The role of the district nurse is constantly changing and a look back in recent history provides an insight into how fast those changes have occurred. District nursing has evolved from its origins that can be traced back to the mid 19th century. Before formal training and registration were developed for nurses working in the community, standards were variable (Baly et al 1987). During the early 19th century the old Poor Law committees often employed nurses to care for the sick in their own home. Even following the Poor Law amendment in 1834 and the advent of the workhouse this practice continued. During the mid 19th century some charities provided a more well-to-do class of women with some training in nursing to provide care. However, this arrangement was not successful as there was no systematic approach to training and care provision.

The work of William Rathbone in establishing the first nurse training school in Liverpool in the 19th century specifically to train nurses for the ‘districts’ of the city did much to promote recognition of the role and to improve the quality of care. This followed his personal experiences of employing a nurse to care for his terminally ill wife, within the home. His work and the support of senior nurses of the time, including Florence Nightingale, established the foundation of the service that can be seen today. The first trained nurses were educated at Liverpool Infirmary and they began working in the homes of Liverpool in 1863 (Baly et al 1987). In 1887 the Queen Victoria Jubilee Institute for Nurses was established and district nursing associations were offered the opportunity to affiliate to this organization providing they could meet the high standards required for the training of nurses. Out of this organization came a new breed of district nurses known as Queen’s Nurses. These nurses were often superintendents of services and some districts could not afford to employ them. By 1902 the Institute had established examinations and created a community nurse who dealt with a whole range of health and social needs.

In 1919 state registration as a nurse become mandatory and was a prerequisite to undertaking training as a district nurse with the Institute. The Queen’s Nursing Institute (QNI), as it became known, continued to be the training organization until 1968. Various changes continued to affect the training of district nurses until in 1981 new mandatory training was introduced before a nurse could use the title ‘district nurse’ (Baly et al 1987). Since that time the training of district nurses has moved into universities and in 1994 the introduction of the community specialist practitioner qualification meant academic recognition at degree level. This move was seen as a positive step and welcomed by the profession.

Traditionally the key role of the district nurse is as the expert in the care of the sick at home. This remains predominantly true. However, the remit has extended to incorporate health promotion and a focus on independence, supporting individuals to reach their personal optimum potential within their health status, and avoiding dependence on both nursing and other services where possible. This concept supports a clear ethic, to respect and maintain the dignity and the individuality of patients and manage care collaboratively in a holistic and proactive way.

Education and training in preparation for district nursing remains a topic for debate, highlighted at QNI conferences; views and opinions are wide and varied, with some feeling that there is not a need to train district nurses as specialists, while others feel strongly that specialist training is essential. One suggestion has been made that pre-registration nurses should be trained in the community, with hospital care being the specialist element, particularly with the move towards care closer to home (Butterworth 2007). In November 2007 the Nursing and Midwifery Council (NMC) and Department of Health commenced consultation on potential changes to pre- and post-registration education, including a shift to community nursing being a first post option for staff (Department of Health 2007a, NMC 2007).

The core elements of the district nursing role are to hold the continuing responsibility for the assessment and provision of care to a group of patients within a chosen locality. This involves planning, implementation and evaluation of the care provided, ensuring at all times that an evidence base underpins practice (Audit Commission 1999). District nurses also require management and leadership skills to promote effective teamwork within a multidisciplinary setting, across the boundaries of health and social care, facilitating the identification of complementary approaches to meet individual need.

The remit of the district nurse has changed significantly in recent years and will continue to evolve in response to changes in the provision of health and social care, such as shorter hospital stays, technological developments and increased life expectancy with its associated morbidity (Audit Commission 1999). The Commission also informs on how the district nursing services nationally undertake more than 36 million contacts each year and have approximately 2.75 million patients on their caseload, the majority of these patients being elderly people. A report by the QNI in 2006 reviewed the changes in district nursing over the last 5 years and presented a view on the changes required in next 5 years to enable the service to deliver high-quality care in the future (QNI 2006). The key messages included:

At national level:

At local level:

The reinstatement of Queen’s Nurses was a direct response to the loss of identity expressed by nurses in the meetings conducted to inform this report. In May 2007 the first group of new Queen’s Nurses were announced; these nurses came from a wide range of community nursing disciplines, including two from district nursing (QNI 2007).

Leadership has become a key focus since the launch of The NHS Plan in 2000. Recognizing the need for leadership skills, district nurses have found themselves alongside other nursing team and ward leaders on courses such as Leading Empowered Organizations (LEO) and the Royal College of Nursing Leadership Programme. However, it would appear that in many NHS trusts in England only senior nurses are attending these programmes. This may make the introduction of new skills difficult as colleagues and others may not have a shared understanding of the leadership concepts presented. However, a few NHS trusts have been innovative, bringing LEO programmes into the whole organization, and have employed a training facilitator to cascade the information. The focus of leadership is now on empowering nurses and ultimately patients to facilitate high-quality care in a partnership relationship. This is ideally undertaken utilizing a transformational leadership style (Davidhizar 1993), in which leaders seek to understand the problems and issues affecting both nurses and patients and then support them through changes and developing new ways of working. The concept of leadership has been enhanced further by other national initiatives including the Leadership at the Point of Care programme, aimed at nurses working directly with patients and focusing on relationship based accountability, enabling nurses to take appropriate responsibility for patient experience (NHS Leadership Centre 2004).

In 1999 a key document was published which continues to have a direct impact on district nurses: First assessment: a review of district nursing services in England and Wales (Audit Commission 1999). This provided an insight into the pressures on the district nursing service and highlighted that there is often a discrepancy between resources, skills and demand for service provision. The report made a series of recommendations for district nursing providers including the need to set clear service objectives, set referral criteria, establish systematic methods of caseload review, improve the management of patient demands and ensure the appropriate targeting of resources.

This report presented a challenge to district nurses, service managers and trusts to review ways in which district nursing services are organized, managed and delivered. The report also spelt out key messages about integrated working, self-managed teams and the way services are developed and provided. The Audit Commission (1999) also highlighted the following variations that exist in district nursing services across the country:

It looked critically at service provision, and following publication of the report, every district nursing service in England and Wales was evaluated against the report; how improvements in the services could be made for the benefit of patients was also investigated. One of the key issues identified was the need to ensure that the patients being cared for by the district nurse were the right patients. The scope of district nursing practice, if not clearly defined, can lead to inappropriate referrals, and ultimately inefficient and ineffective management of resources (Seccombe 1999). By developing locally agreed, clearly stated service definitions, referral criteria and documentation, district nurses can ensure that they are delivering appropriate and high-quality care.

Influences on practice for the district nurse come from a wide variety of sources including the Department of Health, Audit Commission, Queen’s Nursing Institute and most importantly the patients themselves. Liberating the talents. Helping primary care trusts and nurses to deliver the NHS Plan (Department of Health 2002) was driven by the Chief Nursing Officer’s 10 key roles for nurses and the new General Medical Services (GMS) contract and details how the roles of nurses and midwives are changing. It is aimed at discovering how the talents of nurses and midwives working in primary care settings can be used to best advantage in improving the health and healthcare of the population.

Whatever the title, employer or setting there are three core functions to be provided by nurses, midwives and health visitors:

These three core functions overlap and should form the basis for planning services across primary and community care utilizing the following framework:

One major impact for the future is the implementation of the NHS Care Records Service. This will connect more than 30 000 GPs and all acute, community and mental health NHS organizations in a single, secure national system and provide all 50 million NHS patients with an individual electronic NHS care record detailing key treatments and care within either the health service or social care. The NHS Care Records Service will ensure that the right information is available to the right people at the right time (Department of Health 2003). For nurses working in primary care, access to accurate and timely information is key to delivering patient-centred care. The introduction of this national system has not been without its challenges but once in place will provide a vital communication tool for district nurses and other healthcare professionals.

Safeguarding adults has become an issue that has affected and changed practice across many aspects of health and social care work. In 2000, the government published a national framework, ‘No Secrets’, so that local councils with social services responsibilities, local NHS bodies, local police forces and other partners could develop local multiagency codes of practice to help prevent and tackle abuse. Codes of practice were to be in place by October 2001 (Department of Health and Home Office 2000).