Methods
Four municipalities out of 33 in a southern Sweden region of 1200000 inhabitants were selected to obtain demographic and socio - economic variety. The municipalities represented a big city inner district, a small city and two rural municipali- ties. Eligible participants were RNs who had at least two years’ experi- ence of a home nursing service, and who were presently employed by a municipality’s public home care nurs- ing organisation. All RNs (n=168) in each municipality were contacted through the medically responsible nurses who sent out an email with an invitation to participate. Fifteen RNs accepted the invitation. (Table 1.) The participants were all women, had worked as an RN for 3–41 years (median 25), and in home nursing for 2–18 years (median 8). Nine of the nurses had a specialist exam in district nursing, one had a specialist exam in another specialty and three had a shorter (15 credits) course in diabetes nursing. The interviews were carried out individually during 2009. Thirteen interviews took place at the RNs’ offices in connection with their regular work, one took place in the RN’s home and one in a public place. In order to obtain extensive information of present and past experiences, a qualitative interview
method with open questions was chosen.19 The interview questions were explorative and were created according to the researcher’s pre- knowledge as RN in prevention of the diabetic foot.14 In a pilot interview with six people working in a specialist diabetes foot clinic, the questions were tested prior to the study. The ques- tions were thereafter analysed by the research group, all RNs, and evolved into three overarching general ques- tions: What do you do to prevent ulcers on the feet of patients with diabetes? How did you learn this? How can the work with pre- vention of diabetic foot ulcers be improved, locally or in an extended context? The open-ended questions were followed by more targeted questions, based on the researchers’ pre-knowl- edge of diabetes and a home nursing service. For example: What does your staff education consist of? How is your documentation system organised? The interviews lasted for 35–64 minutes (mean 43 minutes), and were taped and transcribed verbatim by the interviewer as soon as possible after the interview. A directed manifest content analy- sis as described by Hsieh and Shannon20 was used in order to identify nursing actions for foot ulcer prevention, as described in the inter- views. By systematically categorising the described work using the formal requirements in the competence description and the nursing process, the very different working tasks could
be sorted and merged into cate- gories. A recording scheme to system- atically categorise the described work into the pre-determined categories and themes was developed prior to the study, based on RNs’ competency description21 and the nursing process.22 (Table 2.) The themes with subcategories were: leadership (for- mal/informal/executive tools); nurs- ing practice (assessment/planning/ nursing action/evaluation); educa- tion (patient/next of kin/HCA/ content/educational method); and research and development.21 Quotes and statements that expressed the categories were merged under each theme. Any doubts about which cate- gory a statement best belonged to were discussed in the research group until consensus was reached. The results are presented under each theme and are exemplified by quotes that express a general opinion of the interviewed nurses. This study was approved by the Regional Ethical Board in Lund, Sweden (Dnr 2009/27).