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
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� 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
� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 67–76
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
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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.
Issues in developing nursing practice Providing care in residential care home settings 71
� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 67–76
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
72 C. Goodman et al.
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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
Issues in developing nursing practice Providing care in residential care home settings 73
� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 67–76
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
74 C. Goodman et al.
� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 67–76
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.
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