Behind closed doors : access to district nursing exploring multiple perspectives

Skinner, Jo (2021) Behind closed doors : access to district nursing exploring multiple perspectives. (PhD thesis), Kingston University, .


The aim of this study was to explore factors that promote or hinder access to district nursing from different perspectives. It was an exploratory, sequential, mixed methods study, carried out in three phases to address the main research question, How do patients, carers, district nurses and health and social care professionals experience access to district nursing in London? Methods included focus groups with patients and district nurses, semi-structured interviews with carers, surveys of district nurses and health and social care professionals and appraisal of service information on provider websites. Levesque et al’s (2013) model of access informed data analysis to consider opportunities for access and accessibility, as well as supply and demand aspects of access. Thematic, descriptive statistical and content analyses were used for the respective findings, revealing hidden worlds in the ways access was experienced. Issues of equity, transparency and power were highlighted as the service is brought to patients at home. The findings suggest: i) the district nurse’s role was not well understood and the service was invisible ii) service information on websites was often absent, limited and variable, and oriented to professionals making referrals, with a lack of information targeted at patients and carers iii) district nurses exerted control of access through overt and covert means, for example, determining who met the housebound criterion iv) self-referral was not widely known or practised and v) patients and carers experienced access as a series of disruptions over which they had little control, and where district nurses appeared to be overwhelmed by demand and workforce shortages. Decisions about access appeared to be influenced by contextual and resource factors, particularly capacity and commissioning. In conclusion, continuity of holistic care emerged as important for accessing district nursing fully, and patients and carers described transformational experiences when access to the service worked well. The study’s findings have informed a model of access indicating access as a continuum, that is not based on utilisation alone, and is a better fit with the unique context and characteristics of district nursing. The study does not claim generalisability but draws on participants’ experiences from a range of perspectives to present new insights to reveal enablers and barriers to access, thereby contributing to knowledge that can inform future research, theory development, access policy and district nursing practice.

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