The medical treatment of patients with home care by district nurses from the family physician’s perspective

Abstract

Background and aim: The aim of this thesis has been to shed light on home care patients, their problems and comprehensive care, and the family physicians experiences of providing medical treatment for home care patients.

Material and methods: One quantitative study (resulting in two articles) from a suburban city area in 1996 concerning one third of the patients receiving home care by district nurses (DNs) (n=116). Information on the patients, their problems and comprehensive care was collected from several sources. One qualitative study used grounded theory methodology (GTM) (resulting in two articles). Data were collected through semi-structured interviews with 13 Swedish FPs concerning one of their patients with home care by a DN, and the treatment of this patient.

Results: A typical patient with home care by DNs was an older single woman with multiple diseases and functional problems. Many care providers were involved in her comprehensive care including both home help staff and hospitals. Several different physicians were often involved. The patients usually visited the FP at the health centre (HC) on average twice a year, but not all patients visited their FP in a year. Many FPs measures were undertaken without a visit. The patients problems influenced the FP s ability to remain in charge of the medical treatment. Patients with reduced functional ability and patients who wanted to manage on their own did not provide information and many could not handle their own treatment. FPs had to rely on the DNs, who saw the patients on average once a week or every other week, for information and help with home care medical treatment. When patients had complex conditions or did not comply with recommendations it was hard to make adequate decisions on the goal of the medical treatment. FPs had to rely on close observation and follow-up by the DNs for information as a basis for constant evaluation of the goal. The DNs working conditions, attitudes and the type of disease the patient had determined whether or not the grounds for relying on the DNs were adequate. The FPs took either the role of a medical conductor, retaining the initiative in the medical treatment, or the role of a medical consultant, leaving the initiative to the DNs. One FP could take different roles in different situations. Which role the FP chose or was forced to take depended on their working conditions, attitude and the type of disease. Conditions for providing home care medical treatment are good enough when there are adequate grounds for relying on the DNs and problematic when there aren t, regardless of the role taken by the FP.

Conclusion: Due to the problems of home care patients, FPs consultations with the patient cannot provide the usual foundation for medical decisions. They have to be able to rely on information and collaboration with the DNs in home care medical treatment, much like the collaboration in a hospital ward. As conductors, FPs detect when conditions are problematic and when no adequate grounds for relying on the DN exist. As consultants, however, they will not detect inadequate grounds as they will receive little or no information from the DNs. In order to stay in charge of the medical treatment as consultants, the FPs working conditions must allow them to know if adequate grounds for relying on the DNs exist. The FPs working conditions must also allow them to be conductors when necessary. The comprehensive care of home care patients includes many different care providers, just like a hospital ward, but without its geographical, organisational and temporal unity. Time and routines to support collaboration is needed and all care providers need to know when they are responsible.