DEVELOPMENT OF COMMUNITY NURSING - ANALYSIS OF THE CENTRAL SERVICES AND PRACTICE DILEMMAS

As examples of nurse practitioners in primary care, Swedish district n urses have been shown, in several studies, to respond well to the gene ral pressure to achieve higher productivity in health care. Yet they h ave less frequently been involved in studies of the detailed content o f the service they provide. To maintain total service quality, change should not be brought about only for the sake of efficacy. This study is divided into an analysis of the basic service provided in district nursing by identifying a typical interaction with a patient; and an an alysis of the daily dilemmas district nurses experience, their consequ ences, and possible measures for change. For the consultation study, d ata were collected from 40 videorecordings of office-hour consultation s by a rural district nurse. Regarding the dilemma situations, a criti cal incident questionnaire was returned by 153 district nurses in a Sw edish county. The analyses showed that the district nurse practises in an area between self-care on the one hand, and the intersection of th e different specialities in health care, on the other. Both the consul tation study and the study of dilemmas in practice showed that the dis trict nurse has to approach the health care organisation from a viewpo int close to that of the patient, which implies that she can, and has to, maintain an overview of the patient's total interaction with socia l institutions. This focal localisation of the shared care and co-ordi nation aspects constitutes a critical target for change and developmen t efforts. The conclusions are that, first, the role of the district n urse/nurse practitioner as co-ordinator and advocate in patient-centre d care could be considered in central health services policies and pla nning. Second, the content of the district nurses' daily work could be taken into account in the implementation of quality programs. These m easures together can lead to an integration between today's theoretica l nursing models and the dynamically changing structures of health car e organisations. Copyright (C) 1996 Elsevier Science Ltd.