Community Nursing can trace its roots back to Florence Nightingale and philanthropist William Rathbone. In Liverpool in 1859, William’s wife was ill and he wanted her cared for at home. After she died, he asked the nurse who had cared for her, Mary Robinson, to provide the same care to others in the city’s poor. Florence Nightingale saw the impact of this and wanted more people to have access to this care. It was rolled out across Liverpool’s 18 nursing districts, giving rise to the term “district nursing”.
The Queen’s Nursing Institute is the oldest nursing charity in the world. It was founded in 1887 with a grant from Queen Victoria and has around 2,500 registered nurses who have worked in the community for more than five years. I spent time with four of the nurses and photographed their work around the country.
Meet the Queen’s Nurses
Angelina Blair, a nurse at Queen’s and a nurse at Rowcroft Hospice at Home in Torquay, Devon, says death has become increasingly taboo.
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Angelina Blair, a Queen’s Nurse and sister at Rowcroft Hospice at Home, visits Kathleen Cartwright in Paignton, Devon, April 2024
“We can’t prepare individuals, we can’t manage symptoms if we’re not open. People used to see dead bodies, families used to see dead bodies, Aunt Mable was the one who always handled the dead, Aunt Pam was the one who always handled the births. That’s what communities were like, but we don’t have that anymore, it’s all hidden and that’s where it changes again.”
Because community nursing takes place outside of traditional medical settings, it often goes unnoticed and unheard. However, the future of healthcare looks set to be a return to caring for people in their own homes. It is cost-effective and could free up hospital beds, plugging the funding gap within the NHS and helping to address the crisis in adult social care.
The NHS has started to introduce virtual wards and advances in technology have made it possible to care for people in their own homes who previously had to stay in hospital.
Kathleen Cartwright, 92, who is terminally ill, said: “I feel like it’s out of this world to be lying here. I’ve got the pain of family members dying without help and I’m just speechless with the care and attention I’m getting. I’d rather be with my family (than in a hospital). They just give me hope and so much love.”
Angelina became interested in working in palliative care after helping her mother die with dignity at home. She says: “There’s something really special about making a difference to someone and the memories that last for those left behind. My mother died at home, we cared for her at home, because that was her wish. I look back on the experience of a good death and how important that is for your memories, for your future, for your life. I wanted to do something to make sure I could do that (for other people).”
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Angelina Blair has been a nurse for 35 years. Hospice at Home has 14 beds in the community. It covers an area of 300 square miles, including rural, coastal and urban areas. All patients at Rowcroft’s Hospice at Home are expected to die within two weeks.
Kim Duckworth is a Queen’s Nurse and a senior community paediatric nurse within the North Devon palliative care team. Kim works with children with complex needs that are life-limiting or life-threatening.
“The type of ventilator I used when I first qualified was very old-fashioned and ran on mains power. It was like a car battery,” says Kim.
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Alisha-Kelly, 14, has muscular dystrophy and scoliosis. She has had a non-invasive ventilator for two years that she wears at night. Kim is fitting her with a new ventilator at home.
“Before these ventilators were available, a lot of these families needed caregivers. But now a lot of these families are more self-sufficient and can get care at home to help with their ventilator needs. This young person doesn’t have anyone and she’s on a ventilator at night and they’re managing that with the family.”
“We work closely with the children’s hospice and develop symptom management plans, especially towards the end of life. Having to do this with a pediatrician in a 10-20 minute clinic slot is quite difficult.”
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Kim Duckworth weighs Tabitha, age 8, who has cardiofaciocutaneous syndrome (CFC) and is attending a school in Barnstable.
Kim says that treating children like Fletcher at home can help them thrive. “He’s very happy and incredibly resilient and just amazing. So despite having this condition that affects him in so many ways, he’s a very happy, very calm little boy. He’s just thriving,” she says.
There is a national shortage of children’s community nurses in England, according to the Royal College of Nursing and the latest report from the charity Together for Short Lives.
Kirsty Balfour, a nurse at Queen’s and clinical manager of Modality Partnership, a homelessness services team in Hull, explained that a large part of her work involves advocating for the interests of her clients, who are experiencing homelessness and are often victims of discrimination within the care system.
“If we really want to help people and improve the health outcomes of our clients – which we all certainly want to do – we have to be non-judgmental and non-discriminatory. So we have to have those difficult conversations and understand where those judgments are coming from and then challenge that,” she says.
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Kirsty Balfour and Anna Darwick, the lead nurse at Pathway, with patient Vicky in her temporary accommodation in Hull.
Vicky, who broke her legs jumping out of a window after feeling suicidal, said: “It’s been four years (with Kirsty and Anna). I was homeless and Anna put me in a hostel and then a shared house. I’ve had to deal with domestic abuse and sexual abuse. It’s not just the jumping out of the window that I’ve had to deal with, it’s everything. Just the way you’re treated by the staff in hospital, it’s really awful. I don’t know what I would have done without Anna.”
“I think people are just busy with their own lives, they don’t want to know. You’re judged every step of the way. I remember a nurse took some of my bedding off me and I remember saying to her, ‘Do you have children?’ She said, ‘Yes.’ Well, I said to her, ‘I hope your children don’t end up like me.’ It was raining and she took the blanket off me because it was a hospital blanket.” Anna notes, “They left you on the street. That’s what they did, without a blanket.”
The average life expectancy of homeless people is 46 years for men and 42 years for women.
Anna Darwick, the lead nurse on the Pathway team, says staff are keen to pay their respects when a patient dies: “If they don’t have family, it (the funeral) is paid for by the council. In the past you had 15 minutes and you could do a quick reading and you could choose a song to play and you could get them a piece of clothing or something to wear. But that’s changed now. We (staff) go if we can and if we can’t, we mark it. We take some flowers.”
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Ken Hearson, a community nurse at Modality Partnership, speaks to patient Lee outside Westbourne House Hostel in Hull.
Community nursing succeeds in reaching people in places outside hospitals and homes.
Fawn Bess-Leith is a Queen’s Nurse and a specialist in perinatal and infant mental health in the London Borough of Newham. She co-founded Botanical Brothers, a horticultural project designed to promote the mental health of new fathers.
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Fawn Bess-Leith, a nurse and healthcare specialist at Queen’s, promotes the mental health of new fathers at Botanical Brothers.
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Fawn measures her patient’s blood pressure. She does this before and after gardening and it drops significantly afterward. “The benefits of gardening are that it helps improve sleep, lowers blood pressure and reduces the risk of obesity, reduces stress and anxiety, which makes you feel relaxed – that’s why you sleep better. You get fresh air. There are all these relaxation and emotional benefits behind touching the soil with your hands and feet.”
Fawn says: “The idea behind this project is that men in general – particularly men from black, Asian and minority ethnic backgrounds – don’t take mental health seriously because of the stigma. As community nurses, we come into the home and focus on the mother and the baby. Throughout my career, I’ve noticed that sometimes we forget about our men. So one of the things I’ve been thinking about is how can I get men to come together and learn about emotional wellbeing. Destigmatise the whole mental health thing and at the same time do something that will help.”
“It takes you away from the hustle and bustle and the toxic air. You hear the trees, you see the colours of the plants, it just relaxes you and it’s such a peaceful place. It doesn’t have to be one of the gardens in the Chelsea Flower Show, one of those top-notch gardens – you go where nature is and you just feel different.”