| Summary: | District nurses are the largest group of community nurses in the United Kingdom and an important aspect of their role is the responsibility to assess the health needs of patients at home. To date there has been limited exploration of the knowledge or decision-making underpinning needs assessment in district nursing practice. The aim of this study was to explore knowledge in use by district nurses at the first assessment visit and the relationship of this knowledge to the decisions they make. The inherent difficulties in exploring the knowledge and decision making of experienced district nurses demanded a systematic and interpretative research approach where the impact of the context could be examined. An ethnographic approach was adopted for the study as the focus on perspectives and activities in the natural setting and the substantial reliance on observation of real examples provided a starting point for this study. Eleven district nurses were accompanied on a first assessment visit. Each district nurse was interviewed twice, immediately following the observed visit and then approximately one year later when preliminary data analysis had been undertaken. This approach to the study revealed a breadth and depth of community nursing knowledge that seemed to incorporate an amalgam of theoretical (knowing that) knowledge with practice based (knowing how) knowledge. The study findings depict the range and scope of the knowledge in use by district nurses and challenge the utility of theoretical models which remove knowledge from the context in which it is used and applied. The most striking findings relate to the influence of the context in which the DN/patient interaction takes place and the reflexive character of the assessment process. In particular, the study illuminates the ways in which DNs utilise a range of cues throughout the assessment process. The information search in assessment is often 'paced' to cope with the uncertainty that exists in many of the complex, multifaceted situations encountered by the DN. Understanding assessment as a paced process was linked to making the best judgement at the time of the first visit. A model of district nurse assessment, which seeks to illuminate the process of assessment, is presented. In particular, this model seeks to highlight the reflexive nature of the assessment process. A typology of district nursing knowledge, which conceptualises six dimensions of practice based knowing in district nursing practice, is also presented. Strategies for decision making are revealed through the application of Carroll and Johnson's (1990) theoretical framework. Recommendations are given for future research and the educational and professional context in which DN practice exists. It is suggested that further research should take cognisance of the ongoing nature of assessment in the community setting. A study conducted over a longer period of time, exploring further the impact of the context on the assessment process, seems particularly important. Given the paced approach to needs assessment and the ongoing nature of assessment identified by the study participants, it is suggested that the qualified DN should be contributing to needs assessment on a continuing basis. This recommendation is counter to recent trends in the skill/grade mix in the DN team which emphasise the need to reduce rather than increase the numbers of qualified DNs. Additionally, given the emphasis on family care by the DNs in this study, it is recommended that DNs should record and examine this important area of their work, so that this aspect of the DN role is identified and acknowledged. Finally, the importance of experiential learning depicted by the participants in this study suggests that work-based and problem-based learning approaches may be the most appropriate way in which to teach DN students about assessment. The findings are therefore important for the education of current and future DNs. This study contributes to the knowledge of assessment practice by increasing understanding of the ways DNs work in relation to the first assessment visit. The model of assessment illuminates the process of assessment and the typology aims to provide a conceptualisation of knowledge in use. Furthermore, the ways in which DNs make decisions is revealed. Therefore, the study findings can inform the education of present and future DNs to the potential benefit of patients and their carers.
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