Rural influences on the social network dynamics of district nursing services: A qualitative meta‐synthesis

Abstract Background and Aims As demands on healthcare services grow, fiscal restrictions place increased emphasis on services outside of traditional healthcare settings. Previous research into long‐term‐conditions suggests that social network members (including weaker ties such as acquaintances, community groups, and healthcare professionals) play a key role in illness management. There is limited knowledge about the engagement of social networks in supporting people who are receiving medical interventions at home. This qualitative metasynthesis explores the work and the interactions between district nurses (DN) and informal network members supporting people who are receiving medical interventions at home and living in rural areas. Methods A search was undertaken on CINAHL, Medline, and PsychINFO for qualitative research articles from 2009 to 2019. Studies that examined DN in rural locations and/or social network support in rural locations were eligible. Fourteen articles were selected. Results Thematic analysis of results and discussion data from the studies resulted in four themes being developed: the development of both transactional and friend‐like nurse‐patient ties in rural localities, engagement of the wider network in the delivery of good care, blurring of professional boundaries in close community relationships, and issues accessing and navigating formal and informal support in the context of diminishing resources in rural areas. These findings suggest that DNs in rural localities work beyond professional specialties and experience to provide emotional support, help with daily tasks, and build links to communities. There was also evidence that nurses embedded within rural localities developed friend‐like relationships with patients, and negotiated with existing support networks and communities to find support for the patient. Conclusions Findings indicated that developing strong links with patients and members of their networks does not automatically translate into positive outcomes for patients, and can be unsustainable, burdensome, and disruptive. DNs developing weak ties with patients and building awareness of the structure of individual networks and local sources of support offers avenues for sustainable and tailored community‐based nursing support.

networks and local sources of support offers avenues for sustainable and tailored community-based nursing support.

K E Y W O R D S
community nurse, district nurse, nursing, rural, rurality, social networks, social support 1 | INTRODUCTION Aging populations, driven by falling infant death rates, longer life expectancies, and increased availability of medical and pharmaceutical interventions 1coupled with uncertain financial climates, rising populations, and increased co-morbidities has led to escalating costs, a high demand on hospital beds, 2 and profound changes in how healthcare is delivered. 1 Rising healthcare need and a slowdown in funding have led to National Health Service (NHS) debt rising to £13.4 billion in 2020. 3 As a way of addressing this gap in funding, more patients are being treated in community settings for increasingly complex conditions to reduce the costs associated with inpatient admission. 4,5 Understanding the consequences of this shift in healthcare delivery style is set to increase in pertinence as wider policy moves health and social care closer to home and community settings. 6 For example, the implementation of the "Long Term Plan" in the NHS in the UK (2019) emphasizes community healthcare by stating an annual primary care budget increase of £4.5 bn. These policies aim to increase service capacity and establish new provisions (such as "hospital at home" [HAH]) services, online consultation services, increased general practitioner (GP) training, and "same day emergency care" units) that overcome barriers currently preventing some health conditions being treated at home by, for example, guaranteeing online tele-health consultations, and direct referrals to community services that means unnecessary visits to hospital can be avoided. 2

| Social networks and self-management
The role of social networks in supporting self-management has most extensively been researched in the context of long-term condition management. 7,8 This research has focused on how the structure of people's networks and the types and range of relationships shape the way in which people access different types of support with their health, practical, and emotional needs. 9 Such studies have found that people who have access to diverse types of relationships, including both "strong," intimate ties (eg, family members, close friends) and "weak," more distant ties (eg, healthcare professionals [HCPs], acquaintances, and community group members) are most successful in managing their long term conditions (LTC) and receiving acceptable health, emotional, and practical support. [10][11][12] This might be in part due to such networks being able to share the burden of illness work, sustain valued relationships, and have better access to relevant knowledge, skills, and experience. 13 Consequently, access to social network support that is acceptable to people may facilitate improved use of medications, healthier lifestyles (eg, smoking cessation or healthy eating practices), 14,15 improved experiences of poor health (eg, by managing adjustment; sharing the burden of health, emotional and practical work; and advocating/liaising with HCPs), 16 and improved physical and mental wellbeing. 10 The increased focus on the community provision of healthcare is likely to result in a widening of the types of conditions and issues that require patients to self-manage. Beyond LTCs, this is likely to include potentially complex and acute conditions, both of which will require further research into the specific roles of social networks in these different contexts.

| The healthcare professional's role in selfmanagement support
Previous research has suggested that in a community context, HCPs may facilitate self-management by offering not only health work, but emotional and practical work too. 9,13 However, the quality and acceptability of such support are often studied in isolation without considering how HCPs interact with the wider network members and the support they provide. Although there is a range of HCPs that are involved in providing good care for patients at home, it is most frequently the district nurse caring and treating that person. 17 Therefore, exploring the relationship dynamics between patients and district nurses may be beneficial when taking a social network approach to exploring healthcare at home. This may include how patients engage with network support when interacting with district nurses; the role of different ties and how network engagement might be in tension or complement district nursing support; how such processes and relationships co-shape the provision of community services; and how dynamics might differ from what is already known about LTC selfmanagement support when self-managing increasingly complex health conditions at home. Furthermore, primary services like district nursing and other community nursing services such as HAH are more likely to occur in rural contexts where adapting to financial challenges has resulted in the scaling back of smaller, more remote hospitals 18 ; and as such, these localities must also be considered when exploring the role of district nurses in patient social networks. The definition of "rural" varies globally with, for example, the UK describing it as areas that fall outside of settlements with more than 10,000 residents 19 ; and in Australia, as all areas outside of major cities. 20 Similarly, there is no standard definition of "rural" within healthcare 21 but there is a consensus that the pressures and complexities of district nursing are exacerbated by rurality. This is in part because HCPs need to become generalists, healthcare services appear underfunded, operating in a context of poor infrastructure and services provided over long distances. 22,23 Furthermore, the lack of peer support paired with the diverse patient group that district nurses treat can cause stress and poor staff retention among the workforce, 23,24 all of which could impact on district nurses' ability to provide self-management support in rural areas. There is some evidence to suggest that district nurses often live within, or near, the communities they serve, 4 which may offer an opportunity for drawing on existing relationships, shared values, and local embeddedness to provide a motivation to overcome rural challenges. Whether this affects the way social network support is provided or whether it is qualitatively different from other urban settings, requires further exploration.
These factors contribute to the growing demands and complexity of healthcare and self-management support in rural areas and the growing pressures on healthcare professionals, individuals, and other members of their personal communities. The pressure on community-based services, in particular, is likely to increase because of the overwhelming demands on inpatient care, and current strategies and policies outlined in the NHS Long Term Plan, 2 which encourage community-based public health interventions for increasingly complex and acute needs. These require patients and their social network to take greater responsibility for the management of their health conditions, which previous research has shown is a challenging prospect for patients when confounded by reduced function caused by poor health. 11 This qualitative metasynthesis will explore the role that district nurses can play within the wider networks of people who are currently receiving professional medical care at home, for a diverse range of conditions, while living in rural areas. It will aim to identify the formal and informal processes that shape the involvement of HCPs with the self-management support of patients and the engagement with members of their social networks.

| AIMS
The review will synthesize the available evidence on the use of district nursing services to explore: 1. The way in which district nurses develop relationships with service users to mobilize and/or become part of their personal network and what impact this has on the ability to deliver good care.
2. How rurality affects professional-patient interactions, social network dynamics, and the ability to fulfill social, emotional, and practical needs.

| METHODS
Metasynthesis offers a rigorous and systematic approach to reviewing and analyzing the literature that allows the development of novel interpretations while ensuring that the findings are reliable and transferable. 25

| Search strategy
The literature search was undertaken by JG in CINAHL, Medline, and PsychINFO using terms related to social networks, rurality, and community nursing, as guided by an abbreviated version of the PICO (Population, Intervention, Context/Comparison, Outcome) framework (see Table 1 for search terms). The search was completed on July 25, 2019, using the article title and abstracts only. Initial scoping searches identified limited articles that contained all three themes (ie, social networks, rurality, and community nursing), therefore, the decision was made to undertake two separate searches: the first combining "social networks" and "district nursing," and the second searching for articles related to "rurality" and "district nursing." A systematic hand search was conducted on the reference lists of existing literature reviews within the search results to find any other relevant articles that may have been missed by the search strategy or poorly indexed. 26

| Article selection
To be eligible for inclusion, studies had to originate from the United Kingdom (UK), Europe, United States of America (USA), Canada, Australia, and New Zealand and be published from 1st January 2009 to 1st May 2019. This was to ensure cultural consistency between the data and to ensure the synthesis was relevant to current practice.
Only qualitative or mixed method studies that were written in English were included (see Table 2). Articles reporting mixed methods were included 27 (n = 1) but only the qualitative data (quotations from district nurses' reflective accounts through semi-structured interviews; and the interpretations made by the original authors) was extracted when reading the full texts. Social networks were defined as personal communities of individuals that provide emotional, practical, or health support, therefore, any articles relating to online networks (such as social media, often referred to as "social networks") or telehealth T A B L E 1 Search strategy showing the synonyms and Boolean phrases used to find all relevant articles for screening S1 AB "Social Participation" OR AB "Social Inclusion" OR AB "social exclusion" OR AB "social Isolation" OR AB "Social relationship" OR AB "Social support theory" OR AB "Social support network" OR AB "Social support" OR AB "Social network" 129,777 S2 AB " District nurs * " OR AB " community nurs * " OR AB "Hospital at home" OR AB "hospital in the home" 7,132 S3 S1 AND S2 125 S4 AB "Rural health" OR AB "rural healthcare" OR AB "Rural * " OR AB "Rural nursing"  Table 3 for acknowledged limitations related to quality criteria of each study). Five articles focused primarily on the community healthcare professional's role, five on rurality's impact on healthcare, and three articles addressed both themes (see Table 3 for an overview of included studies).

| Data extraction and translation
Two data types were extracted from the articles and organized in a easily managed (Table 3). Of the two types of data, in the first order, data included direct quotes from participants and verbatim extracts from the results chapters of each paper. Second-order constructs (the theories developed by the researchers of the original studies) were extracted from the discussions and analyses chapters of the original articles. As is best practice when conducting a metasynthesis, in order to assess reliability, 30% of articles from each search were data extracted by members of the study team; IV and RB. 25 The findings were discussed and consensus reached on the data that should be included, and any areas of contention throughout data extraction were discussed between the research team. From the 14 included papers, 220 first-order quotations relevant to personal relationships, support, and relationships provided by district nurses or rural factors were included to answer the aims of this literature review. A further 83 second-order constructs by the original authors were extracted.
Translation and reconfiguration of the data is arguably the most subjective stage of the synthesis process, 25 and therefore, as with the other stages of this metasynthesis, findings and interpretations were discussed, revised, and elaborated within the study team. 42 In this synthesis, in order to translate the findings into one another and develop new meaning and understanding from the included themes, a line of argument synthesis was applied. This approach allowed data from primary studies that had different contexts, and theoretical and methodological approaches to be combined. 43 In doing so, new theories about the phenomena, the third-order constructs, were developed. 25,43 This was an iterative process of repeated reading that identified recurring and juxtaposing results that could be translated into one another and identify the novel themes. 26 32,34 This support may include practical tasks such as stoking the fire, "Training the dog," 27 organizing or providing transport, 32 organizing financial support in the form of "getting benefits," 32,35 and providing emotional support by spending time talking and discussing personal concerns. 35,36 The rationale for undertaking practical roles might be in order to reduce negative events such as falls when less able patients attempt to do practical work independently; or even prevent self-neglect if patients cannot cook and wash clothing. 21,38 The emotional work undertaken by nurses during health visits may be used as a "lever" for further assessment, 35 which not only reduces negative effects associated with loneliness, isolation, and poor mental health, but also acts as a technique for identifying health needs. 35,36 For example, district nurses would "just, you know, chat about things in general…like a social visit…and sometimes by just doing that, little problems will come out". 35 When district nurses live and work in the same rural locality, there are often pre-existing relationships with the patient and/or T A B L E 4 Summary of synthesis process using second and third order processes The DN acts as a conduit to other services adding more "weak," "transient" relationships into the SN. This usually results in a network dominated by HCPs that is unlikely to provide long-term support and will be biomedically framed. This will likely lead to a lack of support with practical and emotional work; especially considering the mental health with long term condition cohort of this study.

Devik et al, 31 Norway
Values of patients on rural healthcare and how it affects the quality of care.
Patients have to adapt to the change in lifestyle when requiring DN input in rural areas due to the interventions being delayed, interrupting schedules and routines, and being not readily available. Despite this being exacerbated by rurality patients prefer to remain here due to being a "brick" in history and place giving them increased social capital and a sense of self, security and control.
The social capital retained by aging in place means patients can retain their existing ties to help meet health, emotional and practical work. DNs are less likely to become part of the patients SN due to their visits being infrequently, on a healthcare schedule, and therefore, difficult to mobilize by the patient. Patients prefer to navigate the community to find support but targeted those with knowledge of healthcare (e.g. retired nurses).

Farmer and Kilpatrick, 32 Scotland and Tasmania
HCPs outside of their healthcare role creating opportunities for patients to increase their function and social capital. In rural areas.
The DN role in a rural community is both bonding and bridging with others. Nurses have been known to be embedded in the social fabric of the community and their remit extends to lift-giving, delivery and involvement in community facilities. They use their social capital in communities to implement change and establish entrepreneurial services (often outside of healthcare, such as establishing social clubs).
DNs use their position within the network to identify patient, SN and community needs. Especially true in rural areas where resources are limited, DNs go beyond their role and take it upon themselves to meet the needs. They also bridge and bond to other services (often out of reach to the rural patient) as a form of mobilizing others into the SN and improve the patient's social capital. Although not explicit in the data the improvement in social support and capital is likely to improve health; the DNs overarching goal.

Findlay et al, 33 Scotland
Importance of a connection with family and friends when being treated at home.
Frustration and sadness at the lack of support were frequently cited, with contentment noted when friends and family were accessible. The timing of DN visits seem to restrict the ability to maintain existing relationships.
Some participants enjoyed the social aspects of the DN visits but due to timing most found them to be restricting and display ambivalence toward the service and the loneliness it brings. Ideally, individualizing services should reduce loneliness and improve associated mental and physiological health (e.g. frailty). . There is also a risk of emotional burden for the DN as they are likely to be unsupported in the rural setting.

Gossett
11. Reed et al, 27 Australia How local knowledge influences the way DNs care in rural areas.
DNs consider the values of patient and family to personalize care. Knowing the available resources in the rural area helps gather support for the patient. DNs have strong community relationships that empower them to advocate successfully. DNs possess the emotional intelligence to manage a personal and professional relationship and can justify it because of the likelihood of improved outcomes.
DNs face a challenge to meet patient's needs by nurturing a strong SN tie that could overburden them emotionally at EoL. If this is achieved they can successfully mobilize other members of the community and healthcare services. The challenges of burden, confidentiality and emotional distress are overcome by the DNs emotional intelligence.
12. Roden et al, 39 Australia DNs use their social capital for health promotion (HP). The pressures on rural DNs make this hard to sustain.
There is a lack of support and competing priorities for a rural DN. However, DNs had a more positive and committed outlook on HP, possibly because they knew and felt responsible for the community they served. Patients were more likely to follow the HP advice due to the respect they had for the DN. HP was often sacrificed when rural challenges (workforce, infrastructure, resources) limited their availability to patients causing stress and disengagement by the DN.
Effective HP requires committed DNs to be embedded into the community. This increases the tie strength between patient and DN and the patient is then more likely to follow advice. Relationships are mutual, open and conducive to honest reporting of health behaviors. Rurality acts as a facilitator to shared values, community engagement, and therefore, stronger tie but also restricts the time and resources available to deliver HP effectively. DNs may neglect HP as a result of rurality to treat the patient's primary health need.
other social network members. 27,33 For example, one nurse said she was able to help a man to "die at home with his three teenage sonsone of which I employed locally". 27 This is beneficial as it helps to create an egalitarian relationship that is based on shared norms and values. 21,27 Moreover, the nurse may be well placed not only to successfully identify potential social networks of support 37 but also have the increased social capital within the community to enable its successful mobilization. 27,32,38 The quote that "People don't say no to a health care professional as readily" 32 epitomizes this increased social capital and nurses are seen as the "quarterback" of the community 37 ; mobilizing other professionals and healthcare services. 30,32,35,36,41 Nurses "Bridge or bond [patients to others]" 32 such as churches, clubs, or charities 32,36 but also, in some cases, proactively create new social networks of support by establishing their own clubs, community projects, or shops that offer an opportunity for interaction with others in the community. 32

| Blurring of professional boundaries in close community relationships
However, the development of complex nurse-patient relationships may result in some degree of crossing the boundary of one's professional role in order to fulfill key nursing responsibilities, especially in rural areas 27,33,35,36,38,40,41 : individuals that carry out a formal service begin to undertake informal support roles. 30 Nurses reported experiencing the pressure of expectations from patients to act as a substitute for the absent support from family, friends, and peers 33 ; stating they "get calls at home -A lot of calls!". 37 Similarly, researchers highlighted that the familiarity patients had with nurses meant they found their "privacy was invaded" 37 when they were "consulted about health issues in grocery stores or at sports events". 21 Such patient expectations are likely to be unrealistic given that rural factors outlined above restrict the time available to nurses to offer substantial emotional and practical support. 37,38,40 This may leave nurses with difficult choices to make between disappointing raised patient expectations, fulfilling responsibilities to other patients, and the need to prioritize illness over all other types of work, such as domestic tasks or food shopping. 39 Thus, close relationships between nurses and patients may be difficult to negotiate and manage, 21 adding substantial amount of relational work to the nurse workload, and raising issues of overburden or "burnout," confidentiality, and meeting professional and legal responsibilities and standards. 27 Aging in place/being ill in place allows information/health promotion to be more relevant to the patient and their SN, and therefore, accepted and implemented.
They know "what-is-What" will increase long term self and collective efficacy. The acceptance is also due to the increased strength of the tie that is likely to be built between the nurse, patient, and their family. This is because they are reliable, attentive, 1-to-1, and have the time to spend with the patient.
Moreover, in rural community settings where social isolation can be common 37,40 some patients may act proactively use nurse visits as an opportunity for social contact, 36  while also putting additional pressure on nurses to further extending the depth and range of support they provide.

| Issues accessing and navigating formal and informal support in the context of diminishing resources in rural areas
While building close nurse-patient relationships may sometimes be associated with higher personal job satisfaction, 21,38 the need to deal with complexity that such relations introduces associated negative experiences 27 maybe less acceptable to newly qualified nurses who "may not be comfortable with all the different things [emotional and practical support] they had to do," according to their more experienced peers. 21 As with the community as a whole, smaller rural district nursing teams experience an increased sense of shared values and team spirit among themselves 38 and are able to create an "extended family environment" 21 but there is a relative lack of specialist support available; which not only means nurses practice as generalists but also that it restricts the services available that can be mobilized to support the patient. 21,27,[37][38][39] Furthermore, the aging workforce in rural areas means that recruitment from outside the local area is increasingly common. This reduces the embeddedness and shared values of the nurse in "both a geographical and social sense," 31 limits the knowledge the nurse has of the community, and therefore, the influence they have to mobilize other forms of support. 21

| Implications for practice
Engagement with patient's social networks is likely to add value for patients living in rural areas and for community-based nursing teams.
However, expectations for developing close relations with patients as a part of the nursing role should be seen as unrealistic considering the tensions between the growing complexity, demand, and availability of services; but also due to additional tensions that such relations, and relational work (the interpersonal efforts that district nurses will invest in order to develop relationships between themselves and the patient, 47

ACKNOWLEDGMENTS
We would like to acknowledge the University of Southampton and the Dorset County Hospital Foundation Trust for the joint funding and resources for the PhD program of the author JG. Without this, the author would not be able to dedicate the time required to complete this work. The views expressed are those of the authors and not necessarily those of the university or the NHS trust who took no part in designing the study or collection, analysis, and interpretation of data, writing of the report, or the decision to submit the report for publication.

FUNDING INFORMATION
The university of Southampton and the Dorset County Hospital have jointly funded the PhD programme of JG and therefore this study.
Open access funding provided by the University of Southampton.

TRANSPARENCY STATEMENT
Jack Gillham affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.