Aim: The aim of this study was to explore the role and work of district nursing teams. Background: There is an international drive to move care into communities. Despite over three decades of policy, literature, research, and expert opinion aiming to quantify the work of district nursing (DN) teams, there is recognition that it remains poorly defined and the most invisible profession in the National Health Service (NHS). There is limited understanding of the role, contribution and outcomes of care delivered by DN teams. This has been associated with systemic issues in resourcing, capacity, and equity in delivery of care to vulnerable patients in the community. Previous literature on accounts of DNs have been unable to articulate their role and work in sufficient depth. This study addresses this gap in knowledge by conducting a focused qualitative, ethnographic study exploring the work of DN teams providing detailed rich description of the role, contributing to knowledge on the roles and outcomes of DN teams work. Methods: A qualitative, longitudinal focused ethnographic study was conducted with participant observation as the primary method of data collection with two DN teams, including 16 participants, within a city location in Scotland. Data was collected from November 2021 until December 2022 with fieldnotes made during observation of the two DN teams analysed using reflexive thematic analysis to address the aim of the study. Findings: Three main themes were identified: 1) the Organisational context of the DN team and caseload. The DN caseload was poorly defined in terms of referral criteria and there was no maximum caseload size resulting in unremitting demands. This impacted on staff satisfaction with chronic recruitment and retention issues and resulted in the DN role being diluted with further skill-mixing based on availability of staff and not needs of the caseload. 2) The Work of the DN team. There are two main aspects to the work of the DN team: (a) direct patient care tasks that were explicitly seen and used to measure the DN service based on a task-input model; (b) non-direct patient care where the DN team tacitly assumed the role of case manager for patients. This case manager role was seen to be delivered by different staff grades without formal education. However, the effectiveness of delivering case management (CM) depended on the educational level of the team. When this tacit role was performed by DN trained personnel this supported delivery of safe, effective care which prevented hospital admissions. This role was not, however, measured as part of the work of the skill-mixed team, and it was not clear if this was an expected role of non-DN personnel. If this role was not adopted there would be unmet need within the community, but the CM role highlights discrepancies between role expectations and pay banding, where there is not always a DN or a requirement to have a DN to manage a caseload. 3) External factors impacting and influencing the role and work of DN teams. Working in the community was a unique environment with multiple external factors impacting on the role of the DN team navigating communities and lone working. The DN team being located within a general practitioner practice, facilitated the role in CM, with closer relationships to GP colleagues and primary care records for assessment and prescribing. There was frequently poor communication from secondary care to the DN team resulting in the team ‘picking up the pieces’ when discharges were poor. Due to unavailability and variations in standards of private care providers the DN team assumed responsibility for ensuring the safety of care. Political and global factors such as Covid-19, the cost-of-living crisis and Brexit all negatively impacted on the role and work of the DN team. Conclusion: Overall, the work of the DN team was measured as sequential processes of care tasks. The tasks delivered were complex due to the nature of working in the community. There was a tacit aspect to the DN role which involved non-direct patient care with skill-mixed team members adopting a CM role traditionally undertaken by a DN. The explicit work was seen to be delegable within skill-mixing but the tacit aspects of the role, while adopted by different staff grades, were shown to vary in delivery based on skillsets, educational level, and grading. Overall, the DN caseload was poorly defined in terms of its referral criteria and with no limits on caseload size, and fixed historical staff levels this resulted in unremitting demands and care needs of patients going unmet. Consequently, chronic issues with recruitment and retention further diluted skill-mixing in the DN service. There is a need for the criteria of the DN service and caseload to be clearly defined to then inform the skill mixing, education and pay banding of the DN team based on caseload need rather than the availability of human resources.
Bruce Harper-Ovstebo (Thu,) studied this question.