Discussion
L e a d e r s hip
The main results of this study show that RNs in municipalities’ home nursing protect the feet of patients with diabetes by working through others: educating HCAs, leading and evaluating their work, and by avoiding sending patients to hospital unneces- sarily. The RNs are dependent on competent HCAs to perform the nursing process. This situation has been described by Gustafsson et al. as being interdependently dependent.23 The RNs reported diabetes foot ulcers as uncommon, that they treated few foot ulcers, and that foot ulcers mainly originated from hospital stays. This is in contradiction to results from Annersten Gershater et al., who found that 21% of home nursing documen- tation mentioned ongoing foot ulcers, and Prompers et al. concluding that 17% of new patients at 12 European foot clinics were known as home nursing patients.12,13A recent study by Campbell et al. showed that, in patients going through orthopaedic surgery, pressure heel ulcers were developed in acute care in 17% of patients, whereas in community care no ulcers were observed.24 Campbell’s result, implying that foot ulcer prevention is possible, supports the stories of the interviewed RNs. This needs to be explored further. The organisation and the diffuse number of patients for whom RNs are responsible reflect the paradigm of elderly care as social care with medical and nursing service added on top. Flynn et al. have shown that a more supportive nursing practice environ- ment is associated with lower frequencies of pressure ulcers, recommending nurses to participate in organisational decisions, and con- tinuing education opportunities to improve quality of care.25The RNs are by law obliged to provide prevention, but this is not recognised by the social service organisation,26 which does not promote competency development.
Discussion
L e a d e r s hip
The main results of this study show that RNs in municipalities’ home nursing protect the feet of patients with diabetes by working through others: educating HCAs, leading and evaluating their work, and by avoiding sending patients to hospital unneces- sarily. The RNs are dependent on competent HCAs to perform the nursing process. This situation has been described by Gustafsson et al. as being interdependently dependent.23 The RNs reported diabetes foot ulcers as uncommon, that they treated few foot ulcers, and that foot ulcers mainly originated from hospital stays. This is in contradiction to results from Annersten Gershater et al., who found that 21% of home nursing documen- tation mentioned ongoing foot ulcers, and Prompers et al. concluding that 17% of new patients at 12 European foot clinics were known as home nursing patients.12,13A recent study by Campbell et al. showed that, in patients going through orthopaedic surgery, pressure heel ulcers were developed in acute care in 17% of patients, whereas in community care no ulcers were observed.24 Campbell’s result, implying that foot ulcer prevention is possible, supports the stories of the interviewed RNs. This needs to be explored further. The organisation and the diffuse number of patients for whom RNs are responsible reflect the paradigm of elderly care as social care with medical and nursing service added on top. Flynn et al. have shown that a more supportive nursing practice environ- ment is associated with lower frequencies of pressure ulcers, recommending nurses to participate in organisational decisions, and con- tinuing education opportunities to improve quality of care.25The RNs are by law obliged to provide prevention, but this is not recognised by the social service organisation,26 which does not promote competency development.
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