District Nursing and the changes during the sovereignty 1952 to 2022

Does everyone have the same perception of District Nursing nowadays? It is doubtful whether the public know the full extent of the work we do every day, but the opportunity to look back in time is seen on the BBC television programme Call The Midwife which has been helpful in revealing some of the difficult situations nurses met in the community ‘in the olden days’.

We have seen the prominent role of Her Majesty the Queen change over the past 70 years as well; however, most people are aware of how her work and role has changed and grown during the long years of her reign.

It is time to throw some light onto the significant changes for nurses in the community, by going back to the beginning. Nursing care and compassion is still as essential and meaningful as ever; the contemporary differences are the culture, creative insight and comprehensive skills of community nurses. Qualified District Nurses who have passed the specialist practitioner course lead and manage the teams that carry out much of this care today.

Origins

But first we will go back to the origins of District Nursing, to Liverpool in 1859…

The first person to work as a ‘District Nurse’ was Mary Robinson. Mary was a private nurse employed by the businessman William Rathbone to nurse his wife in their home during her final illness and after her death, Mary began delivering nursing care to the poor people in the city. Her patients lived in grim conditions and Mary encountered environmental and nursing challenges; it was difficult, but she grew to enjoy her nursing and felt she could make a difference.

William Rathbone was impressed with her work and he contacted Florence Nightingale for advice about setting up a nurse training school in Liverpool. One of Florence’s nurses, Miss Merryweather, was put in charge and the student nurses. They received training, board and lodging, and in exchange worked for the hospital giving nursing care. Before formal training nurses were often regarded as domestic workers but the new training changed attitudes and nurses became increasingly respected and valued.

Once the nurse’s training was completed, they had to gain experience in hospital for a year before being allowed to work as District Nurses. Their uniform included a frilly starched cap, starched apron pinned to the uniform dress, with button-down collar and button-down cuffs, a belt and buckle, finished off with a waterproof cape.

The training and consequent development of District Nursing garnered national appreciation and training schools opened in the main cities; the nursing philosophy included giving excellent care, promoting health, attending to the cleanliness of the environment they were nursing in, tending to their patient’s ailments and giving midwifery assistance when needed, if they had additional training.

When Queen Victoria celebrated her Jubilee in 1887, a major grant of £70,000 was given to create The Queen Victoria Jubilee Institute for Nurses, the forerunner of today’s QNI. Nursing in the community progressed considerably under this prestigious aegis. When Queen Victoria died in 1901 life was still hard, and even more so during the First World War, when Queen’s Nurses worked on the home front but also joined military hospitals and worked on the front lines.

The 20^th Century

The 20^th Century saw steady advances in communications and transport, all of which helped community nursing roles. Electric telegraph wires were laid and the telephone was invented, although only a few homes owned a phone until the 1920’s.

By the time Queen Elizabeth was born in 1926, the art deco style was popular and homes gradually became nicer places to work in. This was a lively time, known as the ‘Roaring 20’s’, when inhibitions were falling as people tried to forget about the war but nurses were still expected to keep up their diligent standards and not be seen frequenting public houses or dance halls!

During the 1930’s a noticeable shortage in nurses prompted the Lancet Commission to explore how to make nursing as a profession more appealing. The average working week at that time was 48 hours and the uniforms were still dresses with starchy accessories which took time to prepare. Washing was completed by hand or in an old-fashioned tub with a mangle attachment to squeeze the water out of the clothes, incomparable with the speedy automatics available today.

During the Second World War, the future Queen Elizabeth II learnt to drive trucks and do mechanics. Stories from the war describe how nurses cared for the shell shocked and evacuees and rehabilitated the wounded. In 1948 the National Health Service (NHS) was created and District Nurses were henceforward employed by local authorities. The late 1940s also saw the first male District Nurses.

Nurses’ residences remained open until the 1970’s and it is incredible to imagine that a monthly record was kept of nursing students’ weight, their exam results were sent to their parents, and generally it was not until the 1960’s that nurses could marry and live out of the nurses’ home.

In 1967 the Salmon Report advised a need for more development in nursing and improved management. There was continued pontification about that idea until 1972 when the Briggs Committee stated all nursing would in future be degree level and based on research, then in 1983 the Griffiths Report recommended that professional managers be employed to manage nursing services.

Nurse training became university-based from 1987; however the perception of nurses as ‘assistants to doctors’ has persisted. The autonomy of working alone in a community setting should have enhanced nurses’ status, yet it has taken years to recognise that District Nurses do more than simply support doctors, they use extended skills, including prescribing, and work as independent clinicians in their own right.

The 21^st Century

Pre-registration degree level nursing from 2009 enhanced the creative knowledge, skills and leadership taught in core training. Advanced decision-making responsibilities have grown, supported by the values and beliefs in education and commitment to excellent patient care. Nurses in the community today carry out procedures that can be considered high risk, but all are carried out with the utmost care and compassion.

The identification of community nurses varies as some wear ‘civvies’ instead of uniforms; and cosy fleeces have replaced the capes of the early Queen’s Nurses. There have also been significant and much needed cultural changes, sharing expertise and development in clinical supervision, enhanced collegial respect and the warm appreciation of each other’s background, most recently through the Black Lives Matter and Everyone Counts movements.

The QNI has consistently campaigned for greater capacity to meet the increased need for nursing at home, recognising how District Nurses with the Specialist Practice Qualification (DNSPQ) perform a vital role in leading and managing care. The QNI’s new Workforce Standards for District Nursing are designed to support excellent care for all those who need care in the home in coming years.

District Nurses have continued to deliver outstanding care through the Covid-19 pandemic, but there is an observable and disheartening need to be task focussed due to the severe shortage of nurses in many areas. A transformation will be needed. In the community, patients are being sent home from hospital with more complex problems, yet there are fewer nurses to look after them. Acute care, post-operative care, intensive and long-term care are all carried out by District Nurses and there is a renewed need for them to be appreciated, valued and supported so they can carry on giving expert care to their patients.

During her reign, Queen Elizabeth has not wavered in the standard of her singular duties. She is a figurehead and has adapted to changing technology; we have all marvelled at her resilience during the pandemic and her skills with Zoom meetings. As our Queen celebrates her Jubilee with a nostalgic eye, the QNI has continued to be a fantastic support for community nurses in the UK and beyond and is looking to the future.

Sarah Price, Queen’s Nurse, District Nurse, Practice Educator, Examiner

Photo courtesy of Pixabay

Further Reading

The District Nurse
The District Nurse: A Pictorial History