DN workforce’ returned 118 results, of which 5 articles were relevant. A search on ‘district nurse AND workforce AND student nurse’ produced 308 results, many of which had been reviewed in previous searches and it was felt that new material was saturated. This led to the understanding that there were gaps in the knowledge pertaining to UK studies and those with a district nursing focus. The reference lists of the articles were hand searched to increase the likelihood of capturing more articles. Google scholar was also searched to ensure no other articles were overlooked in the process and 7 articles were found.
The study design was qualitative, and the method of data collection was focus groups. These groups were undertaken virtually using Microsoft Teams, recorded, and transcribed with the consent of all participants. The benefit of using the virtual focus group was its accessibility for students who are at different stages in their programmes, working in placement areas or studying. Virtual methodologies have the potential to enhance recruitment of demographically and geographically diverse participants and can be conducted with few technological issues (Halliday et al, 2021). Focus groups are thought to pose some unpredictability because of the interaction and the discussion that can occur. However, the subject, even though related to nursing practice, was not expected to raise any personal or traumatic issues (Sim and Waterfield, 2019). Should any areas of distress arise, there were mitigations in place as part of the ethics process.
Ethical considerations
Ethical approval was granted through the higher educational institution that the research took place in (approval reference no: 21/NAH/006, 30/03/23). Ethical research in nursing is important to cultivate professional values, maintain standards and uphold the fundamental ethical codes (Toumová et al, 2021). This also ensured adherence to the Nursing and Midwifery Council's (NMC's) code of professional conduct (2015), and participants were assured that confidentiality and anonymity would be maintained.
Participants
Students were invited to participate if they were studying on the pre-registration BSc (Hons) adult nursing programme at a large HEI in the UK, on which there were approximately 1600 students. Mental health and child field students were excluded because they did not fit the criteria for applying for a district nursing post on qualification (based on current person specifications). In total, 60 students participated in the study. The scale of the project was important to capture the wider experiences of the group across varying years of study.
Data collection
The sample was recruited using a purposive technique from the undergraduate nursing programme. Campbell et al (2020) described transferability, credibility, dependability and confirmability as key concepts in purposive sampling. Such outcomes were anticipated from the study. The use of purposive sampling supports a depth of understanding of the student experience. A total of nine focus groups were undertaken until the team identified a saturation of the main themes. Guest et al (2017) challenged the notion of a recommended number of focus groups supporting saturation as a key determinant, while suggesting that key themes can be established over as little as three focus groups. However, the study was based across all 3 years of undergraduate nursing courses and the team adopted a strategy to obtain a larger sample size, based on the hypothesis that a cross section of the students' views and ideas would be more significant (Robinson, 2014).
Considerations and limitations
As outlined, there was a sample size of 60 participants. Focus groups are perceived as yielding a rich and in-depth data, highlighting both agreements and inconsistencies (Goodman and Evans, 2015). However, the virtual methodology and lack of face-to-face interaction may have impacted participation and interaction. Literature identifies virtual methods are not the same as in-person engagement. They require thoughtful, deliberative approaches to mitigate risks and prevent the researcher from becoming distanced (Gregory, 2020; Newman et al, 2021). A limitation of the study circled around recruitment. The study took place over a period of 6 weeks. This was during the students' theory blocks, practice placements and annual leave entitlement, which was unavoidable when researching across the nursing year and cohorts of an undergraduate nursing programme. Unless the authors/researchers approached this by allocating a focus group per cohort, which would have been easier to manage, this would have been unavoidable. The authors decided against a focus group per cohort in order to capture a variety of experiences and students in each focus group.
Data analysis
The analysis of the study would contribute to the wider internal agenda to raise the profile of district nursing within the faculty. The qualitative method of thematic analysis was chosen for data analysis, which is a familiar method not associated with a specific theoretical perspective, but which supports the generation of meaningful information from the data extracted (Braun and Clarke, 2013; Nowell et al, 2017). The themes were coded and interpreted using the six-step framework until a higher order of themes were identified, and key quotes were written verbatim and cross referenced to individual participants (Braun and Clarke, 2006).
Results
The results demonstrated that a wide range of students participated from different years of undergraduate study. Only six of the participating students (n=60) were male. Five separate cohorts of students participated, ranging from the most recent cohort in January 2022 to March 2020 (Figure 1). The cohorts correlate to the date the students began their nurse education.
Overall, first-year students comprised those within the first 6 months of their programme (10%). Students who were over half-way through their first year made up the largest percentage of all participants (47%). Second-year students made 30% of participants: those in the first 6 months of their second year (3%) and those in the final stage of their second year (27%). Students who were entering the final 6 months of their adult nursing programme comprised 13% of participants. All but one focus group had a mix of students from differing cohorts.
Data for 34 first-year students demonstrated that 5 students had not had a community placement allocation; 25 participants had experienced one community placement already; four students had experienced two community placement opportunities; and two students who had not been to a community placement reported that they had district nursing allocated for their next placement.
Data for 18 second-year students demonstrated that one participant had never had a community placement; 10 students had experienced one placement; two students had two community placements, and one student had experienced three placement opportunities. It was commented by four students that their next placements would be in community settings.
Data for eight third-year students demonstrated that five had opportunities for one community placement; two students had been to two community placements and one student had experienced three community placements (Figure 2).
Question two in the focus group referred to the total number of community placements students had attended at that point in their education. No students across any cohort had experienced more than three community placements.
Discussion
This research study was designed to produce data about the barriers to district nursing employment for students. The study produced themes relating to role ambiguity, personal preferences, educational opportunities and recruitment, and employer engagement. These themes and subthemes can be viewed in Table 1.
Table 1. Themes and subthemes
| Role ambiguity |
|
| Personal preferences |
|
| Educational opportunities |
|
| Recruitment and employer engagement |
|
Role ambiguity
A main theme was role ambiguity. Students recognised a lack of awareness of the role of the district nurse and needed a clearer understanding. The participants identified that community placements referred to out-of-hospital care and that it was not always clear what these roles entailed. A student raised that the placement they were on was ‘a civic engagement one, which is classed as a community placement’ (Participant 9). Civic engagement placements provide opportunities for andragogical approaches to experiential learning and can structure community-based activities to connect students with activities within communities and link to academic study (Saltmarsh, 2010). Such arrangements may not enable students to observe or participate in nursing within community environments or their traditional roles but still count as a community placement. This was captured in some of the discussions, with participants highlighting gaps in their basic community nursing knowledge, asking questions specifically about topics such as shift patterns, requirements for driving in community roles, as well as the wider team structure and preceptorship support.
Community is packaged into a genre which deserves its own spotlight, so students can understand their options and career trajectory within this. Roles exist within community nursing which can support career pathways and development toward other public health-focussed roles such as health visiting, school nursing and a vast array of clinical specialities. However, the resources given to inform undergraduates is arguably not on par with that of secondary care, and it is widely acknowledged that community careers must take action to raise the profile of roles in this sector to boost recruitment (NHS Confederation, 2022).
Role ambiguity as a topic for district nurses is not a new phenomenon. A previous district nursing education career framework existed to illustrate career pathways, core skills and competence for the role, in addition to key district nursing service responsibilities (QNI, 2014; HEE, 2015).
Participants in the study acknowledged that it is an easier transition to enter secondary care on qualification, with one stating that students are:
‘Exposed to the same thing in hospitals so it's easier to go into on qualification.’
(Participant 27)
Students also perceived that they needed further qualifications before moving into district nursing and that they required 12 months' experience in a secondary care setting, such as a ward environment, with some even citing ward experience as a prerequisite to apply. Reynolds (2022) recognised this as a historic belief about district nursing which aligns to five myths, each feeding other professional myths. These were observed in the study and are underpinned by a lack of understanding of the district nursing role that other nurses perpetuate (White, 2019). Such professional myths hold negative connotations of deskilling within the district nursing role, poor career progression, of it being a place to work in the run up to retirement and that a district nursing role is not true nursing (White, 2019; Reynolds, 2022). The term ‘deskilling’ was prevalent in the study, with participants highlighting negative opinions from ward nurses that focused on the subject of deskilling when moving into a district nursing role. A negative aspect when considering a district nursing role, was said by one participant to be:
‘Other people putting you off, and nurses from secondary care saying you will deskill if you go into the community.’
(Participant 5)
Personal attributes
Students stated that it was their personal preference to seek a job in the acute sector after qualifying. Multiple participants stated that students are used to the hospital and will go to where things are familiar and expressed if they are not given a variety of placement opportunities then they cannot feel confident to practice in other care environments. This has some correlation to professional identity, which reflects the attitudes, knowledge and skills shared with a professional group within an environment or place of work (Sabancıogullari and Dogan, 2015). Studies have described that the construction of professional identity and how nursing students perceive themselves professionally is important in their career trajectory and influenced by a myriad of factors (Mao et al, 2021, Zeng et al, 2022). If students identify with, and develop a professional identity influenced by secondary care, it is likely they will choose a role within that.
Lone working as a subtheme was prevalent within the narrative. Students felt there was an element of threat that came with delivering care in the community and were unaware of the support available to protect or keep them safe. It has been seen that workplace violence can influence nursing students' attitude toward the profession and employment, and nearly half of UK students surveyed had experienced workplace violence (Tee et al, 2016). Solo domiciliary visits expose district nurses to risks associated with lone working because they are usually working in isolation from other team members (Duncan, 2019). Students must be educated on the safety mechanisms and processes in place to support district nurses as lone workers; otherwise, the perceived element of additional risk may dissuade them from district nursing roles.
Concerns regarding lone working were not merely linked to violence but also decision-making in practice. Participants identified that on qualification they would need extra support to make decisions in care and had no idea of how they would be supported from a lone working perspective. Decision making, autonomy and confidence are factors that new graduate nurses working in remote or isolated circumstances will experience (Calleja et al, 2019). Ewertsson et al (2017) have acknowledged that nursing students do not routinely have the ability to transfer knowledge between clinical settings, and their development and identity is formed by personal experiences and authentic interactions between people and patients. This highlights the need for improved undergraduate understanding of district nursing roles and placement exposure to support development of qualities needed to practice independently.
To practice mobile working, district nurses require their own transport, which incurs further costs to the nurse. The subtheme of ‘practical elements’ included fuel costs, the cost of running a car and not having a driving licence. Participants were quoted as saying:
‘Can't afford lessons.’
(Participant 18)
‘I looked at the posts and one of the essential criteria is to be able to travel.’
(Participant 25)
In terms of practicality, this is a difficult problem to solve. Alternative modes to service delivery have been considered (NHS England, 2022b). Active travel such as walking and cycling, electric bikes and the infrastructures to support them, have been considered (NHS England, 2022b). Its goals are to increase access to electric vehicles and incentivise staff to use greener options. District nursing teams could have a diverse set of resources within the team to deliver care according to demographics, if community teams are carefully considered in its implementation. The introduction of electronic records and use of technology can enable accessibility to patients virtually and in real time. It can also reduce travelling time for district nurses and improve efficiency within community nursing practice, while positively influencing the patient experience (Turner, 2015). This information requires disseminating to students with links to the wider themes of role ambiguity, recruitment and employer engagement.
The costs of living as a student nurse and the burden of student debt is thought to correlate with a decreased satisfaction in nursing programmes and nursing careers (Meyer et al, 2021). This resulted in shortages in key healthcare professions such as nursing and also made financial hardship a key issue within these groups (Council of Deans, 2015). This may be a cause of apprehension and discouragement for nursing students, particularly due to the additional financial costs associated with being a district nurse that have surfaced. The QNI (2022) explored the impact of rising fuel costs on district nurses in the UK and found difficulties can arise when attempting to reimburse frontline staff for their losses without impacting taxes, and employment terms and conditions. Paradoxically, pay and rewards are identified as key areas for action for the health and care workforce (The King's Fund, 2019).
Educational opportunities
Nursing programme content and a potential bias towards the acute environment and secondary care pathways of service delivery were acknowledged by some students. Participants highlighted:
‘There is a perception that the be all and end all is the wards.’
(Participant 33)
‘I think there's a lot of focus on hospitals and wards, so they maybe need a little more focus on community nursing.’
(Participant 25)
However, the focus groups illustrated clear benefits for students once on a community placement, as participants cited that their experience was enhanced by other nurses such as assessors and supervisors. This cements the importance of role modelling within the community (Meeley, 2021), which is thought to be enhanced by the pace of care delivered and the close proximity of the practice mentor relationship.
Universities must seek to provide nursing students with the knowledge, skills and understanding of working in community care through curriculum structure and content to inspire a desire and confidence to seek employment in district nursing roles on graduation (Calma et al, 2019). Further to this, a hidden curriculum in nursing education may play a part. This incorporates a set of ethics and learned values which are integral to creating a professional identity and is thought to be an overlooked topic (Raso et al, 2019; Kelly, 2020).
Orgün et al (2019) has described a hidden curriculum as being part of a culture created by organisations such as HEI's, which can be transferred consciously or unconsciously. They identify that in nurse education the values, hierarchy, traditional classroom structures and political socialisation is influenced by students and instructors. Therefore, if HEIs are affiliated with teaching hospitals or educational staff are predominantly from secondary care backgrounds, this may adversely influence the agenda, which on this occasion could have had a negative impact on developing community nurse education.
Nurse educators may need to inquire more deeply into the learning process, in order to understand the connections between students and the inherent organisational structure and institutional culture that medicine and nursing align with (Hafferty, 1998).
The results of this study discovered less community placement availability than in secondary care, which is already known, and as such, resulted in reduced exposure to community practice. The study captured data from students across all years of study, meaning some students had had more community placement opportunities as a result of the year of undergraduate study they were in. It was apparent that the chance of a community placement had no pattern to its allocation. Morris (2017) identified that supportive practice placements for students must be structured and underpinned by a contemporary framework for education and professional development, to provide a clear career pathway in a compassionate and attractive environment (HEE, 2015).
Recruitment and employer engagement
Placement capacity was a theme and given that the study data demonstrated low numbers of community placements, the concerns by students centred on lack of opportunities during the programme. One student expressed that having more community placement experiences would:
‘Open their eyes to what it's like out there’
(Participant 1)
Employer engagement with students could support wider experiences with specialist services while on community placements. The clinical learning environment requires structure for students so that they can saturate all opportunities open to them. This is important because structured approaches such as mentoring models are known to have an impact on student motivation and decisions with regards to their future workplace (Arkan et al, 2018). Williamson et al (2020) acknowledged historic concerns with increasing placement capacity and difficulties for staff to facilitate practice learning for students. They highlight that increases in student numbers on placement can reduce the risk of adverse patient incidents. This is thought to be in part due to extra numbers of student nurses in the system, and student nurses who are still aspiring registrants learning, developing skills, peer reviewing and escalating possible patient safety issues (Williamson et al, 2020).
Student nurses also expressed a need for recruitment information from employers and communication regarding vacancies, application processes, and the content of preceptorship and support packages. Nurse preceptorship teams are common support mechanisms in practice for novice nurses (Sherrod et al, 2020), but the existence of this support must be communicated to students considering any employment on qualification to improve the allure of the profession.
Recommendations for future studies are that the discussions and invitations to participate must be part of a more concentrated, face-to-face recruitment drive. This would ensure the aims of the study and available times for focus groups were more widely disseminated. It would also provide the opportunity for potential participants to ask questions that they may not otherwise ask as part of an online forum.
Conclusion
The literature recognises that workforce gaps, the aging workforce and a growing population with complex care needs are placing increasing demands on district nursing services. This study explored barriers to district nurse employment from the perspective of undergraduate nurses by using a descriptive qualitative design. The themes generated referred to role ambiguity, personal preferences, educational opportunities and employer engagement, and provided insight into the recruitment barriers faced on qualification. Moving forward, it is clear that collaborative engagement is required between community healthcare and education providers to inform the district nursing role and incentivise district nursing as a career option. Educational and governmental strategies that support community career pathways are required to promote a balanced view of nursing roles and ensure career opportunities are provided to sustain the district nursing workforce.
Key points
- A clearer understanding of community nursing roles is required by pre-registration students to encourage them to consider a career in district nursing
- Equal placement opportunities (community and hospital placements) are essential to provide students with equal insight into working in the two settings and support development of knowledge and skills
- Nursing programmes must teach inclusively across all care environments.
CPD reflective questions
- Reflect on professional challenges you have overcome in response to negative perceptions of community nurses
- Appraise current educational and governmental strategies that support community career pathways
- What strategies can organisations implement to improve student engagement and recruitment?
- What would you ensure a student experienced and understood in your setting
- What would you say to address a student's concerns (e.g. cost, time, lone working) or counter myths related to a district nursing career.