During the covid-19 pandemic, coverage has been largely silent on the issue of those working behind the closed doors of a patient’s home. For example, district nurses operating in a non-clinical environment have been working at heightened risk to themselves, navigating environments that do not have standard infection control management. Part of this risk has been a result of unclear guidance, as well as practical issues including a lack of PPE and the impossible task of social distancing in a patient’s home (Green, 2020). 

District nurses are typically responsible for health education; general nursing care, and on occasion responsive clinical care in the community (Maybin et al., 2016). Their ability to provide chronic care management contributes to palliative care provision and where possible, hospital avoidance. The uniqueness of their role comes from their ability to also navigate being a professional guest in a patient’s home, as well as boundary spanners integrating wider services and teams (Gilbert, 2016). District nurses’ perceptions of both their role and the way in which they uphold care delivery may differ from other professions in primary or community settings. Consequently, the invisibility of their work frequently creates confusion amongst other professions and the public (Maybin et al., 2016; NHS Long Term Plan, 2019). 

Government strategy has called for more nursing care to be delivered in the community and in people’s homes (NHS Long Term Plan, 2019). This drive is intended to reduce both hospital stays and unplanned admissions. To meet this aim, district nursing teams are being positioned as crucial to the delivery of the Long Term Plan objectives, and as such they are a specific focus for workforce expansion plans. However, future efforts to expand the district nursing workforce are likely to be compounded by the covid-19 pandemic. 

At present, a considerable number of vacancies for nurses within the community are filled by bank and agency workers (Interim NHS People Plan, 2019). According to a report from the Royal College of Nursing (RCN) and Queen’s Nursing Institute (QNI), figures indicate that the number of district nurses working in the NHS in England has slowly declined over the last ten years by almost 43%. The decline in workforce numbers has continued despite the government’s 2018 golden hello of £10,000 to newly qualified district nurses which coincided with the scrapping of nursing bursaries for prospective students. 

More recently and as part of efforts to raise the profile of district nursing, HEE has pledged to grow pre-registration clinical placement capacity, emphasise high-quality learning experiences within community settings and have set aside £18.5 million to support community nurses wishing to take the new specialist practitioner qualification. While the NHS interim people plan and the NHS long term plan both focus on addressing the nursing shortage, recruitment and retention strategies alone may not help to increase or create a sustainable future for district nurse services.

The future of district nursing may involve role transformation including greater emphasis on care coordination rather than delivery. Leading community teams and managing the integration of community and primary care may become a priority as their boundaries become blurred. Despite this there appears to exist an implementation gap from policy to practice, one which may not consider front-line capacity, experience or desire. Making these implementation pathways clearer, particularly in the post pandemic recovery phase, in terms of raising the profile and working conditions of district nursing may require addressing a number of difficult questions about the profession’s future. For example, who is best employing district nurses if they are to work across networks; how will differing perceptions of care be reconciled across services; what does the blurring of primary and community services mean for the accountability and responsibility district nurses are required to uphold? 

The future of district nursing looks set to become embedded among teams of GPs, pharmacists, community paramedics and other allied health professionals (NHS Long Term Plan, 2019). Sustainable workforce expansion may require exploration into multi-stakeholder perspectives including both frontline workers and those at a leadership and human resource management level. It may also require a necessary questioning of whether the expectations being place upon a profession dwindling in numbers, is setting them up for failure or success.  

Ruth Abrams is an organisational psychologist researching workforce experiences of organisation, workflow and service delivery within the healthcare sector within the Faculty of Health and Medical Sciences, University of Surrey. 

Kamal R. Mahtani is a practising NHS GP, Associate Professor and Co-Director of the Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences.

Veronika Williams is Director and Associate Professor, School of Nursing, Faculty of Education and Professional Studies, Nipissing University, Canada; Honorary Researcher, Nuffield Department of Primary Care Health Sciences and Associate Senior Tutor, Department of Continuing Education, University of Oxford.  

Competing interests: None declared. 

Disclaimer: The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.

 

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Competing interests: None declared