Modin Sonja, Törnkvist Lena, Furhoff Anna-Karin, Hylander Ingrid
Department of Neurobiology, Care Science and Society, Centre for Family and Community Medicine, Karolinska Institutet, Alfred Nobels allé 12, S-14284 Huddinge, Sweden.
BMC Fam Pract. 2009 Jun 22;10:45. doi: 10.1186/1471-2296-10-45.
District nurses (DNs) provide home care for old persons with a mixture of chronic diseases, symptoms and reduced functional ability. Family physicians (FPs) have been criticised for their lack of involvement in this care. The aim of this study was to obtain increased knowledge concerning the FP's experience of providing medical treatment for patients with home care provided by DNs by developing a theoretical model that elucidates how FPs handle the problems they encounter regarding the individual patients and their conditions.
Semi-structured interviews were conducted with 13 Swedish FPs concerning one of their registered patients with home care by a DN, and the treatment of this patient. Grounded theory methodology (GTM) was used in the analyses.
The core category was the effort to stay in charge of the medical treatment. This involved three types of problems: gaining sufficient insight, making adequate decisions, and maintaining appropriate medical treatment. For three categories of patients, the FPs had problems staying in charge. Patients with reduced functional ability had problems providing information and maintaining treatment. Patients who were "fixed in their ways" did not provide information and did not comply with recommendations, and for patients with complex conditions, making adequate decisions could be problematic. To overcome the problems, four different strategies were used: relying on information from others, supporting close observation and follow-up by others, being constantly ready to change the goal of the treatment, and relying on others to provide treatment.
The patients in this study differed from most other patients seen at the healthcare centre as the consultation with the patient could not provide the usual foundation for decisions concerning medical treatment. Information from and collaboration with the DN and other home care providers was essential for the FP's effort to stay in charge of the medical treatment. The complexity of the situation made it problematic for the FP to make adequate decisions about the goal of the medical treatment. The goal of the treatment had to be constantly evaluated based on information from the DN and other care providers, and thus this information was absolutely crucial.
地区护士（DNs）为患有多种慢性病、有症状且功能能力下降的老年人提供居家护理。家庭医生（FPs）因未充分参与此类护理而受到批评。本研究的目的是通过建立一个理论模型来增加对家庭医生为接受地区护士居家护理患者提供医疗服务经验的了解，该模型阐明了家庭医生如何处理他们在个体患者及其病情方面遇到的问题。
对13名瑞典家庭医生就其一名接受地区护士居家护理的注册患者及其治疗情况进行了半结构式访谈。分析采用扎根理论方法（GTM）。
核心类别是努力掌控医疗服务。这涉及三类问题：获得足够的洞察力、做出适当的决策以及维持适当的医疗服务。对于三类患者，家庭医生在掌控方面存在问题。功能能力下降的患者在提供信息和维持治疗方面存在问题。“固执己见”的患者既不提供信息也不遵循建议，而对于病情复杂的患者，做出适当决策可能存在问题。为克服这些问题，采用了四种不同策略：依靠他人提供的信息、支持他人进行密切观察和随访、随时准备改变治疗目标以及依靠他人提供治疗。
本研究中的患者与在医疗中心就诊的大多数其他患者不同，因为与患者的会诊无法为医疗决策提供通常的依据。来自地区护士和其他居家护理提供者的信息以及与他们的合作对于家庭医生努力掌控医疗服务至关重要。情况的复杂性使得家庭医生难以就医疗服务目标做出适当决策。必须根据地区护士和其他护理提供者提供的信息不断评估治疗目标，因此这些信息绝对至关重要。
