Introduction
This chapter presents data exploring the experiences and challenges of community nurses in supporting care staff to manage the healthcare needs they are faced with. As well as exploring whether the ignorance demonstrated by the researcher, of the complexity present in these care homes, was unique to her, or if it resonated with other community nurses. In order to add strength to the findings from the original case study and reflections of the practitioner
researcher, the experiences of other community nurses were sought. Data in this chapter were generated from interviews carried out during both phases of the study. In Phase 1 interviews were conducted with four of the district nursing team that supported the case study care home. In the second phase a further 18 interviews were conducted with district nurses and specialist nurses from across The Trust. Those interviewed comprised two district nurse team leaders (DNTL), two district nurses (DN), ten primary care nurses (PCN), two healthcare support workers (HCSW), four community matrons (CM), and two clinical nurse specialists (CNS).
As in the previous chapter findings from the case study were used to direct these subsequent interviews. As previously described, an interview guide was prepared for each interview; however, it was not followed rigidly, but was used as an aide memoire. Once again interviews took the form of a free flowing conversation, allowing, where relevant, emergent topics to be explored in more detail. This chapter begins by presenting data that confirmed many of the researcher’s thoughts and observations from her time spent at the original care home,
confirming that as a district nurse she was not alone in having little understanding of the level of complexity, or the challenges facing these care homes. Next it will present data that did not confirm what she had found. Finally it will present data highlighting a number of new issues raised by the nurse participants, which either challenged the researcher’s initial thoughts and observations, or of which she had been unaware of during her time spent at the original care home. As in the previous chapter, the same headings and sub-headings have been used, in order to make it clear how these findings relate to those in Chapter 6. The findings are also presented diagrammatically in Table 8.
Confirmed findings - Ignorance of complexity
This section will present data from the interviews with the nurse participants that add strength to the findings from the previous chapters. Confirming many of the reflections of the researcher from the case study and/or other care homes, as well as providing further evidence that the service provided by the district nurses risked failing to meet all the needs of residents or care home staff. This is summarised, once again, as:
Level of need and degree of complexity present The added complexity that dementia brings Level of healthcare skills needed by care staff
Level of healthcare support needed by residents
Dissatisfied with the care home/district nurse relationship Funding pressures
Table 8: District nurses response to the complexity
Themes from case
study Sub headings
Confirmed Findings
Unconfirmed
Findings New Findings
Practitioners ignorance of the level of complexity
Level of need and degree
of complexity
Ignoring the complexity in residential care homes Limited access to medical information Added complexity that
dementia brings Levels of healthcare skills
that care staff possessed Level of healthcare support
needed Dissatisfied with the Care
Home/district nursing relationship
Funding pressures
Ignorance of complexity
Level of need and degree of complexity present
Other community nurses appeared ignorant of the level of need and complexity that was present amongst the residents, summarised as:
Residents ‘too complex’ Ignorance of needs
Residents ‘too complex’
Limited understanding was shown by district nursing participants of the changes that had taken place in terms of the residents now living in residential care homes. Assumptions were made by some that if a resident’s needs increased greatly they would simply be transferred to a nursing home:
…..and also I have found a lot of patients that are residential should not be
residential they should be nursing...the amount that they need is not, they are not suitable for residential homes, they don’t get enough...and there is not enough medical input at all, because they are run purely by carers and managers who have
probably not got medical background…..P13, PCN, I
Opinions were expressed such as residents are ‘too frail and too ill’, that care homes were ‘taking on people who are far too complex’ and care staff ‘can’t deal with it’, referring to the health problems they were faced with. A couple of district nurses even expressed an opinion that financial considerations were playing a big part in why certain residents were admitted. There appeared to be little appreciation on the part of many of community nurses that rather than being inappropriately placed, as they believed, these residents were in fact typical of those living in a residential home today.
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Ignorance of needs
Further evidence of ignorance on the part of the community nurses to the complexity present was demonstrated through the service provided to the residents, summarised as:
‘Task orientated’ ‘Simple dressings’ Role lacks clarity
‘Task orientated’
Support provided by the district nursing service appeared, in these care homes, to focus on the meeting of ‘tasks’. In the previous two chapters it was suggested that care staff were unclear of the role of a community nurse, believing that they provided care that was simply ‘task focused’. Sadly, the interviews with district nursing participants did little to dispel this notion, with a number of the nurses themselves using phrases such as ‘focused on tasks’, or ‘task orientated’ to describe the care they provide to residents.
The most common reasons given for visits were for wound care and pressure area care. In certain teams insulin administration was also commonplace. Less frequently mentioned were catheter care, provision of equipment and management of constipation and rarely mentioned was palliative care provision, support, or advice. However, when challenged as to whether problems such as pressure sores, skin tears, leg wounds and constipation were likely to be a true reflection of the healthcare needs of frail, elderly residents, almost all those interviewed had to agree that this was unlikely to be the case. Given the care staff’s ignorance regarding the community nurses’ role, specific tasks may be all that care staff were referring to the service. However, this situation does not appear to be helped by the nurses themselves:
…..They probably do have other health problems but we have only just been asked to see, by the house manager or one of the carers, just asked oh… the patient fell the other night and do you mind just having a look at their leg, where they probably might have just put a plaster or something on it you know. So you know we might well be not asked to see them for things that maybe we should be…..P9, PCN, I …..I think we are a bit more aware of the ones that live out in the community because we tend to look at them sort of like holistically, whereas if you go to a care home....I know that it shouldn’t be, they ask you to look at a leg and that is what you look at, that kind of thing. You don’t tend to look at the whole picture as such because you know they have got food, you know they have got their medicine, you know they are kept clean, or they are supposed to be kept clean, so you don’t tend to look at it that way, or how safe their home is because they are supposed to be in a safe environment...P15, DN, I
As the above accounts demonstrate, participants would often focus on the problem for which they had been asked to visit and there was little evidence of a holistic approach to either
assessment or care being used. The reasons given for this were on the whole put down to time and caseload pressures and will be discussed in greater detail later. The perception by care staff that community nurses only dealt with certain tasks could also explain why the community matrons were often the first service approached for help and support, rather than community nurses.
‘Simple dressings’
Some district nursing participants described their work in care homes as simple or straightforward, talking about providing care for ‘minor’ problems such as lacerations, red bottoms, or as one district nurse put it for ‘simple dressings’. Yet believing their role in a care home to be one in which they merely carry out simple tasks as quickly as possible suggests that more complex healthcare needs risk being missed:
…..half the time the ones that are queuing up in the little surgery part….are only minor stuff, lacerations and things like that, so it is not that they need anything too complex; they are only needing simple, simple dressings….P18, DNTL, I
Visits appeared to focus on the meeting of physical needs. All but one of the nurses interviewed came from a general nursing background and a number acknowledged that they were either reluctant to, or lacked the confidence and skills, to manage certain health needs, in particular mental health issues. There was a tendency to deal only with physical problems and if other issues were noticed, such as the person appearing depressed for example, this would not always be followed up:
…..At the moment I think the role of the DN is purely to go in and do the dressing of wounds, give injections. You know we have a remit and we tend to stick to the remit…I think we tend to put the onus back on the manager, or the owner, saying you know this person seems depressed get the GP in, get this one in, get that one, telling them what to do and maybe asking them 2 weeks later, oh what happened with that, whereas I don’t think really we get too involved…..but maybe we should…P1, PCN, I
Role lacks clarity
Some participants felt their role in care homes lacked clarity, as evidenced by one nurse who mentioned that different district nursing teams were offering different levels of support to care homes, with one team taking on care that another would refuse to be involved with. Others suggested that they should be offering support to both care staff and relatives of residents, overseeing the care residents received, as well as providing teaching and education to care staff. However, as already discussed, there was little evidence of the existence of such a role. Instead the reality appeared to be a service that was focused on providing specific nursing interventions only, could only offer support to those who they had been asked to visit and was heavily reliant on care staff to pick up problems and refer them on, something that, as already mentioned, may not always happen.
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Further evidence of a lack of clarity in regard to their role was demonstrated through the grade of nurse visiting these care homes. It was not uncommon for more junior staff to routinely visit, including HCSWs. What had been of surprise in Chapter 7 was that the team would send in HCSWs, yet this did not appear to be unusual. The HCSWs tended to carry out follow up visits for wound care, pressure area management, or catheter care. However, due to their skill set they were often simply duplicating the care given by the care home staff. Sending in this grade of staff could create problems, with one HCSW mentioning that care staff had been reluctant to take advice from someone who was not a qualified nurse:
…..mainly scrapes or skin tears….pressure relieving, when they have pressure relieving equipment. I might do pressure area checks…..wound care. There might be catheters as well. But normally the care staff in a home change catheter bags and things like that. So I don’t really, we just check to make sure that everything is going OK….P2, HCSW, I
Some of the senior district nursing participants and specialist nurses acknowledged that there was a need for more experienced district nurses to take on a bigger role in care homes, as the increasing levels of healthcare needs required input from nurses who were able to look at things from a different perspective, as well as pick up on issues possibly missed by more junior
members of staff. However, this was not always possible and due to other demands the most senior district nurses, i.e. the team leaders, were rarely visiting these care homes, a situation possibly not helped by the decrease in the number of team leaders that had taken place over the course of the study, putting increasing demands, in terms of managerial responsibility, on their time:
…..generally overseeing things. Because I had a team leader background that is what I used to do, looking at things, looking at a different perspective so I used to try to find out issues that hadn’t been looked at…..I used to see things differently because I always used to go and...see things that the staff nurses hadn’t picked up so, things like...like someone with dementia not having a cot side, or the mattress or things like that, footwear things like that….P22, DNTL/CM, I
The added complexity that dementia brings
Evidence was presented in Chapter 7 of how, as a practitioner, I felt I lacked knowledge and experience of caring for those living with dementia. This was another finding that was confirmed, with the majority of nurse participants experiencing similar challenges, summarised as:
‘It is depressing’
Providing care can be challenging Care practices ignore dementia Need dementia training
‘It is depressing’
Historically dementia care came under the umbrella of mental health teams, with general nurses having limited experience of dealing with this client group. The majority of participants felt they lacked the necessary knowledge and/or skills in dementia care, with many frustrated that they didn’t always know how best to help patients living with dementia:
…..it is very challenging...it is hard, extremely hard because you want to ask them, you want to ask them something but you don’t get no reply, so you have to watch out for facial expressions...any hand movements, anything like that. But it is, it is hard...extremely hard….P12, HCSW, I
…..I find it depressing really because it is so sad to see them and...I mean they think they are fine but they are not fine, they need an awful lot of help and support. I am not qualified in that area at all and I would like more information, like more study days, just something because it is, it is so sad…..P17, PCN, I
The majority of nurses interviewed, whether working with the district nursing service, or as specialist nurses, had experienced some difficulty caring for this group of patients. Many would use negative words such as ‘‘difficult’, ‘challenging’, ‘frustrating’, ‘hard’, ‘depressing’,
‘demanding’ and even ‘upsetting’ to describe their experiences of working with these patients. Those who had previously worked in social care, or on elderly care wards, were less likely to use such language.
Providing care can be a challenge
Participants identified a number of areas of care provision that they found particularly
challenging. The one that appeared to present the biggest challenge was dealing with what was perceived to be challenging, or unpredictable behaviour and/or aggression. Many participants spoke of finding such behaviour difficult to cope with, especially if they were not supported by a member of care staff and, as they didn’t want to inflame a situation, would walk away and try to visit again later in the day, putting further pressure on their time. Another challenge was residents who were ‘non-compliant’ with nursing care. An area that appeared to be especially problematic was the administration of insulin to a resident living with dementia. As this participant explained:
…..we had a lady with dementia…who we had to give her insulin, every day, every single day and this lady did not understand why she had to have insulin…and every time we went you had to try to explain to her….the minute she saw the needle she just flipped….one nurse went to give her the insulin and she just pushed the nurse and the nurse stuck the needle in herself, so you know that it was then, because of the injury to the nurse, that it was decided to, that they needed to do something about it. This had gone on for months and we had all been saying that we need to do something about this, so we finally got the diabetic nurses to look at it, to assess does this lady have to have her insulin this way and it
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turned out that no she didn’t, that she could go on to tablets….This lady was much happier, the nurses were much happier and the staff were much happier, because they use to dread us coming in….P1 PCN, I
Patients requiring insulin would normally be visited at the beginning of the nurses’ shift, the time when care staff could also be very busy and so were not always on hand to provide support. A number of district nursing participants gave examples of residents refusing care, or becoming, as they called it, agitated and even aggressive, resulting in nurses having to revisit, sometimes on numerous occasions, as the insulin could not be given. Some participants were particularly concerned that a lack of knowledge and skills in this field had resulted in them failing to pick up problems amongst this group of residents. They spoke of difficulties communicating with residents and as a result were unsure if needs were fully assessed. For this reason they were heavily reliant on the care staff to provide them with information and assistance. However, the situation was made more difficult if a member of care staff did not know the resident, or did not volunteer to accompany them when they visited the resident. This, it was reported, was more likely to happen if the resident was not living on a specialised dementia unit:
Issues such as these were made harder if participants then encountered difficulties accessing support from other healthcare professionals. Problems reported included assumptions made that care homes should be able to manage, as well as other healthcare professionals themselves lacking knowledge and skills in the field and unable to offer any useful support or guidance. One participant spoke of the frustration they had felt on being told by a specialist nurse, who was approached for advice, ‘I don’t know, but when you figure it out ring me back’.