Achieving congruence in ‘being and doing’ community nursing
Conceptual and theoretical frameworks for person-centred community nursing practices have not yet been fully developed. There is a need to explore this further in order to guide future district nursing, which forms part of the community nursing discipline in the UK. The contemporary district nursing role is undergoing change, although there appears to be little consensus about the district nurse's (DN) vision across the UK, and little indication of the theoretical position underpinning this change. Meeting strategic requirements (National Health Service (NHS), 2019; Scottish Government (SG), 2017a&b), DNs have advancing clinical expertise and are recognised for their technical skills. However, one may contend that this emphasis on ‘doing’ in practice contributes to practice decisions made exclusively on task performance by strategic decision-makers, and DNs continually viewing themselves as invisible (National Assembly for Wales,, 2019; Queens Nursing Institute (QNI), 2006; Dickson 2018; 2020). District nursing education may contribute to this lack of clarity as curricula are based on borrowed theory from other disciplines that continue to focus on ‘how to do’, with little emphasis on ‘how to be’ a DN, and the continued decrease in DN numbers across the UK may be a consequence. In this paper, I explore current evidence that underpins district nursing practice, education and research in the UK, and advocate the use of the Person-centred Practice Framework (PCPF) (McCormack and McCance, 2017) as a means of unifying and guiding ‘being a person-centred DN.’ This will enable practitioners who can draw on multiple forms of evidence to inform their advancing practice. This article offers philosophical and pedagogical principles to underpin person-centred education going forward. I argue this will promote congruence between ‘doing’ and ‘being’ a DN, giving a voice to DNs, and direction to their specialism.
District nurses (DNs) have an important role in person-centred practice within the community due to their involvement in assessing and caring for people principally in domiciliary settings, helping people live with long-term conditions and frailty, preventing deterioration and promoting health and wellbeing (Dickson et al, 2017). In the UK, DNs lead teams of community nurses who work within larger integrated teams. Similar roles exist in other countries (e.g. Australia, the Netherlands and Sweden), but most of these countries do not require a post-registration qualification. Despite the number of UK universities offering the Specialist Practitioner Qualification (the UK professional qualification) increasing from 33 to 43 since 2012 (Queens Nursing Institute (QNI), 2021), in the past 10 years, the numbers of qualified DNs has decreased by 43% in England (NHS, 2018; Royal College of Nursing and QNI, 2019) (data is unavailable in the other three UK countries). Anecdotally, there are increasing numbers of DNs leaving the discipline for other community roles, for example, advanced practitioners. This appears to be as a result of such roles being awarded a higher pay grade. However, there may be other contributory factors. The author's doctoral work revealed that DNs felt a ‘burden’ of responsibility for managing caseloads, teams and associated tasks, resulting in compromise to their wellbeing (Dickson et al, 2018; 2020). Maybin et al (2016) conducted a study for the Kings Fund which concurs. Their study sought to explore ‘good care’ from the perspectives of sservice users and district nursing staff; they found pressures of work, lack of resources, control and weak leadership as ‘getting in the way of good care’. They further suggest that it is contributing to reducing numbers of DNs. Another contributing factor may be the little attention being paid towards retention of nursing staff, as stated in a report by Buchan et al (2019). This workforce crisis is set within the backdrop of 40 000 vacancies in nursing across the UK, and the COVID-19 pandemic amplifying the problem (House of Commons Public Accounts Committee, 2020). Maybin et al (2016) suggest this decrease in the workforce has resulted in many community nursing teams becoming ‘task focused’, resulting in a negative impact on staff wellbeing and care outcomes. The perceived lack of visibility in district nursing, which is another factor (Goodman 1996; QNI, 2019; Dickson et al, 2020a), may be due to the little attention being given to the role/work of specialist practitionersin the literature. Most of the literature refers to DNs in general ‘community nursing’ terms, equating this role to a range of other roles being undertaken in communities. In the literature, the tasks performed by nurses ‘doing community nursing’, are given more privilege than the uniqueness of ‘being’ a DN. Therefore, it is challenging for DNs to build a body of knowledge that articulates their specialism.
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