This site is intended for health professionals only

Public health: the role of the district nurse

Recognition of the major determinants of health and their influence on individual lifestyles has been given greater significance in recent government policies with the aim of narrowing the health divide.(1,2) Community nurses have been recognised as having a role in promoting health. However, the government paper Making a Difference focused on the role of health visitors, school nurses and practice nurses in public health, with a less clearly defined role for district nurses.(3)
This is despite district nurses having close contact with local populations, particularly older people and those with chronic diseases. The knowledge and skills of district nurses, however, are not always recognised, as identified in the report The Invisible Workforce on the work of the district nurse.(4) This is despite the role of the district nurse continuing to change because of  the increasing dependency of patients being nursed in the community as a result of intermediate and secondary care being shifted into primary healthcare settings, an ageing population and an increased focus on managing people with long-term health problems, such as diabetes, heart diseases and cancer.
Policy drivers have also had an impact on the role, such as the introduction of the National Service Frameworks, the new GMS contract, the Expert Patient Programme and the creation of specialist roles, such as community matrons.(5-8) These changes are timely where district nurses need to rethink their role in terms of the NHS modernisation and their contribution to public health, particularly in the context of other primary healthcare team members.

Public health
Acheson defines public health as "the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society."(9) This definition identifies the collaborative nature of public health work, which is seen as a collective view in meeting the health needs of local populations. The Royal College of Nursing (RCN) and the Community Practitioners' and Health Visitors' Association (CPHVA) have identified the principles of public health.(10,11) The RCN identifies six key aspects to public health work that can be utilised in practice (see Box 1).

[[nip31_box1_74]]

The work of the district nurse, however, is mainly concerned with working at an individual level, where district nurses are involved in giving health education advice to those who already have a chronic illness. Although this approach has been criticised for its focus on individuals and families, with less concern for health in the wider community, it is an important aspect of public health work. Providing a service at home can help reduce service inequity and inequalities in health for those who are housebound and those whose health needs may be overlooked by other members of the primary healthcare team. However, a combination of approaches should be utilised (see Box 1) in order to maintain a positive conception of health. This approach is concerned with the health and social wellbeing of communities in its widest sense.(12)

Barriers to a public health role
District nurses may argue that their work is concerned with clinical priorities and that public health work is given a low priority when managing a busy caseload. Being attached to general practice could also act as a barrier to public health as general practice in the UK follows a medical model approach to healthcare.(13) However, the role of the practice nurse is evolving in response to the GMS contract and the National Service Frameworks in achieving targets that include a health promotion focus. There are also professional implications, as the third part of the nursing register recognises only specialist community public health nurses, of which district nurses are not included.(14) This division could suggest that district nurses need not be concerned with this aspect of their role. Indeed, the more complex roles that are required of a public health approach, such as lobbying and campaigning for healthier communities, have been seen as the traditional roles of health visitors. However, health visitors may also argue that this part of their role has been eroded because of managing busy caseloads and the need to achieve government targets.

Integrated working
Primary healthcare teams, however, provide an ideal skill mix in order to fulfil the aims of a public health approach. Practitioners are also familiar with the community in which they work and they are known by the local community. Added to this is their local knowledge of services and sectors that are involved in health and community care.
Practitioners working together in an integrated way can complement each other's roles and prevent gaps in service and duplication. Health visitors and school nurses are experienced in working with well populations and vulnerable groups, and they have knowledge and experience of community development work. In contrast, district nurses, practice nurses, community sick children's nurses and community mental health nurses are mainly concerned with chronic disease management and mental health problems. These roles can include working with groups as well as individuals and offering clinics to prevent and monitor health problems.
Bull recognises the need for and benefits of nurses working in an integrated way.(15) Zahner and Gredigs' views on public health nursing identify the importance of collaborative working, and integrated teamworking would seem to complement this approach.(16) Despite the benefits of working in this way, the Audit Commission's survey of district nurses found that not all primary healthcare teams had adopted this approach.(17) Indeed, there are problems in teamworking in primary healthcare, such as a lack of understanding of each other's roles and a lack of a shared philosophy. Therefore it will be important to invest time and commitment in building a successful team if the above approach to public health is to be a success.
The team will need to decide on a shared philosophy with shared objectives so that the aim of the team is clear with everyone working towards that aim. This may take many weeks or months to achieve, but it is important that practitioners agree as failure to do so can result in the team losing direction and in the long term becoming disenchanted.
District nurses can act as change agents as they are already accustomed to managing teams as part of this role. New ways of working, however, may result in resistance by some team members; therefore district nurses need to understand the principles of change management if they are to succeed.(18) Although a district nurse may instigate this way of working, a more suitable change agent may emerge from the team from another discipline, and this needs to be recognised, as self-interest must be forsaken in the interests of other team members and ultimately the public. It must be recognised that collaboration with statutory and nonstatutory sectors will be essential when specific programmes are being planned. Understanding how people live and manage their lives in different circumstances is also essential where consultation with the public is fundamental in providing needs-led programmes.

The way forward
Practitioners will face a number of challenges when developing roles that integrate public health and primary healthcare.(19) These will include:

  • Time and resources - protected time will be needed for possible training and skills for the role.
  • Developing and maintaining a local health profile.
  • Defining the health priorities for the local community.

Perhaps the most challenging issue, however, will be to develop a shared philosophy of primary healthcare and public health, as without a shared vision the venture is unlikely to succeed. Practitioners may therefore need to revisit the concepts and principles of a public health approach in informing their understanding of what can be a complex activity.

Conclusion
The government's response to reducing health inequalities has seen a resurgence in a public health approach to healthcare. District nurses have a pivotal role in primary healthcare and are in an ideal position to make a difference to the health of local populations. However, district nurses cannot undertake a public health role on their own. They will need to work collaboratively with other primary healthcare team members as well as statutory and nonstatutory sectors and the public themselves. Working as part of an integrated team can provide the experience, knowledge and skills to provide a public health approach to primary healthcare, and district nurses can act as change agents in managing this process by involving themselves in local policy groups rather than being driven by others.

References

  1. Department of Health. The new NHS. Modern, dependable.London: DH; 1997
  2. Welsh Office Department of Health. Better health - better Wales. Cardiff:
  3. The Stationery Office; 1999.Department of Health. Making a difference: strengthening the nursing, midwifery and health visiting contribution to health and health care. London: The Stationery Office; 1999.
  4. The Queen's Nursing Institute. District nursing - the invisible workforce. London: QNI; 2002. 
  5. Department of Health. National
  6. service framework for older people. London: DH; 2001.Department of Health. The new GMS contract. London: DH;2003.
  7. Department of Health. Creating a patient led NHS: delivering the NHS improvement plan. London: DH; 2005.
  8. Department of Health. Supporting people with long term conditions:liberating the talents of nurses who care for people with long term conditions.  London: DH; 2005
  9. Acheson D. Public health in England. London: HMSO; 1988.
  10. Royal College of Nursing. Public health: nursing rises to the challenge. London: RCN; 1994.
  11. CPHVA. Public health: the role of nurses and health visitors. London: CPHVA; 1997.
  12. Baggot R. Public health: policy and politics. London:Macmillan Press; 2000.
  13. Billings J. Profiling for health: the process and practice. London: CPHVA; 1996.
  14. Nursing and Midwifery Council. Standards of proficiency for specialist community public health nurses. London: NMC; 2004.
  15. Bull J. Integrated nursing: a review of the literature. Br J Commun Nurs 1998;3:124-9.
  16. Zahner SJ, Gredig QB. Improving public health nursing education:  recommendations of local public health nurses. Public Health Nurs 2005;22: 445-50.
  17. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.
  18. Spencer S. Unsworth J. Burke W, editors. Developing community nursing practice. Buckingham: Open University Press; 2001.
  19. Bradley S, McKelvey D. General practitioners with a specialist interest in public health: at last a way to deliver public health in primary care. J Epidemiol Commun Health 2005;59:920-3.