Background
Methods
Research design
Narrative of a typical home visit in nursing homes | You have been working here in a nursing home for some time. Today we are interested in your experience of how a nursing home visit is usually carried out. Tell us about typical situations as well as positive and negative experiences during the visits? Can you describe exemplary situations? |
Description of the last GP visit | Could you please recall your last home visit to a nursing home resident? How did this particular visit go? Please describe the visit in detail. |
Experience with areas of responsibility and distribution of tasks | We are interested in the distribution of tasks in a nursing home. What are your tasks and responsibilities, and what are the tasks and responsibilities of the nursing home staff? |
Ideas and vision about the ideal care in a nursing home | Give your imagination free reign. How do you imagine ideal medical care in a nursing home would be provided? What would you like to see; also in the case if your parents were residents there? What do you think the nurses would expect? What process might be optimal for the nurses? And what processes would be best for the residents and what would they likely prefer? |
Participants
Characteristics | Number included |
---|---|
Gender | |
male | 21 |
female | 9 |
Age | |
36–40 | 2 |
41–50 | 8 |
51–60 | 12 |
61–71 | 8 |
Years of work experience as a physician | |
11–15 | 4 |
16–20 | 5 |
21–25 | 6 |
26–30 | 5 |
31–38 | 10 |
Data collection
Data analysis
Results
Core category “productive performance” of home visits and its context
“so that a reasonable mixed calculation is somehow profitable in the end. You can´t care for too many residents in nursing homes who, ah, disrupt the schedule so much so that surgery appointments aren’t possible” (AA6/42)
Types of home visits
Types of home visits | Influencing conditions and causes | Strategies to achieve “productive performance” | Consequences of “productive performance” |
---|---|---|---|
• Visits on demand • Periodic visits • Nursing home round • Visits based on ad-hoc-decisions | • Nurse characteristics • Resident characteristics • Nursing home environment | Preparing strategies • Scheduling and planning • Preparing On-site strategies • Gathering information • Seeking nurses´ attendance • Decision making • Taking care of the resident Investing strategies • Instructing and teaching • Dealing with documentation • Providing information | • Satisfaction • Annoyance • Disrespect • Avoiding contact to the nurses • Give up care |
“the nursing home calls me, the patient complains of foot pain, I would like to check that”(BA2/7)
“the resident has dyspnea, ah, I won´t visit but will call the ambulance instead. There´s no reason to attend because I would be on my own without the necessary equipment or staff to assist me“(CA3/4)
“I personally do the rounds in two nursing homes, today I saw about 40 residents on two wards in one nursing home between 7:30 and 11:30. I went there, was expected, the nursing staff were waiting for me and had prepared a book with the questions of the day. I advised them to set up this book” (AA1/3)
“first I meet up with the nurse (…) we sit down together and talk theoretically who should be visited and what I have to sign and so on. After that I go through the nursing home to the individual residents” (AA10/54)
“depends whether there was something out of the ordinary”(CA1/2).
Influencing conditions and causes
Nurse characteristics
“for example I currently undertake wound management for a resident who has very bad …problematic wounds and I do this exclusively with the head nurse” (BA1/4)
“well, [the claiming of time] varies between the nursing homes, depending on nurse or the geriatric nurses qualifications“ (BA3/32)
"How are the blood glucose levels? (…) This often gives the opportunity to obtain a lot of information from the [nursing staff] (…) often very precise and exact statements about the mental status of the patient, especially from the experienced nurses. How well [the resident] is integrated, are there any changes or mental problems? This is also often very helpful” (CA1/10)
"one of them suffers from Alzheimer´s disease, the other is over100 and also has dementia. I only visit them with the same nurse because [the resident] is anxious with people she doesn´t see regularly” (BA4/54)
“where someone is quasi waiting for me” (AA3/14)
“and then you initially have to search for a quarter of an hour until you find a nurse” (CA5/46-48 )
Resident characteristics
“people are glad to be visited so they don´t have to go to the practice. Many of them couldn´t even come. Well, this is always really pleasant” (AA6/22)
Nursing home environment
“well, the opportunity to work with a team of nursing staff. It’s a bit like that in a hospital. In the practice, you are on your own, I am alone with my patient and [in the nursing home] the nurse is attending and this seems to me like a hospital atmosphere – I like that”(AA10/100)
Strategies to achieve “productive performance”
Preparing strategies
Scheduling and planning
“the typical days for home visits in City1 are the afternoons of Wednesday and Friday. You can imagine, on these two days, one or two nurses and ten GPs are ready to visit. I think it´s more relaxed to visit the nursing home in the morning when no one else is there. I have all the time in the world, there is no pressure (laughing) the nurses normally have finished breakfast and that has proven its worth“(CA5/20)
Preparing
“we ask the nurses for a fax detailing which of the residents require a visit so that we know who requires a smear test or if suture material is needed, or anything else that we additionally have to bring . The list is sent back a day before the visit, mostly in time. And I take all the relevant patient-records with me” (AA2/8)
“I immediately expressed my upset that I want to know something like this [hospital admission]” (CA4/34)
On-site strategies
Gathering information
Seeking nurses´ attendance
“they [the residents] tell me things they won´t tell to other people and therefore nobody else should come along” (AA7/118)
Decision making
“so I decided with the others and against the explicit instructions of [the head nurse] , that [the resident] will stay here. I cannot do otherwise” (CA5/128)
Taking care of the resident
“Finally I talked to [the resident] for only twenty minutes and otherwise we didn´t change anything concerning the therapy? And then she was also satisfied” (AA/50-54)
“however they are socially isolated to some degree. Relatives don´t come around and sometimes there aren’t any friends any more. In this respect, I am just a conversation partner and simply listen to one or other minor problem which is sometimes outside the medical sphere”(CA2/28)
Investing strategies
Instructing and teaching
“I observed while she [the resident] was being tested and recognized that she wasn’t inhaling correctly (…) I took the opportunity to go through all details about the application with the nurses” (AA9/68-76)
Dealing with documentation
“they [nurses] print it for me to sign so that it is documented and then taken forward” (CA/25)
Providing information
“well, I try to do it in a personally way, that seems to be the best for me. If that doesn´t work because they [the nurses] are in the resident rooms, I go to their office and put it properly on the table”(AA2/87)
Consequences of “productive performance”
Satisfaction
“it represents a sensible ward round, that both professionals have the same level of knowledge. This happens best when the same is seen at the same time” (AA5/21)
"and I even get a coffee and some cookies and we [the nurse and I] talked privately, something normally that there is no time for. I found that was very nice. (…) and we chatted a bit."(AA2 / 51–53)
“finally I talked to her [the resident] for twenty minutes and otherwise we didn´t change anything, eh? Therefore she was satisfied” (AA/50-54)
Annoyance
“the resident had a swollen hand and I arrived but I couldn´t see any swelling. I was upset, I can tell you (…) And none of the nurses could even say why they called me” (AA7/94-96)
Disrespect
“and in the time required for me to spell Hydrochlorothiazide for them [the nurses],it would have been faster if I had written it down myself” (AA1/129-133)
Avoiding contact to the nurses
“on one ward I experienced very poor collaboration, so I decided not to go to the nurses’ office any more. I just collected the documents I needed, went to the residents and communicated by fax (…) that is definitely not good behavior for a physician“ (AA8/128)
Give up care
“the care became more and more disputed, so I asked to be replaced by another GP” (AA07/213)