District nurses' experiences of providing care in residential care home settings

District nurses’ experiences of providing care in residential care

home settings

CLAIRE GOODMANCLAIRE GOODMAN BSc, MSc, PhD, RN, DN

Director, Primary Care Nursing Research Unit, Department of Primary Care and Population

Sciences, University and Kings College London, London, UK

ROSEMARY WOOLLEYROSEMARY WOOLLEY BSc, MSc

Research Assistant, Department of Post Registration Nursing, University of Hertfordshire, Hatfield,

UK

DENISE KNIGHTDENISE KNIGHT BSc, MSc, RN, HV

Principal Lecturer, Department of Post Registration Nursing, University of Hertfordshire, Hatfield,

UK

Accepted for publication 29 April 2002

Summary

• Little research describes the involvement and contribution of primary health

care services in residential homes, despite policy and research concerns that older

people in residential homes are a vulnerable population for whom care must be

improved.

• The aim of this research was to explore the actual and potential contribution of

primary care nurses in residential homes for older people, particularly district

nurses.

• Five focus groups were held with district nurses in one county in England, to

explore how participants represented their views, values and experiences of

working in residential homes.

• Our major finding was the importance of context in shaping the experience of

district nursing involvement. General practitioner attachment determined the

frequency of visiting homes and affected workload. District nurses had regular

contact with residential homes for discrete nursing tasks, but appropriateness of

referrals and input was not agreed.

• The focus group discussions with district nurses revealed how problematic

their work in residential homes was and a lack of consensus about their role. The

data suggested that uncertainty about providing care in a setting that straddles

the health and social care, public and private divide, and anxieties about

managing their workload overshadowed their acknowledged concerns about the

Correspondence to: Dr Claire Goodman, Primary Care NursingResearch Unit, Department of Primary Care and Population Sciences,University and Kings College London, Holborn Union Building Level2, Highgate Hill, London NI9 3UA, UK (tel.: +44 207 288 3092;e-mail: [email protected]).

Journal of Clinical Nursing 2003; 12: 67–76

� 2003 Blackwell Publishing Ltd 67

older people in residential care homes. Further research is needed to substantiate

the findings, obtain residents’ views and address issues of how to achieve

integrated and equitable health and social care for this group.

Keywords: district nursing, older people, residential care homes.

Introduction

This paper presents the findings from the first phase of a

study that examined the district nursing contribution to the

health care of older people in residential homes in UK.

Throughout the paper residential homes are defined as care

homes that provide only board and personal care. Any

nursing needs that residents may have in these care homes

therefore are the responsibility of primary health care

nursing services. District nurses in particular have regular

contact with older people in residential homes. The Audit

Commission report on district nursing (Audit Commission,

1999) noted that the number of district nursing contacts in

residential homes increased by 13% over the previous

5 years. Older people in this setting consistently account for

7% of all district nursing contacts and the proportion of the

residential home population being seen by district nurses is

rising as the average age of the residents rises. A review of

the literature on the health experiences of older people in

residential homes suggested that, whilst there was a range of

needs that could benefit from nursing assessment and

interventions, there was minimal information on the role

and contribution of primary care nurses.

BACKGROUND AND LITERATURE REVIEW

The extent to which older people in residential homes have

on-going health needs and how those needs are managed by

health and social care providers, or by primary care nurses

in particular, has not been adequately mapped (Woolley &

Goodman, 2001). There is, however, recognition by both

policy and research commentators that older people in

residential care homes in the UK are a vulnerable

population for whom care must be improved [Royal

Commission (chaired by Stuart Sutherland), 1999; Royal

College of Physicians, Royal College of Nursing, and

British Geriatrics Society, 2000; Department of Health

(DOH), 2001a]. The way in which policy about older

people has affected both their needs and the contribution of

residential homes are articulated and considered.

POLICY ISSUES

Demographic trends in the UK, such as a marked

reduction in fertility levels and decreasing mortality, have

resulted in an ageing population especially among the

�oldest-old� (aged 80+) (Bartlett & Phillips, 2000; Wanless,

2001). It is expected that the number of older people over

the next two decades will remain relatively static, but by

2051 the number of people aged 90 and over will increase

more than fivefold (Bartlett & Phillips, 2000). This means

that there is likely to be continuing demand for residential

care as one of the support services available to older people

for the foreseeable future.

From the late 1980s care in the community reforms

have emphasized that wherever possible people should be

supported in their own homes (DOH, 1989). Never-

theless, the number of residential homes and residential

home places increased up to 1998 but has since levelled off

to 24 800 homes and 346 000 places in England on 31

March 2000 (DOH, 2000). Following publication of the

National Services Framework for Older People (NSF )

(DOH, 2001b), residential homes have been cited as

possible providers of intermediate care and rehabilitative

services for older people.

The policy debate about residential care has more

frequently focused on the respective responsibilities of

individuals and the state for financing long-term care of

older people (Sutherland Report, 1999). Recently, how-

ever, the Government has committed itself to assuring

minimal standards in care homes (DOH, 1999, 2001a).

The Royal Commission (chaired by Stuart Sutherland)

(1999) has also been instrumental in fuelling fresh debate

about the distinctions made between health and social

care, and particularly the nursing and personal care needs

of older people in long-term care. The criteria for

eligibility for care in a residential home are currently set

by local authority social services departments, who decide

which services they will arrange or provide following a

needs-based assessment (Age Concern, 2001). It is

expected health care will continue to be provided by

primary health care services for those assessed as not

requiring full-time nursing care. Concerns have been

raised that older people in residential homes are not

receiving appropriate health care (e.g. Turrell et al.,

1998), and that medical specialists have gradually with-

drawn from the continuing care of older people (Black &

Bowman, 1997; Counsel and Care, 1998; Turrell et al.,

1998; Royal College of Physicians, Royal College of

Nursing, and British Geriatrics Society, 2000). In this

68 C. Goodman et al.

� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 67–76

literature there is little discussion of the nursing contri-

bution to this area of care.

The NSF (DOH, 2001b) sets out a 10-year programme

of action to ensure integrated health and social care

services for older people. Primary care nurses are expected

to contribute and be lead professionals in developing the

single assessment process, provide support for social care

workers and ensure that effective links are established

between health and social services. Residential homes are a

prime example of where these new patterns of working

should occur.

The evidence for the range and type of health need that

primary health care professionals encounter in residential

care settings for older people is now considered.

EVIDENCE OF HEALTH NEED

It is difficult to assess and compare studies of health

needs and care of older people in residential homes due to

the different foci of studies, different measures of depend-

ency and disability employed, and the lack of distinction

between different care home populations. Most studies

have examined specific health problems such as diabetes,

continence, skin care and mental health status but have not

addressed the continuing health needs of older people in

residential care (Woolley & Goodman, 2001).

It was assumed that the impact of needs-led assessment

following the NHS and Care in the Community Act 1990

and the parallel decline in continuing care beds funded by

the NHS would be to increase the levels of dependency of

older people in long-term care. Turrell et al. (1998) claims

that research exploring this assumption and its implications

for the NHS has been non-existent. However, a longitu-

dinal survey and cross-sectional survey, of 2544 and 11 899

people, respectively, admitted to residential and nursing

home care in 1995 and 1996, showed that residents are

increasingly old (aged 80+) and considerably more depend-

ent than a decade ago (Netten, 2001). This is particularly

with regard to cognitive impairment and inability to per-

form self-care tasks such as washing. In private or voluntary

residential homes (which now represent 90% of residential

homes, DOH, 2000), the proportion of people defined as

highly dependent had risen by 28%.

High levels and comorbidity of cognitive impairment,

depression, dementia and behavioural problems have been

identified by several studies (Jagger & Lindesay, 1997;

Medical Research Council Cognitive Function and Ageing

Study, 1999; Godlove Mozley et al., 2000). Depression in

particular has been identified as a major health threat for

older people in residential homes (Ames, 1990), the symp-

toms of which often go unnoticed by staff (Bagley et al.,

2000). These findings raise questions about how primary

care nurses and others should support social care staff to

become more aware of residents’ mental health as well

as the more apparent physical care needs. The kind of

clinical care needs residents have is now examined.

Surveys demonstrate the prevalence of specific clinical

care needs among older people in residential homes. These

include continence promotion (Peet et al., 1995, 1996; Roe

& Shiels, 2000), prevention of infection (Yates et al.,

1999), pressure ulcer care (Shiels & Roe, 1999), dental

health (Lall, 1999), diabetes care (Taylor & Hendra, 2000),

visual problems (Sturgess et al., 1994) and palliative care

(Komaromy et al., 2000). For example, two separate

surveys by Peet et al. (1995) (n ¼ 6079) and Roe & Shiels

(2000) (n ¼ 652) found that around a third of residents in

residential homes had a continence problem.

EVIDENCE OF HEALTH CARE PROVISION AND LACK

OF DISCUSSION OF THE DISTRICT NURSING ROLE

Many studies focusing on specific health needs have

highlighted the difficulties of providing high quality care

and made suggestions for improved practice (Sturgess

et al., 1994; Peet et al., 1995; Taylor & Hendra, 2000). For

example, Komaromy et al. (2000) found that, although

social care staff were committed to providing quality

terminal care for residents, barriers to good practice

included staff shortage, lack of knowledge of palliative care

and the physical layout of the home.

Through the provision of specialist support, advice and

training for care staff, a few intervention-based studies

have aimed to ameliorate physical or psychiatric condi-

tions (Ames, 1990; Proctor et al., 1998, 1999; Llewellyn-

Jones et al., 1999; McMurdo et al., 2000). These have had

variable success and the criticism of many studies is that

they have not considered how existing primary care

services can be involved, although Llewellyn-Jones et al.

(1999) offered training to general practitioners.

Very little research in the UK has explored the nursing

contribution to the care of older people in residential

homes (Woolley & Goodman, 2001). The only area that

has received attention has been the discharge of older

people from hospitals into care homes (Reed & Roskell

Payton, 1996; Morgan et al., 1997; Reed & Morgan, 1999).

Primary health care input into residential homes has been

poorly documented and almost nothing has been men-

tioned about district nursing involvement. Concern is

expressed, however, by primary health care practitioners,

particularly GPs and geriatricians, about who has the

responsibility for the health care of residents (Black &

Bowman, 1997; Turrell et al., 1998; Royal College of

Issues in developing nursing practice Providing care in residential care home settings 69


Physicians, Royal College of Nursing, and British Geri-

atrics Society, 2000).

The nursing contribution in continuing care, however,

has not been recognized or discussed (Ford & McCormack,

1999). Only two research studies have specifically looked at

the input of NHS services into residential homes for older

people. Counsel and Care (1998) surveyed residents from

seven residential, two nursing and two dual-registered

homes and sought the views of 142 care home managers.

Although the study looked at whether residents kept their

own GP following admission, and found that access to

health professionals such as physiotherapists and occupa-

tional therapists was poor, nothing was said about district

nurses. Crosby et al. (2000) monitored the contacts with

primary health care services made by residents in 10

nursing homes, 14 residential homes and three dual-

registered homes over a 16-week period in 1996. Evidence

was provided that a high level of demand was placed on

district nursing services by a minority of highly dependent

older people in the residential homes.

In a study that set out to examine the contribution of

primary health care services to residential care homes in

one county, one aim was to describe the involvement of

primary care nurses. This paper presents the findings

from five focus groups held with district nurses to explore

their experiences of working with residential homes.

Method

The study used qualitative research methods within an

interpretivist approach that emphasized discovery, a focus

on the everyday experience of participants, and their

perceptions and understanding (Holloway, 1997; Murphy

et al., 1998). The research question asked how participants

described the role of district nurses in residential homes

for older people.

Focus groups were chosen as a method to identify the

issues that district nurses felt were important in providing

care in residential settings and to explore the significance

of this area of work of district nurses. Kitzinger (1995)

identifies focus groups as a method that capitalizes on the

interactions of research participants and can explore and

clarify views and tap into subcultural norms.

This paper presents the findings from five focus groups

held with district nurses and community staff nurses

across one county in England between February and July

2000. The five focus groups were geographically deter-

mined in order to account for the different settings and

concentrations of residential homes across the county.

Following ethics committee approval, practitioners were

approached through their managers and professional leads.

For four of the focus groups, the group was organized to

occur either directly before or after a prearranged meeting

that district nurses were attending. For the other group,

the district nurses who took part said they wanted to be

sure they would have enough time for the discussion and

arranged a separate time to meet. Group size ranged from 7

to 15 (in the largest group three practitioners left to visit

patients before the discussion finished). At least three

separate district nursing teams were represented in each

focus group. The focus groups lasted between 40 minutes

and 1 hour. In total there were 44 participants. The parti-

cipants were all qualified district nurses or community staff

nurses, apart from a social worker who expressed interest in

taking part in one of the groups and was invited to attend

by one of the participating nurses. Her contributions have

not been included in the findings presented in this paper.

Each group was facilitated by a member of the research

team, who introduced the purpose of the group by

explaining that we were interested in their experiences and

descriptions of working in residential homes. Residential

homes were defined as care homes where residents did not

have access to on-site nursing care and had social and

personal care needs. The facilitator’s role was to initiate

the discussion, ask for further explanation, confirmation or

further comment from other participants, and to try to

ensure that there were opportunities for all to contribute.

The discussions were tape recorded. Another member of

the research team took notes throughout the process,

noting who spoke, whether particular individuals led or

dominated the discussion and their impression of the

discussion as a whole. This researcher did not participate

in the group and sat at the edge of the room. These field

notes were used to help in the transcription of the

tapes (undertaken by the observer-researcher) to identify

different participants and to annotate the transcript to

inform the analysis.

In a review of the use of focus groups as a research

method in nursing research, Webb & Kevern (2001)

suggest that the approach to analysis in many studies that

use focus group data is relatively unsophisticated and in

particular that the interaction that occurred within groups

is rarely reported or discussed. They suggest that

researchers should ask specific questions of the group

process and interaction to deepen the understanding of the

data obtained. In this study, the analysis of the interaction

focused on where there was consensus and a common

experience. This was determined by evidence in the

transcripts of participants assenting to statements and

comments made by other nurses and instances in the

discussion where multiple similar examples illustrated

the point being made. Reference was also made to the



observer’s notes and the discussion between the research-

ers of how they remembered the strength of responses to

different issues. For example, in each group reference was

made to the unpredictable nature of the work in residential

homes, where one visit invariably led to the nurse being

asked to see other residents. In each group, the transcripts

showed how this experience was endorsed by other nurses

with examples that confirmed the experience and created

discussion between the group members about named

homes as examples of where this experience was partic-

ularly common. The observer had noted nods, laughter

and issues which generated the most animated and/or

prolonged discussion and participation from group mem-

bers. Also noted was when there was ambiguity and active

disagreement. For example, although all group members

agreed that it was difficult to predict how much time they

would spend on a visit to a residential home, some

participants accepted this as an inevitable consequence of

being the only health professional who visited regularly

whilst others saw it as something to be controlled and

actively discouraged.

ANALYSIS

Transcripts and field notes were read through several

times by both researchers as an exercise in familiarization.

Independently and jointly, key and recurrent ideas were

noted and discussed. Six themes that emerged from this

analysis are presented below.

Findings

THE IMPORTANCE OF CONTEXT FOR THE PROVISION

OF CARE

An important finding from the focus group discussions

was the importance of context in shaping primary care

nursing involvement in the homes. Factors additional to

immediate patient need influenced the frequency and

nature of their involvement. Throughout the analysis this

theme was prominent, an issue we will refer to again in the

discussion.

SIGNIFICANCE OF GP ATTACHMENT

Participants described their involvement with residential

homes as variable and highly reactive. All had had some

involvement with a residential home and the majority

agreed that they were visiting at least twice a week and

many had responsibility for two or more homes. For the

majority of participants the homes which they visited was

determined by the older person’s registration with a GP.

Where all the residents of a home were registered with one

practice, one district nursing team would always visit.

More commonly, district nurses would visit wherever the

patients of the practice were resident, as would be the case

if the person were in their own home. This meant that,

although they had regular contact with residential homes,

this was variable and unpredictable and several district

nursing teams could be visiting the same residential home

at similar times. Also, where GP practices took respon-

sibility for many residential care homes, the attached

district nursing team’s workload was directly affected.

For some participants, only visiting older people

registered with the GP they were attached to was a good

arrangement. It supported residents’ choice, maintained

continuity of care, reflected district nursing practice in

clients’ own homes and meant that they did not have to

liaise with GPs they did not know. For others it affected

the working relationship they had with the homes, created

confusion when encountering need in residents who were

not registered with their GPs, and inequity in workload

between district nursing teams.

There was no agreement within and between groups as

to what was the best approach. Some teams covered for

each other when there was obvious duplication of visits by

district nurses, but many emphasized the extra time and

confusion caused by having to work with GPs they did not

have links with. One participant, who worked in a

semirural area and had responsibility for one residential

home, argued that her relationship with the residents and

care staff at this home was strengthened by the fact that

she was seen as �their� district nurse.

DISTRICT NURSING IN CLIENTS’ OWN HOMES/

IN A CARE HOME

In this theme, all groups agreed that the principles guiding

their involvement in residential homes was on the basis

that the care provided was as if the person was in their

own home. However, the discussion revealed that many of

their experiences and concerns arose from the fact they

were working within a formal setting where others took

responsibility for the ongoing care of the older person.

District nurses would visit residential homes following a

GP referral or a direct request from the home. The reason

for requesting their involvement was described as task

specific. There was consensus that the majority of their

work in residential homes related to wound care, contin-

ence management, and care of patients with diabetes.

Interestingly, involvement in the care of residents who

were dying was described as infrequent.



There was animated discussion in the groups about

whether many of the referrals received were appropriate

and arose from need or were the consequence of

inappropriate care. Three recurrent themes were the time

spent on care that was preventable or should not need

district nursing expertise, use of the district nurse as an

extra resource and lack of control over referrals.

LACK OF PREVENTIVE OR ANTICIPATORY CARE

In this theme, district nurses in several groups identified

how they were often asked to attend to superficial wounds

that they felt had been caused by poor lifting and handling

or little understanding of how to prevent problems.

Superficial wounds were a particular issue because some

homes, in distinguishing between what was nursing care

and what was social support, required care staff to have a

nurse assess and dress any wound, however, small, even

when participants felt that all that was required was a

protective covering. This was seen as generating unne-

cessary and repetitive work. Participants also perceived

that there was more district nursing involvement where

care home staff were less aware of anticipatory care. For

example, in the prevention of constipation, some care staff

were perceived as either not recognizing the importance of

monitoring residents’ dietary intake or not communicating

information effectively among themselves about changes

in a resident’s health.

THE DISTRICT NURSE AS AN EXTRA RESOURCE

The majority of participants said that they had good

relationships with the care homes that they visited. There

were, however, some tensions arising from how the care

staff understood their role. The district nursing presence

in the home led to opportunistic demands on their time for

advice on care, requests to see other residents and also

help in decision-making about whether a doctor was

needed. Several participants identified how they would

visit a home intending to see one patient and be asked to

see others. This had consequences for practitioners’ time

and caseload management. There was also a feeling that

the district nurse was seen as an accessible substitute

doctor or, in situations where the doctor was reluctant to

call, a useful advocate in validating the home’s request for

a visit. These two quotes capture the group’s experiences:

(Dn15) They all want us to look at things they’re not

sure about bothering the doctor about.

(Dn18) Yes, yes

(Dn15) So they don’t, it could be a lump or a bump

or a warty thing or a mole or an area of skin, and they

ask you to have a look at them because they haven’t

wanted to bother the doctor and you were in anyway.

So that’s kind of saying where we fit in the hierarchy.

(Dn15) We also had this other problem where if – I

don’t know if I am speaking personally – but we

would allocate your work, maybe say have 30 visits

and 6 nurses in for 5 patients each and one person

who had 5 patients could have 5 patients in the

residential home…and then the person walks in there

and finds they have 15.

(Dn17) and I do think they try and use us to

gatekeep between us and the GP, yes (all speaking) so

GPs get fed up with them calling all the time. So, if

they can get the nurse to say that they need the

doctor, it’s so much better for them if they can ring

up and say this nurse said.

It was clear from the discussions that district nurses

could see that care staff needed support in providing care

but there was concern about the consequences this had for

the district nursing service. As the following quote

demonstrates, one participant saw that it was important

to set boundaries and to say �No�. The imagery used is that

of avoiding capture, although others saw this was some-

thing to be negotiated and where compromise was

necessary:

(DN3) I think, yes, it (i.e. being placed in a difficult

situation) does, but I think you have to learn to say

�No�, otherwise we’d be in there all day and we have

other demands on our time. But because you are a

captive audience (our italics) when you’re in there and

they just try and keep their little claws (our italics) in

you.

It was notable that the discussion in all five groups

focused on issues of process and organization of care and

relationships with care staff. Very few examples were

volunteered of clinical care, experiences with individual

patients or debate about different approaches to assess-

ment. Participants suggested the residential homes that

placed the fewest demands on district nursing staff were

the ones providing good care. However, others thought that

the homes that had the most guidelines and formal training

for staff were those that also made the sharpest distinction

between health and social care. Consequently, anything

that was not defined as social care, however, trivial, would

result in a referral to the district nursing team.

Participants all agreed that because of community care

policies, people who would previously have been assessed

as needing nursing home care were now being admitted to

residential homes. Only one participant, however, dis-

cussed involvement in the ongoing assessment of individ-

ual residents, and her role in advising whether they should



be receiving nursing care. There was also a lack of

agreement between the groups as to whether it was

appropriate to offer services to residential homes that

might be available to patients in their home. For example,

some district nurses would not offer a night sitter service

for a dying patient in a residential home. Others would,

because the social care staff were responsible for so many

residents and were believed to have as much need of

support as the informal carers of people dying in their own

homes.

One area that did emerge as distinctive in the district

nurses’ descriptions of their work in residential homes,

was the extent to which they engaged in ongoing teaching

and support of social care staff.

DISTRICT NURSE AS TRAINER AND EDUCATOR

In order to address what were seen as inadequacies in care

and lack of understanding of health promotion, district

nurses reported offering ongoing training and reinforce-

ment of what was good practice to social care staff. This

was not, however, represented as a particularly rewarding

area of work:

(DN6) …The problem is that the turnover of staff is

so great in these homes that you do a teaching

session, you (looking at other nurse) did a lot when you

were there, the next month you go back and they’ve

been changed, gone, and you’re back to square one

again.

(DN9) Some homes do their own teaching and keep

up-to-date with the sort of pressure areas and

pressure care and all the rest of it. Other homes do

nothing.

District nurses who offered teaching on simple wound

care, moving and handling and management of continence

problems characterized this either as a way of reducing

demands on the service that were either inappropriate or

as avoiding future problems. In one group, participants

discussed a home where concerns about standards of social

care meant that teaching sessions by district nursing staff

were used as a strategy to improve the situation. This had

been done with the support of the GP and local inspection

unit. Here district nurses became mediators and advocates

of acceptable practice between social care staff and the

management of the home.

Some participants felt their work in care homes was

another example of district nurses filling a gap, and

compensating for a lack of staff development and training.

Others argued that if this was not carried out it was

residents who suffered and their care should always be the

priority:

(DN6) Can I just ask, do they have to pay the district

nursing service for the training that DNs put into

these homes?

(DN10) They should do.

(DN8) They did do in the sessions that I did, but

they were done on a quite big and a formal setting

and they were charged for my time, but normally

when it’s one-to-one it’s, you’re doing it to save you

or, or more and more problems when you go in.

(DN6) and we’d have to teach carers at home. It’s

just that once you’ve taught somebody’s wife how to

put the husband’s catheter on, you don’t have to keep

redoing it every few months.

(Others) No, no.

Discussions revealed common problems and experien-

ces but lack of awareness between district nursing teams in

the same geographical area of what other teams were

doing. Some district nurses accepted that they had an

open ended commitment to care homes and provided

regular teaching sessions, whilst others described strat-

egies for limiting their involvement and uncertainty about

offering extra services or providing teaching support.

Discussion

The focus groups revealed many shared experiences, but

less consensus as to what the district nurse’s role in

residential care settings should involve. For many it was

the number of homes registered with their GPs, transience

of the social care staff, unpredictability of how many

patients they would see and the relationship they had with

the homes that shaped their involvement. These contex-

tual issues have hardly been considered by research into

the health needs and experience of older people in

residential care (Proctor et al., 1998, 1999; Bagley et al.,

2000; Moniz-Cook et al., 2000; Moxon et al., 2001).

For all primary care nurses, how care is delivered is

determined by a process of negotiation, balancing of

individual need and caseload demand, and what other

services may be available (Kenrick & Luker, 1996; Ryan

et al., 1998; Carr, 2001; Goodman, 2001). However, in

residential settings extra difficulties arise from the lack of

clarity about health and social care, how the role is

understood and the effects this work has on the wider

caseload.

The reactive, demand-led and task-specific nature of

district nursing work has also been well documented

(Worth, 1996; Griffiths, 1996; Audit Commission, 1999).

However, work in residential care homes appeared to

retain its task-driven character, unlike other areas of

district nursing work where the task may be the reason for



the first contact with a patient but masks a wider range of

involvement, knowledge and continuity of care (McIntosh,

1996; Goodman, 1998). Only in the area of providing

teaching and support to social carers did district nurses in

this study identify activities that were extra to the tasks

they performed in residential homes. Even then, it was

unclear from the discussion the extent to which this input

represented ongoing support or a conscious strategy to

reduce demands on district nursing time. Both the recent

National Service Framework for Older People and Audit

Commission report on developing mental health services

for older people identify the importance of providing

support, advice and training for social care staff in long-

term settings (DOH, 2001b; Audit Commission, 2002).

This aspect of district nursing involvement has not been

studied nor the types of support that achieve the best

outcomes for residents and staff.

A recent report on the health needs of older people in

residential care has argued for a population-based approach

for this vulnerable group and involvement of specialist

nurses in gerontology (Royal College of Physicians, Royal

College of Nursing, and British Geriatrics Society, 2000).

In the focus groups, the majority of district nurses did not

appear to have adopted such a strategy. Nor did the organi-

zation of their work through GP attachment encourage

them to think about residents in particular homes as

discrete groups who could benefit from ongoing district

nursing involvement. This was despite practitioners with

responsibility for specific homes being able to sustain

relationships with staff and achieve a shared understanding

of their respective roles.

There is an expectation that all primary care nurses will

adopt a public health role in their work (World Health

Organisation, 1997). The largely medical focus of the

evidence to date on the health needs of older people in

residential care has overlooked the contribution of public

health approaches that employ population and social

models of health needs assessment. To achieve high

quality integrated health and social care of older people

requires district nurses and others to re-evaluate their

work in residential care homes.

Health and social care for older people are inextricably

linked and the social needs of older people are frequently

precipitated by poor health (Glendinning & Lloyd, 1998;

Vernon et al., 2000). How the district nurses in the

present study represented their experiences reflects in part

the ongoing tension between what is health and what is

social care, and what is paid for and what is free – a debate

that has always influenced how nursing work in UK is

discussed (Twigg, 1997). Lewis (2001) has argued that the

legacy of what she characterizes as half a century of

dispute over the health and social care divide has been that

older people with less acute or �intermediate needs� may be

treated inappropriately. Although it has been suggested

that the role of the district nurse in residential homes is

unambiguous (Stevenson, 2000), much of the discussion in

the focus groups highlighted how problematic this work is,

especially when the distinctions between and definitions of

caring, common sense and nursing are so blurred. It is this

confusion that might make district nurses appear anxious

to develop strategies that either reduce their input or set

boundaries as to what they will do. This is an uncom-

fortable situation.

LIMITATIONS OF THE STUDY

This paper describes an exploratory phase of a larger

study. A very small and unrepresentative group of

practitioners participated in the focus groups. The

practitioners in the focus groups were self-selecting and

so their views may have been more polarized than those of

other practitioners. The focus group method also assumes

that all participants are equally able to articulate their

thoughts and experiences. However, it is difficult to gauge

the extent to which particular participants dominated the

discussion of the groups (Holloway, 1997). There were

recurrent themes, but they offer only a partial account of

district nursing practice in these settings and do not

incorporate social care staff and resident views. The

usefulness and applicability of these preliminary findings

lie in what has been revealed about the contextual

influences on practice and apparent confusion and dis-

sonance about aspects of district nursing work. These are

issues that need to be more extensively researched before

they can inform decisions about practice and the organ-

ization of care.

Conclusion

The everyday experience of negotiating the health/social

and public/private divides when providing care in resi-

dential homes appeared to leave many district nurses

confused. Hiscock & Pearson (1999) noted how internal

occupational preoccupations can deflect practitioners from

working across the health and social care divide for local

populations. Paradoxically, as policy advocates closer

working and co-operation, uncertainty can cause practi-

tioners to limit their involvement and focus increasingly

on their own professional concerns. These preliminary

discussions suggest that anxieties about workload demand

and boundaries of care overshadowed practitioners’ con-

cerns and awareness of the needs of this vulnerable



population. It is important to explore in more detail

nursing work in residential homes so that genuine shared

assessment and partnership in care can be achieved for this

patient group.

References

Age Concern (2001) Local Authority Assessments for Community Care

Services – April 2001. Age Concern, Factsheet 41.

Ames D. (1990) Depression among elderly residents of local-

authority residential homes, its nature and the efficacy of

intervention. British Journal of Psychiatry 156, 667–675.

Audit Commission (1999) First Assessment: a Review of District

Nursing Services in England and Wales (National Report). Audit

Commission Publications, Abingdon.

Audit Commission (2002) Forget Me Not 2002: Developing Mental

Health Services for Older People in England. Audit Commission

Vincent Square, London.

Bagley H., Cordingley L., Burns A., Godlove Mozley C., Sutcliffe

C., Challis D. & Huxley P. (2000) Recognition of depression by

staff in nursing and residential homes. Journal of Clinical Nursing

9, 445–450.

Bartlett H.P. & Phillips D.R. (2000) The United Kingdom:

demographic trends, recent policy developments, and care

provision. In Aging in East and West. Families, States, and the

Elderly (Bengston V.L., Kim, K., Myers, G.C. & Eun, K., eds).

Springer, New York, pp. 169–188.

Black D. & Bowman C. (1997) Community institutional care for

frail elderly people. BMJ 315, 441–442.

Carr S. (2001) Nursing in the community – impact of context on the

practice agenda. Journal of Clinical Nursing 10, 330–336.

Counsel and Care (1998) Bringing Health to Homes. The Relationship

Between Health Services and Homes for Older People. Counsel and

Care, London.

Crosby C., Evans K.E. & Prendergast L.A. (2000) Factors Affecting

Demand for Primary Health Care Services by Residents in Nursing

Homes and Residential Care Homes. The Edwin Mellen Press,

Ceredigion.

Department of Health (1989) Caring for People: Community Care in

the Next Decade and Beyond. Department of Health, London.

Department of Health (1999) Fit for the Future? National Required

Standards for Residential and Nursing Homes for Older People.

Department of Health, London.

Department of Health (2000) Community Care Statistics 2000

Residential Personal Social Services for Adults, England. Depart-

ment of Health, London.

Department of Health (2001a) Care Homes for Older People.

National Minimal Standards (C80/077240). Department of

Health, London.

Department of Health (2001b) National Service Framework for Older

People. Department of Health, London.

Ford P. & McCormack B. (1999) Determining older people’s need

for registered nursing in continuing healthcare: the contribution

of the Royal College of Nursing’s Older People Assessment Tool.

Journal of Clinical Nursing 8, 731–742.

Glendinning C. & Lloyd B. (1998) The continuing care guidelines

and primary and community health services. Health and Social

Care in the Community 6(3), 181.

Godlove Mozley C., Challis D., Sutcliffe C., Bagley H., Burns A.,

Huxley P. & Cordingley L. (2000) Psychiatric symptomatology in

elderly people admitted to nursing and residential homes. Aging

and Mental Health 4(2), 136–141.

Goodman C. (1998) The Purchasing and Provision of District Nursing

Services in GP Fundholding Settings: a Case Study. University of

Hertfordshire, Hatfield.

Goodman C. (2001) The use of metaphor in district nursing:

maintaining a balance. Journal of Advanced Nursing 33(1), 106–

112.

Griffiths J. (1996) An ethnographic study of district nursing work.

Unpublished PhD Thesis, University of Liverpool, Liverpool.

Hiscock J. & Pearson M. (1999) Looking inwards, looking outwards:

dismantling the �Berlin Wall� between health and social services.

Social Policy and Administration 33(2), 150–163.

Holloway I. (1997) Basic Concepts for Qualitative Research. Blackwell

Science, Oxford.

Jagger C. & Lindesay J. (1997) Residential care for elderly people:

the prevalence of cognitive and behavioural problems. Age and

Ageing 26, 475–480.

Kenrick M. & Luker K. (1996) An exploration of the utlisation of

managerial factors on research utilisation in district nursing

practice. Journal of Advanced Nursing 23, 697–704.

Kitzinger J. (1995) Introducing focus groups. British Medical

Journal 311, 299–302.

Komaromy C., Sidell M. & Katz J.T. (2000) The quality of terminal

care in residential and nursing homes. International Journal of

Palliative Nursing 6(4), 192–200.

Lall B. (1999) A pilot screening programme to assess the dental

treatment needs of older people in residential and nursing care.

Journal of BASE (British Association for Service to the Elderly) 68,

19–23.

Lewis J. (2001) Older people and the health-social care boundary in

the UK: half a century of hidden policy conflict. Social Policy and

Administration 35(4), 343–359.

Llewellyn-Jones R.H., Baikie K.A., Smithers H., Cohen J.,

Snowdon J. & Tennant C.C. (1999) Multifaceted shared care

intervention for late life depression in residential care: ran-

domised controlled trial. BMJ 319, 676–682.

McIntosh J. (1996) The question of knowledge in district nursing.

International Journal of Nursing Studies 33(3), 316–324.

McMurdo M.E.T., Millar A.M. & Daly F. (2000) A randomised

controlled trial of fall prevention strategies in old peoples’ homes.

Gerontology 46, 83–87.

Medical Research Council Cognitive Function and Ageing

Study (MRC CFAS) and Resource Implications Study (RIS

MRC CFAS). (1999) Profile of disability in elderly people:

estimates from a longitudinal population study. BMJ 318, 1108–

1111.

Moniz-Cook E., Woods R. & Gardiner E. (2000) Staff factors

associated with perception of behaviour as �challenging� in

residential and nursing homes. Aging and Mental Health 4(1),

48–55.

Morgan D., Reed J. & Palmer A. (1997) Moving from hospital into a

care home – the nurse’s role in supporting older people. Journal

of Clinical Nursing 6, 463–471.

Moxon S., Lyne K., Sinclair I., Young P. & Kirk C. (2001) Mental

health in residential homes: a role for care staff. Ageing and

Society 21, 71–93.



Murphy E., Dingwall R., Greatbatch D., Parker S. & Watson P.

(1998) Qualitative research methods in health technology: a

review of the literature assessment. Health Technology Assessment

2(16), 89–163, NHS R&D HTA Programme.

Netten A. (2001) Residential and Nursing Home Care of Elderly

People – Research Outline. University of Kent at Canterbury,

Canterbury.

Peet S.M., Castleden C.M. & McGrother C.W. (1995) Prevalence

of urinary and faecal incontinence in hospital and residential and

nursing homes for older people. BMJ 311, 1063–1064.

Peet S.M., Castleden C.M., McGrother C.W. & Duffin H.M.

(1996) The management of urinary incontinence in resi-

dential and nursing homes for older people. Age and Ageing 25,

139–143.

Proctor R., Burns A., Stratton Powell H., Tarrier N., Faragher B.,

Richardson G., Davies L. & South B. (1999) Behavioural

management in nursing and residential homes: a randomised

controlled trial. Lancet 354, 26–29.

Proctor R., Stratton Powell H., Burns A., Tarrier N., Reeves D.,

Emerson E. & Hatton C. (1998) An observational study to

evaluate the impact of a specialist outreach team on the quality of

care in nursing and residential homes. Aging and Mental Health

2(3), 232–238.

Reed J. & Morgan D. (1999) Discharging older people from hospital

to care homes: implications for nursing. Journal of Advanced

Nursing 29(4), 819–825.

Reed J. & Roskell Payton V. (1996) Constructing familiarity and

managing the self: ways of adapting to life in nursing and

residential homes for older people. Ageing and Society 16, 543–

560.

Roe B. & Shiels C. (2000) Focus on continence: survey of care

policies. Elderly Care 12(1), 34–38.

Royal College of Physicians, Royal College of Nursing and British

Geriatrics Society (2000) The Health and Care of Older People in

Care Homes – a Comprehensive Interdisciplinary Approach. Royal

College of Physicians of London, London.

Royal Commission (chaired by Stewart Sutherland) (1999) With

Respect to Old Age: Long Term Care – Rights and Responsibilities.

HMSO, London.

Ryan D., Tilley S. & Pollock L. (1998) Review of Literature of the

Effectiveness of Community Psychiatric Nurses in Achieving Health

Outcomes for People with Mental Illness. Department of Nursing

Studies, University of Edinburgh, Edinburgh.

Shiels C. & Roe B. (1999) Pressure sore care. Nursing Standard

14(6), 41–44.

Stevenson J. (2000) NHS Responsibilities for Meeting Continuing

Health Care Needs for People Who Live in Nursing Homes or in

Residential Care Homes (Briefing Paper 5). King’s Fund, London.

Sturgess I., Rudd A.G. & Shilling J. (1994) Unrecognised visual

problems amongst residents of Part III Homes. Age and Ageing

23, 54–56.

Taylor C. & Hendra T. (2000) The prevalence of diabetes mellitus

and quality of diabetic care in residential and nursing homes. A

postal survey. Age and Ageing 29, 447–450.

Turrell A.R., Castleden C.M. & Freestone B. (1998) Long stay care

and the NHS: discontinuities between policy and practice. BMJ

317, 942–944.

Twigg J. (1997) Deconstructing the �social bath�: help with bathing

at home for older and disabled people. Journal of Social Policy

26(2), 211–232.

Vernon S., Ross F. & Gould M. (2000) Assessment of older people:

politics and practice in primary care. Journal of Advanced Nursing

31(2), 282–287.

Wanless D. (2001) Securing Our Future Health: Taking a Long-Term

View: an Interim Report. HM Treasury (http://www.hm-treasury.

gov.uk), London.

Webb C. & Kevern J. (2001) Focus groups as a research method: a

critique of some aspects of their use in nursing research. Journal

of Advanced Nursing 33(6), 789–905.

Woolley R. & Goodman C. (2001) A review of the health needs of

older people in residential care settings. Unpublished report,

University of Hertfordshire, Hertfordshire.

World Health Organization (1997) Health 21; Health For All in the

21st Century. World Health Organization European Health For All

Series No. 5. World Health Organization (WHO), Copenhagen.

Worth A. (1996) Identifying need for district nursing: towards a

more proactive approach by practitioners. Ntresearch 1(4), 260–

268.

Yates M., Horan M.A., Clague J.E., Gonsalkorale M., Chadwick

P.R. & Pendleton N. (1999) A study of infection in elderly

nursing/residential home and community-based residents. Jour-

nal of Hospital Infection 43, 123–129.



Documents

District nurses' experiences of providing care in residential care home settings