Exploring care for older people : district nurses’ experiences and clinical practice

Background and aim: The health care system needs to prepare in order to provide high quality care to a growing older population. In Sweden, much primary health care for older people is the responsibility of district nurses (DNs), but research into DNs’ clinical care has not been extensive. The general aim of this thesis was therefore to explore the clinical care DNs provide to older people and DNs’ experiences of this care, focusing on preventive home visits (PHVs), medication management, and leg ulcer care.

Material and methods: The thesis includes five studies. Study I used qualitative content analysis to analyze data from group interviews with 20 DNs about their experiences of PHVs. In Study II, DNs used the Safe Medication Assessment (SMA) tool in PHVs with 113 people to identify factors related to unsafe medication management and to describe interventions used to improve the safety of medication management. Study III employed data from the Swedish Prescribed Drug Register on 671,940 community-dwelling older people to examine the extent and quality of their drug use. In Study IV, the electronic records of 97 patients before and 96 after the intervention were used to evaluate DNs' leg ulcer management. In Study V, grounded theory method was used to collect and analyze data from group interviews with 30 DNs about providing leg ulcer care in accordance with guidelines.

Results: Study I found facilitators of and barriers to a successful health dialogue in the PHV. Three main themes illustrated professional dilemmas in the health dialogue that the DNs had to resolve to achieve the purpose of the PHV. In Study II, DNs found several factors related to unsafe medication management when they used the SMA during PHVs. DNs intervened to improve medication management in more than two-thirds of the visits. Study III found that the prevalence of most drug groups and of inappropriate drug use increased with age. Polypharmacy and use of potentially inappropriate medications were already prevalent in 75-year-olds. Study IV found that nurses' documentation ofleg ulcer management was sparse and far from consistent with clinical guidelines. Study V resulted in a theoretical model that illustrates how DNs balance compensating, motivating, and compromising strategies to follow clinical guidelines as far as possible and provide leg ulcer care that is good enough.

Conclusions: DNs experience facilitators of and barriers to health dialogues during PHVs and must balance a personal and a professional approach, a task-oriented and person-oriented approach, and a salutogenic and a pathogenic approach. The proportion of people who use drugs in most drug groups and who take inappropriate drugs increases with age. Using the SMA tool in PHVs may help improve the safety of medication management in older people and may be appropriate at age 75 and age 80. DNs cannot always follow guidelines but try to adhere to a treatment plan that is acceptable to patient and that hopefully can lead to a healed leg ulcer.

List of scientific papers

I. Lagerin A., Törnkvist L., Hylander I. District nurses' experiences of preventive home visits to 75-year-olds in Stockholm: A qualitative study. Primary Health Care Research & Development. 2015 Dec 1:1-15.
https://doi.org/10.1017/S1463423615000560.

II. Lagerin A., Carlsson C.A., Nilsson G., Westman J., Törnkvist L. District nurses' preventive home visits to 75-year-olds: An opportunity to identify factors related to unsafe medication management. Scandinavian Journal of Public Health. 2014 Dec;42(8):786-94.
https://doi.org/10.1177/1403494814550680.

III. Lagerin A., Törnkvist L., Nilsson G., Jonell, K., Fastbom J. Extent and quality of drug use in community-dwelling people 75 years and older: a Swedish nationwide register-based study. [Manuscript]

IV. Lagerin A., Nilsson G., Törnkvist L. An educational intervention for district nurses: use of electronic patient records in leg ulcer management. Journal of Wound Care. 2007 Jan;16(1):29-32.
https://doi.org/10.12968/jowc.2007.16.1.26986

V. Lagerin A., Hylander I., Törnkvist L. District nurses' experiences of caring for leg ulcers in accordance with clinical guidelines: A grounded theory study. [Manuscript]