The pandemic emphasised the essential role of nurses within the NHS and global health systems. It highlighted their physical, and their emotional labour (Delgado et al, 2017), and the emotion management undertaken by the UK healthcare professionals (Dowrick et al, 2021). The recent nurses' strikes have propelled their role back into the UK media spotlight. As such, this will influence the public image of nurses and nursing, and whether an individual will consider a future career as a Registered Nurse. Hughes (2023) set out a gloomy view of the current state of the NHS and, in particular, of district nursing, and how cost improvement programmes have reduced the attraction of community nursing roles, not only due to the grades and low pay on offer, but also because of workload pressures.
Remarkably there have been a large number of studies on the job satisfaction of hospital nurses, as evidenced by systematic literature reviews (Lu et al, 2012; Lu et al, 2019). However, there have been very few studies on the job satisfaction of nurses working outside hospitals. While being a hospital nurse is a different role from that of a community nurse, the job satisfaction research is informative regarding influencial factors, such as personal attributes, work characteristics and leadership, as well as job performance, intention to quit and burnout.
An early study (Traynor and Wade, 1993) tested a measure of job satisfaction to assess the morale of community nurses (of whom 30% were district nurses). The measure had six components, namely: personal satisfaction, satisfaction with workload, satisfaction with professional support, satisfaction with training, satisfaction with pay and prospects, and overall job satisfaction. The district nurses were generally satisfied, although there was apprehension about organisational change (change related to GP contract and the emerging Trust status) at that time.
Caers et al's (2008) literature review of community nurses' job satisfaction included 21 papers (1972-2006), of which, the majority reported US based studies (only 2 were UK studies). The studies employed a range of job satisfaction measures and the roles of community nurses varied across the included studies. The range of community nurse roles and the variety of job satisfaction measures resulted in ambiguous findings regarding job satisfaction. Therefore, they recommended the Home Healthcare Nurses' Job Satisfaction Scale to measure community nurses' job satisfaction, as it combined strong psychometric properties and specificity for community nursing.
Halcomb et al's (2018) more recent literature review was undertaken in the context that there has been significant growth in the primary healthcare nursing workforce globally, but limited evaluation of important workforce issues such as job satisfaction and career intentions of community nurses. The 20 included papers had been published between 2000-2016 with four papers reporting studies conducted in the UK. The samples spanned the range of roles across community nursing (excluded residential care and mental health nursing) and included primary health nurses, general practice nurses, school nurses, community nurses and district nurses. Again, the range of community nurse roles and the variety of job satisfaction measures resulted in ambiguous findings across studies, with similar factors influencing job satisfaction and negatively impacting it, as reported in the studies of hospital nurses. Thus, there was consensus across the studies that respect, recognition, a professional role, autonomy and workplace relationships had a positive impact on job satisfaction, while the perception of poor remuneration had a negative impact. Worryingly, a significant number of community nurses in these studies reported their intention to quit their roles.
‘Since the COVID-19 pandemic it is clear that more UK nurses are feeling demoralised and incidences of missed care have increased, which has impacted upon levels of dissatisfaction and nurse retention.’
A secondary analysis of an online survey conducted in May 2017 of 1742 nurses working in acute adult care across the UK, revealed that nearly two thirds (60%) reported that they were demoralised, with similar levels (59.6%) reporting that their clinical area was understaffed (Senek et al, 2020). There were strong associations between reporting having to leave necessary care undone (missed care) and being demoralised, and reporting being demoralised and reporting a lack of support. Qualitative data from 398 nurses revealed four main themes relating to job satisfaction, namely: staffing issues (lack of adequate staff), lack of support (failures of leadership and organisational support), risk (to self/others including patients), and personal impact (well-being and job satisfaction). Since the COVID-19 pandemic it is clear that more UK nurses are feeling demoralised and incidences of missed care have increased, which has impacted upon levels of dissatisfaction and nurse retention.
The imperative for the NHS is to increase the recruitment and retention of nurses, and particularly in community nursing, so that hospital admissions can be avoided and people can be cared for at home, which for most, is their preferred care setting. The first ‘taste’ of community nursing as a potential career option is a clinical placement and, with most healthcare contacts occurring outside hospitals, it is important that student nurses are exposed to the potential opportunities of a career in community nursing and have positive learning experiences in their placements. The Queen's Nursing Institute (QNI) (2021) has reported an online survey of 1056 pre-registration students, 42% (n=442) of whom were in their first year and 68% (n=716) were studying to be adult nurses. Nearly a quarter (24%) of the placements at the time of the survey completion, had been a district nursing placement. The student nurse respondents suggested various options to enhance placement learning, namely: face-to-face or virtual multi-disciplinary team or clinical commission group (CCG) meetings; information on how to improve access to care and inclusivity; discussion of ‘never’ events in the community; lived experience interviews with community nurses working in different settings; lived experience interviews or testimonials to understand the patient's and family's perspective; peer support from other learners; and health creation/social prescribing.
Even if a newly qualified nurse chooses to enter the community nursing workforce for their first nurse role, there is no certainty they will remain in the workforce. An early English longitudinal study (Murrells et al, 2008) using a national sample (at qualification (n=3009; 80%), 6 months (n=2524; 64%), 18 months (n=2118; 53%), 3 years (n=1785; 45%)) examined job satisfaction trends during the first 3 years of a nursing career and found that it varied by specialism, context and setting. At that time, the newly qualified nurses were least satisfied with pay. This study noted that job satisfaction is not a unitary construct but comprises of components that interact with job characteristics, and understanding these interactions is important to inform policy development and managerial support. Longitudinal studies, especially those which run over 3 years, are expensive. Therefore, it is no surprise that another longitudinal study of newly qualified nurses in the UK has not been funded.
All newly qualified nurses now have a preceptorship to provide structured support during their first year of practice as recommended by the Nursing and Midwifery Council (2022). NHS England (2022) has published national standards and a framework for good practice, which is supported by NHS Employers (2022), who acknowledge the benefits for both the preceptee and the employer. Tucker et al's (2019) evaluation of a preceptorship programme for district nurses revealed the importance of the early career support, guidance, reassurance and permission to seek support while a professional identity is established to deliver on the increasingly complex role of being a district nurse. The preceptees valued a named preceptor with whom they could have a trusting relationship as they developed professionally.
However, a preceptorship on its own may not be enough to retain the district nursing workforce in light of increasing workload pressure (King's Fund, 2020), resulting in high levels of reported stress and burnout. The King's Fund set out an Autonomy, Belonging, Contributing (ABC) framework of nurses' core work needs and urged employers to develop strategies to ensure that nurses' needs for autonomy, belonging and contribution at work can be met so that they can deliver high quality care to their patients and the communities in which they work (King's Fund, 2020). Miles (2023) has suggested the introduction of Professional Nurse Advocates (PNAs) to reduce stress, burnout and absenteeism in district nursing, echoing their successful introduction to midwifery (although, this had its challenges).
The recent pay negotiations may go some way to improving that component of job satisfaction but much remains to be done to address the other components, such as work characteristics and perceptions of organisational support for those working in district nursing services. It would be short-sighted if managers do not nurture the existing district nursing workforce.