McGarry, J. (2008) Exploring relationships between older people and nurses at home. This is an extended version of the article published in Nursing Times; 104: 28, 32-33.
BACKGROUND: The location of nursing care continues to move to the community and closer to patients’ homes. Policy reforms and changing demography suggest that older people will increasingly become the main recipients of care in the home.
AIM: To explore the nature of the care experience between nurses and older people.
METHOD: The study used an ethnographic approach, which incorporated participant observation and semi-structured interviews with nurses and older patients (aged 70-94 years).
RESULTS: Sixteen nurses and 13 older patients took part. Three themes emerged: the location of care; the nature of nurse-patient relationships; and the meaning of health and illness.
DISCUSSION: These themes offer an account of the ways in which roles and relationships are constructed and care is delivered and experienced by nurses and older people in the home. Relationships between nurses and older people in this environment are multifaceted.
CONCLUSION: The qualities valued in the nurse-patient relationship in this care setting should be recognised and made more explicit at organisational and policy level.
Julie McGarry, DHSci, MMedSci, PG Dip, BA, PGCHE, RGN, RMN, is lecturer and deputy director, graduate entry nursing, School of Nursing, University of Nottingham.
Recent years have seen a marked shift in the location of nursing care from the hospital setting to community-based care (Department of Health, 2006) and, more particularly, the home. These trends appear set to continue and are the result of a number of interrelated factors, such as: changing demography; an increasingly ageing population; a shift from acute illness to more long-term conditions; changes in caring responsibilities and roles; and the perceived cost implications of these factors (Goodman et al, 2003).
A number of key policy initiatives have supported this shift in the location of care (DH, 2001; 1997; 1996; Office of Public Sector Information, 1990). They indicate that the drive towards the home as a key location of nursing care is set to continue. In addition, the scope of care provision in the home has also expanded (Hudson, 2005; McGarry and Nairn, 2005; Goodman et al, 2003). More recently, the DH (2006) white paper Our Health, Our Care, Our Say provides further confirmation that the reforms, with the underpinning philosophy of expanding service provision at home, are set to continue.
Alongside the general shift in the location of care, the focus on the development of primary care services and support for particular client groups and service users, for example, older people, have also been identified (DH, 2001). Changing demography (Wilson, 2000) and the sustained emphasis on the relocation of care in the home strongly indicate that older people will continue to be the main recipients of primary care.
Historically, a number of commentators have highlighted the particular situation of older people regarding care provision, illuminating the often disempowering nature of interactions between nurses and older people in the hospital setting (McCormack, 2001; Davies et al, 2000). However, to date there is little evidence available regarding older people’s experiences of nursing care in the home environment.
While healthcare is increasingly located outside of traditional institutional settings, nursing in the home setting has received little research attention (Luker et al, 2000). In addition, the home environment as a setting for care provision is largely beyond the public-professional gaze and therefore remains potentially hidden from scrutiny.
Nursing in the home encompasses both the physical and the social dimension within which caring takes place. Carr (2001) suggested that consideration of the context within which care takes place is crucial to nursing in this setting. While it has been recognised that the location of care may raise a number of complex and unique issues, paradoxically, St John (1998) suggested the context of care has often been a ‘taken for granted’ assumption within nursing. This means there has been little in-depth exploration of the impact of the care location in terms of nurse-patient relationships and experiences of care.
Taken as a whole, these observations present a picture of a changing landscape of care for nurses and older people in terms of care provision, and one which is relatively uncharted. The findings presented here arose from observations of the gaps in knowledge from existing literature in terms of the nature of nurse-patient relationships in the home and formed the basis of the study.
The focus of the study was set within the specific context of nursing care provision within the older patient’s own home. The rationale for undertaking it was twofold. First, the study sought to provide a clear, in-depth account of the nature of relationships between nurses and older people in this setting, from the perspective of both nurses and older patients. Second, in so doing, it was envisaged that issues which impact on the quality of caring practices, within the context of the changing climate of care, would be understood more clearly.
The study used an ethnographic approach incorporating participant observation and semi-structured interviews. The rationale for this approach centred on accessing and experiencing the daily lives of nurses and older patients, through observing and talking to them, in order to uncover social meanings, interpretations and activities in naturally occurring environments. With participants’ permission, all interview data was recorded and transcribed. All observational data was recorded as field notes in a journal.
Sixteen nurses based in the community took part in the study. Five were qualified district nurses, nine were registered nurses and two auxiliary nurses. The length of time they had worked in the community setting ranged from four months to 24 years.
Thirteen older patients (two male and 11 female) who were receiving care from district nursing teams at the start of the research took part. Their ages ranged from 70-94 years and they had been receiving district nursing services for the current episode of care for between two months and eight years.
While it is recognised that the experiences of nurses and patient ages were wide-ranging, the nature of the study design and sampling strategy (purposive) meant that potential participants were chosen on the basis of their potential to inform the study through breadth of experiences.
One nurse researcher carried out participant observation over 10 months. Forty-seven episodes of participant observation were undertaken. Each episode comprised a working day of 7-9 hours and the researcher ‘shadowed’ participants for the whole working day.
During this 10-month period, semi-structured interviews were carried out with all participants, with follow-up interviews six months later. An interview guide was developed which incorporated specific demographic questions and prompts for areas of exploration or clarity that had arisen from the observations.
In total 29 interviews were carried out with nurse participants (16 initial interviews and 13 follow-up interviews; in the follow-up interviews two nurses had left the area and one was on long-term sick leave). In total 22 interviews were carried out with older patient participants (13 initial interviews and nine follow-up interviews; in the follow-up interviews, two patients had died, one was in hospital and one had left the area).
Relevant documentation, for example, local trust policy on the role of the district nursing service and patient-held care plans, were also used as additional sources of information.
This study carried out data analysis using an iterative approach. In practice, this meant that throughout data collection, transcripts and records were reviewed and new themes and concepts were identified and explored in subsequent fieldwork and interviews.
The local research ethics committee granted ethical approval for the study. Informed consent was sought from all participants before taking part. In addition, throughout the study, participants were informed of their right to withdraw at any point. All data was coded to preserve participants’ anonymity and confidentiality.
Three themes emerged from the data: the location of care; the nature of nurse-patient relationships; and the meaning of health and illness. They offer an account of the ways in which roles and relationships are constructed and care is provided and experienced by nurses and older people in the home.
The findings presented here are supported by extracts from interview transcripts, while the themes have been developed through exploration of the data as a whole.
The location of care
This theme begins to explain how relationships are negotiated and experienced by nurses and older people in the home setting, for example through notions of ownership and the home environment as being on patients’ terms:
District nurse: ‘You’re seeing people on their terms, I think that’s probably the biggest thing. The problem with hospitals is they peel off their dignity with their clothes on the way in, and you’re seeing patients in hospitals very much on your terms and you mould the patients to your way of thinking, whereas in the community you’re there very much as an invited guest and if they don’t want you there they’ll tell you… you know you have to accept that you as an invited guest, you have to give people the dignity and the respect that they want and that they deserve in the way that they want and deserve. So you’re always there on their terms, not on your terms.’ (District nurse 3)
This also highlighted a number of key points that focused on the organisation and quality of caring practices valued by nurses and older people in the home, for example:
Male patient: ‘I mean conversation is a great sort of aid to life, isn’t it? You know it’s very important because not hearing another person’s voice and not being able to discuss things with them or ask them problems, now that’s where the nurses come in, you see, they’re so good, they come, they come in and they chat to you and they buck you up a bit you know.’ (Patient 10)
Registered nurse: ‘Because you don’t get the full picture [in hospital] so if you don’t get the full picture how can you possibly know the person behind the patient, you just don’t, you just don’t get the chance.’ (Registered nurse 8)
The nature of relationships
Central to the study were aspects of the nurse-patient relationship: these held particular significance and were highly valued by both nurses and older people. This was expressed in a number of ways, encompassing longevity of the relationship between nurses and older patients or other family members, continuity, family and kinship:
District nurse: ‘When you’re in somebody’s home and you’re meeting with their family, their friends and their extended families and you see them in their lives, not just talking about their lives but you see them living it, the relationship there is such a privileged one really...’ (District nurse 7)
Registered nurse: ‘I think you sort of, I mean I know I have developed, albeit only in the last couple of months, a friendship with [patient] in that she tells me snippets of her family and in return I tell her snippets of my family and she gets to know me (a) as [name] the nurse and (b) as [name] the person as well.’ (Registered nurse 6)
Female patient: ‘I mean it’s always [name] and [name] or [name], all of them, it’s like being, it’s like being a family. And I’ve known them for such a long time and it’s like home from home.’ (Patient 5)
The meaning of health and illness
This theme illuminated the interwoven nature of the nursing care intervention within the wider context of the older patient’s daily life and the ways in which nurses and older patients negotiated care in the home.
For example, nurses spoke of the illness as ‘being part of the patient’s life’ or ‘part of their body’:
Registered nurse: ‘…Um, because he's had the ulcer for such a long time he sees it as part of him and I think he appears to, he enjoys our visits and I don’t know how to explain it really, they seem to, well I suppose it’s part of their body.’ (Registered nurse 2)
However, it was also clear that nurses were aware of the potential impact of treatment on the wider facets of patients’ lives. For example, issues such as effectiveness of a particular treatment versus comfort or acceptability within the context of patients’ daily lives:
Registered nurse: ‘The wound could do with Soffban, a soft substance around it and crepe bandages but she just will not tolerate any sort of bandages. So we just have to go and adapt the dressing she’s prepared to use because there’s no point us putting on what we want and then her taking it off or being uncomfortable.’ (Registered nurse 4)
The study also highlighted challenges to traditional notions of professional boundaries in terms of care delivery and the realities and importance of negotiation as part of everyday practice in the home:
Registered nurse: ‘I asked her [patient] from purely a comfort viewpoint did she want me to put some more padding on that would stop it leaking from the foot. The downside to that is if you put more padding on it means she can’t get her slipper on. So you try to weigh up her comfort and also of having it leak through onto her slipper. And I want her to have that choice.’ (Registered nurse 6)
Three significant implications for practice arose out of the study findings. First, for nurses working within the home, the impetus to clearly define and articulate the full breadth of their role is essential in the present climate of changing roles and care provision. This has been argued in the past (Low and Hesketh, 2002) but is yet to be fully realised. The role of community nursing has been subject to a range of changes and role realignment over the years, which has not adequately reflected the day-to-day complexities and dynamic nature of district nursing practice. These have been highlighted in this study through the pivotal role of negotiation and the facets of nurse-patient relationships in the home that are highly valued by nurses and older people. For example, these aspects include respect, continuity of care delivery, longevity of nurse-patient relationships and the recognition of the impact of ill health on daily life.
Second, for policymakers and PCTs, these findings have important implications in terms of future service provision, for example, skill mix and the future role of district nursing teams. As organisational changes in the primary care setting continue to alter the way in which care is experienced in the home, the multidimensional realities underpinning this needs to be recognised at a strategic level.
Finally, for older people, the core qualities that underpin receipt of care in the home have been clearly highlighted. In the changing climate of primary care, older people will certainly be among the chief recipients of care in the home (DH, 2006). As such, the aspects of the nurse-patient relationship in the home valued by older people, as identified above, need to be recognised and accounted for.
The study findings reveal the perspectives of nurses working in the home setting and older patients. As care continues to move closer to home, it is crucial the implicit qualities valued within nurse-patient relationships in this care context – and which contribute to the quality of care – are recognised and made more explicit at organisational and policy level.
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