The Unique Knowing of District Nurses in Practice

Abstract

Several issues have impacted on district nursing practice and education within the UK, which can be conceptualised within four main areas: national policy; local organisational structures and practice; professional and disciplinary theory; and practice of individuals (Bergen and While 2005). However, there has been a lack of direction in district nursing in recent years within the UK, with a decline in the number of district nurses being educated (Queen’s Nursing Institute 2014a) and the educational standards supporting district nurse education being over 20 years out of date (Nursing and Midwifery Council 2001). In addition to this, the standards of education for pre-registration nursing (Nursing and Midwifery Council 2010) have supported a graduate workforce with an increasing focus on nursing in the community. This was identified as a consideration for me as an educator when examining the future educational requirements of nurses beyond the point of registration in the community, and became the focus of this study.

Knowing in practice is a key concept within this thesis, that is, the particular awareness that underpins the being and doing of a district nurse in practice (Chinn and Kramer 2008). This study explores the unique knowing of district nursing in practice, and how this professional knowing is developed. Understanding the knowing of district nurses and how this is developed will contribute to future educational frameworks and ways of supporting professional development within community nursing practice. A question that is often asked is what makes district nurse knowing different from nursing in inpatient settings, and this emerges in this thesis.

A qualitative study using an interpretative approach within a case study design was adopted using three Health Boards within Scotland as the cases. Within each Health Board area, interviews were undertaken with key informants and also, group interviews with district nurses were undertaken using photo elicitation as a focussing exercise. The data were analysed using framework analysis (Spencer et al. 2003). This approach illuminated a depth and breadth of knowing in district nurse practice and how this knowing is developed. The study findings depict the complexity of knowing in district nursing, acknowledging the advancing role of district nursing practice, where the context of care is an essential consideration. The unique knowing can be described as a landscape that the district nurse must travel: crossing a variety of socio-economic areas; entering the private space of individuals, and the public space of communities; as well as acknowledging professional practice; navigating the policy agenda while maintaining clinical person-centred care; and leading others across the terrain of interprofessional working. The unique knowing in practice that characterises the expertise of district nurses is a matrix of elements that incorporates different aspects of knowing that contribute to leadership, as suggested by Jackson et al. (2009). The participants in this study recognised that due to the complexity of the district nurse role, and its continuing advancements, that district nurse education needs to move to a Master's level preparation and it needs to continue to be supported by a suitably qualified practice teacher. Furthermore, the findings within this study demonstrate that the development of the unique knowing in district nurses does not happen in isolation and it is very complex. It consists of networks, conversations, engagement with policy, understanding of professional contexts, adhering to organisational boundaries, and interaction with complex and challenging situations. Theory and practice are mutually dependent on each other; change is inevitable and is unpredictable; and practices change by having experiences, therefore change is integral to practice. Consequently, it was concluded that the interdependent elements, which interact, develop the unique knowing of district nurses in practice. Finally this thesis makes recommendations and discusses future implications for policy, practice and research