Development of community nursing: analysis of the central services and practice dilemmas.

As examples of nurse practitioners in primary care, Swedish district nurses have been shown, in several studies, to respond well to the general pressure to achieve higher productivity in health care. Yet they have less frequently been involved in studies of the detailed content of 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 analysis of the daily dilemmas district nurses experience, their consequences, and possible measures for change. For the consultation study, data were collected from 40 videorecordings of office-hour consultations by a rural district nurse. Regarding the dilemma situations, a critical incident questionnaire was returned by 153 district nurses in a Swedish country. The analyses showed that the district nurse practises in an area between self-care on the one hand, and the intersection of the different specialties in health care, on the other. Both the consultation study and the study of dilemmas in practice showed that the district nurse has to approach the health care organisation from a viewpoint close to that of the patient, which implies that she can, and has to, maintain an overview of the patient's total interaction with social institutions. This focal localisation of the shared care and co-ordination aspects constitutes a critical target for change and development efforts. The conclusions are that, first, the role of the district nurse/nurse practitioner as co-ordinator and advocate in patient-centred care could be considered in central health services policies and planning. Second, the content of the district nurses' daily work could be taken into account in the implementation of quality programs. These measures together can lead to an integration between today's theoretical nursing models and the dynamically changing structures of health care organisations.