Care for communitydwelling frail older people: a ...

ORIGINAL ARTICLE

Care for community-dwelling frail older people: a practice nurse perspective Jill Bindels , Karen Cox, Guy Widdershoven, Onno CP van Schayck and Tineke A Abma

Aims and objectives. To evaluate care programmes for community-dwelling frail older people from a practice nurse perspective and gain a deeper understanding of their role within the programmes. Background. In response to the increasing frail population, three regions in the Netherlands implemented care programmes, in which a proactive approach is used to identify frail older people in the community and provide them with the appropriate care and support. Design. A constructivist grounded theory approach. Methods. A formative process evaluation was performed, in which study participants were practice nurses (n = 23) focusing on the identification of and care for frail older people in primary care settings. Based on the principles of grounded theory, data were collected via semi-structured interviews and focus groups and analysed. Results. The practice nurses explain that ‘building a trusting relationship’ with the older person and ‘making connections’ between older people, family and other professionals are key elements of good care in the programmes. ‘Targeting the wrong audience’ and ‘providing good care’ reflect the doubts and feelings of insecurity the practice nurses have about the screening and selection procedures and their own role and expertise in the programme. Conclusion. According to the experiences of practice nurses, a trusting relationship with the older people is necessary to provide good care. Practice nurses feel they should receive more support and education to conquer issues concerning social problems in frail older people. Moreover, practice nurses considered the screening and selection procedures to be unsuccessful in identifying frail older people who do need care. Relevance to clinical practice. A trusting relationship should be given high priority in the care for community-dwelling frail older people. To improve the care programmes, screening and selection procedures need adjustments. Practice nurses should receive more support in dealing with older people with psychosocial problems.

Authors: Jill Bindels, MSc, PhD Student, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht; Karen Cox, PhD, Dean, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht and Fontys University of Applied Sciences, School of Nursing, Eindhoven; Guy Widdershoven, PhD, Professor, Department of Medical Humanities, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam; Onno CP van Schayck, MD, PhD, Professor, Department of General Practice, CAPHRI

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12513

What does this paper contribute to the wider global clinical community?

• Screening of frailty does not indi•

cate the degree in which older people want or need care. Care for frail older people not only consists of a set of predefinable tasks, but also requires competence, responsiveness and attentiveness that are vital values in providing frail older people with good care.

School for Public Health and Primary Care, Maastricht University, Maastricht; Tineke A Abma, PhD, Professor, Department of Medical Humanities, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands Correspondence: Jill Bindels, PhD Student, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands. Telephone: +31 43 388 1983. E-mail: [email protected]

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Key words: care ethics, frail older people, frailty, home visits, practice nurses, primary care, relationship Accepted for publication: 19 October 2013

Introduction Nowadays, the healthcare system is experienced as fragmented and not yet prepared for an ageing population which increasingly suffers from multiple health conditions [The Organisation for Economic Cooperation and Development (OECD 2011)] With an ageing population, the number of frail older people increases as well (Wilhelmson et al. 2011). Frailty is one of the major problems faced by older people and is a risk factor for adverse health outcomes, such as falls, disability and even death (Fried et al. 2001). In 2008, the Dutch government launched The Dutch National Care for the Elderly Programme to improve care for frail older people. In the framework of this programme, a regional cooperation is set up between three regions in the province of Limburg in the southern part of the Netherlands. These regions have implemented care programmes to identify and support frail older people (Metzelthin et al. 2013, Stijnen et al. 2013). Practice nurses (PNs) working in primary care practices function as case managers for frail older people in those care programmes. Practice nurses have a significant role in the care programmes, and their contributions and attitudes are therefore crucial to the success and effectiveness of the programmes. Thus, the aim of our study is to gain a deeper understanding of the PNs’ role in the programmes and their perception on the care for frail older people. The evaluation was designed as a formative process evaluation; a process evaluation is suitable, first and foremost, to identify what actually occurs in complex care interventions. This knowledge is needed to understand and explain the effectiveness of such interventions (Hulscher et al. 2003). More specifically, this study addresses the following research question: What meaning do PNs endow to the process of identifying and caring for frail older people living in the community and how can this care process and the role of the PNs be optimised?

Background Due to fragmented and uncoordinated care, problems experienced by frail older people can remain undetected (Lowenstein 2000). Adverse health outcomes of frailty can

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put a burden on society by creating higher health expenditures due to increased hospitalisation and demand for longterm care (Slaets 2006). Primary care practice seems pre-eminently suitable to coordinate care for frail older people because of the local orientation and focus on the person instead of the illness (Lacas & Rockwood 2012). In the Netherlands, PNs in primary care see patients in the primary care practice or visit patients at home, and they are mainly involved in the care for chronic patients. The PNs use disease-specific protocols under supervision of a general practitioner (GP) (Derckx 2006). The role of nurses in primary care is growing. A review from Laurant et al. (2005) showed that nurses in primary care can provide as high quality of care as GPs and perceive their work with older patients as a joyful but complicated activity (Fagerberg & Kihlgren 2001). Interventions aimed at preventing adverse health outcomes related to frailty among older people show conflicting results (Beswick et al. 2008). Daniels et al. (2010) conclude that interventions focusing on frail older people might be effective if they include an individualised assessment, are tailor-made, and have multiple components such as physical exercise and the use of technology. Van Haastregt et al. (2000) found that preventive home visits showed no effects. A multicomponent intervention focusing on environmental and behavioural changes was found to be effective at reducing perceived functional difficulties (Gitlin et al. 2006). Despite the many interventions that have been developed, it is still unclear why certain results are achieved. A qualitative approach can help to gain a better understanding regarding why some interventions are successful, while others are not (Beswick et al. 2008, Gustafsson et al. 2009).

The programmes The care programmes implemented in the three regions focus on the identification and care of frail older people living in the community. Within the programmes, PNs and GPs proactively approach potentially frail communitydwelling older people to assess their health and prevent a further deterioration of problems. Although the programmes slightly differ in the three regions, the main elements are the same. These elements and the differences © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing

Original article

between the care programmes are described below. More detailed information about the care programmes can be found in the articles of Metzelthin et al. (2010) and Stijnen et al. (2013). In each of the care programmes, the PN, in cooperation with the GP, screens or selects older people that are possibly frail (step 1). In one region, the Groningen Frailty Indicator (GFI) is used to screen community-dwelling people of 70 years or older. The GFI is a 15-item postal screening instrument that includes questions concerning the physical and psychosocial factors of frailty (Steverink et al. 2001). In the other two regions, the GP and the PN select community-dwelling people aged 75 years or older from their information system who, according to their opinion, might be frail. In all three regions, home visits are performed by the PN to further assess the health of the selected older people (step 2). The PN uses an assessment tool that consists of questions focusing on several domains of health, such as polypharmacy, mobility problems, physical activity and problems on the social domain. If additional examination is necessary, the PN can perform a second assessment or bring in other professionals (e.g. geriatrician, occupational therapist) (step 3). In collaboration with the GP and the older person, the PN develops a care plan (step 4). In one region, a toolbox is included in the protocol which supports the PN in developing a care plan. This toolbox is organised around five topics to guide the treatment: meaningful activities, adapting the environment, activities or skills, social network and social activities, daily physical activities and stimulate health (Daniels et al. 2011). The care in the other two regions may consist of additional diagnoses, preventive care or advice, treatment in primary health care or referral to other professionals (Stijnen et al. 2013). The remaining steps consist of providing the care or referring to other professionals who provide the care (step 5) and conducting an evaluation and follow-up (step 6).

Method Design The overall evaluation of the programmes was designed as a responsive evaluation (Stake 1980, Abma 2006). A responsive evaluation aims to enhance the dialogue among the stakeholders of an intervention or programme and create the mutual understanding which is a necessary condition for improvements (Abma 2005). In responsive evaluation, healthcare programmes and interventions are assumed to have different meanings for those involved © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing

Care for community-dwelling frail older people

(Abma 2006). Therefore, several stakeholders are included in the overall evaluation of the programmes: the older people, healthcare professionals and policymakers. In this paper, we focus on the perspective of the PNs. A constructivist grounded theory (CGT) approach was used to explore the experiences of PNs. Grounded theory seemed an appropriate method because it encourages an open exploration of the PNs’ experiences (Guba & Lincoln 1989). Data collection and data analysis were performed simultaneously, and preliminary analyses were used to focus the collection of further data (Charmaz 2006). Indepth interviews and focus groups were used to gather the data. This study obtained approval of the medical ethics committee of the University Hospital Maastricht/Maastricht University.

Participants Twenty-three PNs (22 women and one man; aged 27–59) of 39 that were working in the care programmes participated in the study. Due to their role as case manager, their view and perspective on the care process can provide valuable insights into the implementation of the programme and help to explain the relative success and effectiveness of the care programmes. All PNs are working in primary care practices in the Netherlands and had between 1–20 years of experience caring for older people. All PNs have a registered nursing degree or are doctor’s assistants who have followed a two-year practice nurse programme at bachelor level. To elaborate on the categories that came up during the data gathering and analysing process, emergent purposeful sampling was used to select PNs for the in-depth interviews until saturation of the emerged themes was reached (Draucker et al. 2007). The selection of PNs depended on the themes that came up during the analysis. The analyses included themes such as the follow-up of patients and the relationship between the PNs and their patients. To examine these themes, we selected PNs who already had performed follow-up home visits. For the interviews, project leaders of the care programmes approached PNs through email or telephone. The researcher informed PNs about the content and the purpose of the research. In total, 12 PNs participated in interviews. After the interview phase, all 39 PNs were invited to participate in three focus groups; 14 PNs attended the focus groups meetings, of which three also participated in the interviews. The PNs received the invitation through email followed by a phone call for those who did not respond or did not give a reason for absence. The low number of par-

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ticipants fact that fore not meetings

in the focus groups meetings is explained by the many of the PNs work part-time and were thereavailable on the dates on which the focus group were organised.

Data collection The data were collected from May 2010–February 2012. Prior to the data collection, the first author observed the PNs during ten home visits, totalling 16 hours, during which time, the researcher focused on the interaction between the older people and the PNs and the procedure the PNs followed during home visits. By observing the PNs prior to data collection, the researcher gained a contextual understanding of the programme processes (Freeman & Hall 2012). To obtain the personal views and experiences of the PNs, the first author (JB) conducted semi-structured interviews in PNs’ workplaces. The interviews lasted between 45–60 minutes. During the interviews, a topic list was used. Examples of topics addressed were methods used to assess the frail older people, reactions of older people, problems experienced during the care process, cooperation with other professionals and job support. To achieve a focus and define gaps in the emerging theory, the topic list was reconsidered and adjusted if necessary after each analysis phase (Charmaz 2006). All interviews were recorded on tape and transcribed verbatim. The focus groups were organised to gather rich data by creating an interaction between the participants. Based on the analysis of the in-depth interviews, the first and second author (JB and KC) developed a case description of a frail older person. This case description formed the starting point of the dialogue. The moderator of the focus groups [the second author (KC) and later the first author (JB)] guided the dialogue and addressed the following topics: assessment and selection procedure, identified health problems of older people, collaboration with other professionals, case management and self-perceived difficulties. The focus groups lasted between 15–2 hours and were taperecorded and transcribed verbatim.

Data analysis Within the CGT method, data were explored and qualitative codes and categories were identified during, instead of, before data analysis. Data analysis and data collection were both part of an iterative process of induction and deduction (Charmaz 2006). Therefore, data analysis was carried out at several moments in time during the data collection process. Two researchers [first author (JB) and second

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author (KC)] read the entire interview transcripts to identify emerging themes and subthemes. Open codes were attributed to text fragments. First, each interview was analysed separately, after which the analysis of the different interviews was compared. In the last step of the data analysis, the third and fifth researchers (TA and GW) were involved. An analysis scheme was developed that integrated all themes and subthemes.

Ensuring rigour The language spoken during the interviews was Dutch, and to avoid potential bias in the analysis due to the translation of the extracts, the following steps were taken. The extracts of the data were kept in Dutch as long as possible. The research team discussed the translation and involved a professional translator to maintain the meaning of quotes (Nes et al. 2010). The research team discussed the point of saturation and decided that repetition of findings occurred after consulting 23 PNs. To increase trustworthiness and gain familiarity with the research setting, the researcher (first author) stayed in the research setting for 16 hours during observations. Method triangulation was reached using observations, interviews and focus groups to gather the data. Furthermore, the data were analysed by multiple researchers, which increases the dependability of the findings (Polit & Beck 2008). To increase transferability of the findings, thick description was used. A thick description includes information on the context and meaning of the studied setting, including the use of long quotes of the participants to adequately represent their voice (Ponterotto 2006). This provides the readers with the opportunity to vicariously experience the events described and to evaluate for themselves to which degree the findings are applicable to their own situation (Abma & Stake 2001).

Results Four main themes emerged from the data: ‘building a trusting relationship’, ‘making connections’, ‘targeting the wrong audience?’, and ‘providing good care.’ The PNs describe that ‘building a trusting relationship’ and ‘making connections’ with patients, family members and other professionals are key elements in detecting problems and providing care for frail older people. The themes ‘targeting the wrong audience?’ and ‘providing good care’ reflect the doubts PNs have with regard to the care they provide and the selection procedures included in care programmes for older people. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing

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Building a trusting relationship According to the PNs, building a relationship with the older person and gaining their trust is essential in providing care. PNs describe why a trusting relationship with their patient is important and explain how they try to establish a trusting relationship. The need for a trusting relationship Practice nurses explain that it is necessary to gain trust before the older people share their problems and experiences with the PNs:


and experience of the PN can help in creating this relationship. PNs have to find creative ways to get in contact with the older people: It can often be important to have a reason to visit, even if it’s just to measure a person’s blood pressure, which has to be repeated again, and each time you try to gather a little bit more information and win a bit more trust. (PN 8, Focus group)

In some cases, the PN chooses to wait and carefully monitor the situation until the older person is aware of their worrisome health situation and their need for medical or social care:

So you sometimes need to have a few conversations before you

I… and not just me… but also the doctors in our practice assume

bond with people and before they dare to open up more. (PN 13,

that people have to want it. And sometimes it is better to just wait

Focus group)

and observe while the situation gets worse, instead of forcing the

Building a trusting relationship with the older people is especially needed when they avoid care: I had this one lady who literally slammed the door on me, like um, no I didn’t ask for that. Now, one and a half years later, I’ve finally won her trust, and only then can you achieve something. (PN 11, Focus group)

Strategies to develop a trusting relationship Practice nurses use different strategies to build a trusting relationship. In some cases, the PN knows the older person through other care programmes, in which the PN was working (e.g. diabetes or chronic obstructive pulmonary disease programmes). In cases such as these, it is easier to establish a trusting relationship. If older people are suspicious of the PN, the GP can help the PNs get access to the older people, because of the long-lasting relationship with their patients and the respect most patients have for their GP: What they [the older people] respond well to with me is when I say: the doctor is concerned and would like me to come and visit to see how you’re doing. (PN 6, Focus group)

Taking time for the older people to get acquainted with the PN and letting the older people share their story are often mentioned in the interviews and focus groups. More home visits and recurrent contact seeking by the PN are necessary to hear the older person’s stories and gain their trust: I sometimes notice that you really need to go back a number of times if you want to get anywhere with a patient. (PN 7, Focus group)

Some PNs explain that building a trusting relationship is a dynamic process, and the steps are not fixed. Intuition

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing

patient. (PN 10, Focus group)

Making connections Within the care programmes, PNs visit older persons at home and report their findings back to the GP. PNs describe themselves as connectors between older people and the GP: And that’s what he [the doctor] says: you’re my ears, eyes and hands, because it’s often in the last 10 minutes, after sitting at home with someone for an hour, drinking coffee for an hour and listening to all their stories about the children, grandchildren and how things were so different in the past, that you get hold of something. I’d definitely say that I often know more about people than the GP. (PN 10, Focus group)

If necessary, PNs also establish contact and collaborate with other professionals to provide the appropriate care for older people. By recurrent contacts, PNs find it easier to collaborate with other professionals. PNs define themselves as spiders in the web of care for frail older people; they often are the contact person for other professionals involved in the care: I conducted the assessments and, because I go back regularly, they keep me as their contact person, the key to the situation, and I also have the Social Support Act, the municipality calling me and saying, you’re listed as the contact person. (PN 8, Focus group)

Some PNs try to include the family or informal caregivers in the caring process. Family members can be a source of information for the PNs. PNs further state that it is important to share responsibility with the family members and to inform them about the situation of their parents or

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relatives. One PN describes the contact with a relative after an older person moved to a nursing home: I said to the son, what do you think, how do you feel about it? Yeah, he said, I, um, was actually prepared for it, because you’ve

Some of the older people who are identified as frail and are enrolled in the programme already receive appropriate care from other professionals. In such cases, PNs decide to stop the programme for those people after a first home visit:

called me and walked me through things each time. So that’s also

When you persist with questions, you learn that they already have

very important, sharing the things you see with the children. If

a physiotherapist and that they’ve already had an occupational

there are indeed children or family….then they can’t come back

therapist visit them and then there’s nothing else that I, as a prac-

later and say, yeah but you should have done this or you should

tice nurse, can offer at that time. (PN 1, Focus group)

have done that. (PN 1, Interview)

Targeting the wrong audience? Practice nurses perceive that many older people who are enrolled in the programme appear not to be frail. These people participate in the programme, either through a positive result on the screenings instrument (GFI) or through the selection criteria used by the GP and PN; however, after further assessment during the first home visit, PNs decide that no further care is necessary: Yeah, so I notice that there are benefits to be gained from visiting people. That really gives you a good feeling. But I’ve also visited people who don’t really belong in the project because they actually score lower [on the GFI] than what they sent me. (PN 21, Interview)

Practice nurses indicate that the results of the screening do not provide insight into the current situation of the older people:

Practice nurses mention that by visiting older people at home, they gather relevant and additional information. Seeing the home environment gives PNs a better picture of the older person and helps to identify the ‘right people’ for the care programme: You see a lot more in the home setting than when people come to the practice. They come to the practice dressed up nicely, hair nicely done, and at home it’s a mess. (PN 22, Interview)

Providing good care Although PNs have doubts about the effectiveness of the programme, they indicate that small efforts can have a big impact: So then you’ve got those people in touch with a physiotherapist and an occupational therapist who give them tips on how to improve the quality of their lives. And then you go and visit that person again, they’re doing really well, and the tips have really helped. For instance, he’d been sitting at the computer, slouching,

You see, the GFI is a snapshot really. When I go to people’s homes

and had a sore back. And that person says: I’ve had a sore back

to do the assessment I get the chance to delve deeper. Then you

for years and this really helped. It’s those little things, and then I

learn that the person wasn’t feeling well on the day they filled in

think: we’re really doing good work. That’s a good feeling. (PN

the GFI, which means the score is higher than it actually is. (PN

13, Interview)

19, Interview)

Practice nurses also experience that some of the most vulnerable and frail older people do not respond on the postal screening instrument. The PNs suspect that those people show care avoidance behaviour or are unable to fill in a screening instrument due to physical or cognitive impairments. If PNs are aware of such situations, they can use a personal approach to convince people to participate in the programme. However, the situation of older people who do not respond to the screening instrument and who do not visit the GP regularly is often unclear for primary care professionals: The people we have found are fairly confident. I don’t think people who are really frail, fill in the form. That is a big weakness. (PN 16, Interview)

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The PNs cannot always provide care because older people do not want to or do not need care at that moment. However, the assessments during the home visits provide the PN and GP with valuable information about their patients: But the advantage is that all information also comes in the patient file and that’s all set, so if anything happens to the patient, we have all the necessary background information. (PN 3, interview)

Practice nurses question whether they are able to provide good care for older people who experience problems on the psychosocial domain. According to PNs, loneliness and social isolation are most common among frail older people living in the community. PNs feel not equipped to deal with problems on the psychosocial domain:


Original article Most of what you see is loneliness, but we can’t solve that, you know. You can offer so many different things, but loneliness comes from within. Even if you have a full day programme, people can still feel alone. (PN 21, Interview)

Most of the PNs who work in the programme also work in other programmes. They offer patients help with smoking cessation, diabetes and risk management of cardiovascular diseases. Some PNs express that they are limited in providing good care due to the time available for elder care. PNs describe conflicting values in performing their job; they want to deliver good care and work cost effectively: But because diabetes care is so big now, I’ve had very little time for elderly care. That’s really been neglected here at the practice. (PN 18, Interview)

Discussion Practice nurses in our study describe a trusting relationship with frail older people living in the community as a necessary condition to provide these older people with appropriate care. This is particularly important for older people who avoid care and for people who are not yet aware of their healthcare needs. PNs describe that many older people in frail conditions avoid professional care. Researchers have argued that older people tend to underreport their health problems because they fear placement in a nursing home or they believe that the health problems they experience are a natural consequence of ageing and do not need treatment (Bender 1992). Janssen et al. (2011) describe that accepting help and support can be difficult for older people because it confronts them with their deteriorating health. Our findings are in line with earlier work of Janssen et al. (2012) who underline the importance of responsiveness to care. Resorting to strong paternalistic behaviour by ‘forcing’ an older person to accept treatment or support can lead to disrespect of the person’s autonomy and resilience (Hyland 2002, Lloyd 2006). Our findings show that the PNs adopt a relational approach and underline the importance of a trusting relationship. This is in accordance with Paes (2009) who noticed that a mutual relationship, in which the older person and healthcare professional work together to improve the quality of life, can foster the acceptance of support and care. In a mutual relationship, the older person is an actor in the relationship and not solely the subject of care. The importance of a trusting relationship is also supported by earlier research of Dinc and Gastmans (2012) who © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing


conclude that trust is essential in nurse–patient relationship for the patient and for a positive outcome of care. Our results show that nurses have developed several strategies to gain the trust of older people. Taking time for the older person is a necessity in creating a trusting relationship and cannot be hastened (Eriksson & Nilsson 2008). The concept of trust is closely related to attentiveness, an ethical element of care described by Tronto (1993). Nurses in our study describe that in an effort to gain trust, it is necessary to let the older person share their story. Attentiveness is described as the ability of professionals to be open to and identify the needs of their patients (Brannelly 2006). Practice nurses question whether they included the right people in the programme as they feel that a majority of people in the programme are not frail or are already receiving appropriate care. Researchers also conclude that the optimal screening instrument for frailty has not yet been found (Hamaker et al. 2012, Mathoulin-Pelissier et al. 2013). In the light of the doubts about the (cost-)effectiveness expressed by the PNs in the programme, researchers and policymakers should strive towards a screening and selection procedure that only selects the older people that are frail and in need of care. Furthermore, PNs in the study expressed the fear that the frailest older people do not respond to the questionnaire. To increase response rates, our results imply that next to the use of a screening instrument, nurses and other professionals should explain the programme to older people. Practice nurses further question their own expertise and are afraid they cannot provide good care for people with problems on the psychosocial domain. We therefore suggest, in line with Murphy (2006), that education on loneliness and issues concerning social problems should be included in the care programme to support PNs in performing their caring tasks. Due to a perceived lack of options, which they can offer patients, primary care professionals experience frustrations and powerlessness when being confronted with loneliness in older people (van der Zwet et al. 2009). Therefore, appropriate interventions to target loneliness in older people should be developed for use in the primary care practice. The study only included the perspectives of the PNs although other professionals (e.g. GPs, occupational therapist, and geriatrician) were involved in the care for frail older people as well. However, we felt that the PNs had such a specific and central role in the care process that their experiences had a particular value in understanding the care programmes. To understand the processes within the care programmes, the perspectives of the target population should also be taken into account. As this study is part of a

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responsive evaluation that includes multiple stakeholder perspectives, the experiences of the target population and other stakeholders will be published elsewhere.

Conclusion Practice nurses experience that in the programme, a trusting relationship with the older person is the basis for good care. A trusting relationship is especially needed as a basis to provide care for frail older people who initially are not responsive to care. PNs act as connectors in the programmes and collaborate with various professionals in the care programmes. The PNs question whether the appropriate screening and selection strategies are used to include older people in the programmes. They suspect that some of the frailest older people do not respond to the screening questionnaire due to physical or cognitive impairments or due to care avoidance behaviour. This implies that the programme partly targets the ‘wrong audience’, namely the older people who are still relatively healthy. Furthermore, the PNs experienced that many of the older people enrolled in the care programme do not need additional medical care. Care needs that the PNs do notice are more socio-psychological in nature, such as feelings of depression and loneliness. The PNs do feel that they gather valuable information about the older people due to the programme and that they can help some older people by offering them small solutions which can improve their quality of life.

Relevance to clinical practice An awareness of the importance of a trusting relationship is essential in programmes for frail older people living in the community. To give nurses the opportunity to provide good

care, they should receive support in dealing with people with psychosocial problems. More research is needed to develop interventions and strategies that can support PNs in targeting loneliness in older people. Furthermore, more research is needed to improve screening methods for frail older people. The knowledge that GPs and PNs have about the situation of older people should be included in the screening and selection procedure.

Acknowledgements The authors thank the respondents for their willingness to participate. Sincere thanks are given to Floor Koomen (Maastricht University), Ine Hesdahl (Maastricht University), Astrid Dello (Maastricht University) and Silke Metzelthin (Maastricht University). This study was part of a project funded by ZonMW – the Netherlands Organisation for Health Research and Development (Grant 311070201). This study obtained approval of the medical ethics committee of the University Hospital Maastricht/Maastricht University.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Conflict of interest The authors declare that they have no conflict of interests.

References Abma TA (2005) Responsive evaluation: its meaning and special contribution to health promotion. Evaluation and Program Planning 28, 279–289. Abma TA (2006) The practice and politics of responsive evaluation. American Journal of Evaluation 27, 31–43. Abma TA & Stake RE (2001) Stake’s responsive evaluation: core ideas and evolution. New Directions for Evaluation 2001, 7–22. Bender P (1992) Eye on elders: deceptive distress in the elderly. The American Journal of Nursing 92, 29–33.

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Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J & Ebrahim S (2008) Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. The Lancet 371, 725–735. Brannelly T (2006) Negotiating ethics in dementia care: an analysis of an ethic of care in practice. Dementia 5, 197– 212. Charmaz K (2006) Constructing Grounded Theory: A Practical Guide Through

Qualitative Analysis. Sage Publications, London. Daniels R, Metzelthin S, Van Rossum E, De Witte L & Van den Heuvel W (2010) Interventions to prevent disability in frail community-dwelling older people: an overview. European Journal of Ageing 1, 37–55. Daniels R, van Rossum E, Metzelthin S, Sipers W, Habets H, Hobma S, van den Heuvel W & de Witte L (2011) A disability prevention programme for community-dwelling frail older persons. Clinical Rehabilitation 25, 963–974.


Original article Derckx E (2006) Eerste nurse practitioners met differentiatie huisartsenzorg [First nurse practitioners with differentiation GP care]. Tijdschrift voor Verpleegkundigen [Journal for Nurses] 3, 26–30 [in Dutch]. Dinc L & Gastmans C (2012) Trust and trustworthiness in nursing: an argument-based literature review. Nursing Inquiry 19, 223–237. Draucker CB, Martsolf DS, Ross R & Rusk TB (2007) Theoretical sampling and category development in grounded theory. Qualitative Health Research 17, 1137–1148. Eriksson I & Nilsson K (2008) Preconditions needed for establishing a trusting relationship during health counselling – an interview study. Journal of Clinical Nursing 17, 2352–2359. Fagerberg I & Kihlgren M (2001) Registered nurses’ experiences of caring for the elderly in different health-care areas. International Journal of Nursing Practice 7, 229–236. Freeman M & Hall JN (2012) The complexity of practice: participant observation and values engagement in a responsive evaluation of a professional development school partnership. American Journal of Evaluation 33, 483–495. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G & McBurnie MA (2001) Frailty in older adults: evidence for a phenotype. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 56, M146–M156. Gitlin LN, Winter L, Dennis MP, Corcoran M, Schinfeld S & Hauck WW (2006) A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. Journal of the American Geriatrics Society 54, 809–816. Guba EG & Lincoln YS (1989) Fourth Generation Evaluation. Sage, Beverly Hills, CA. Gustafsson S, Edberg A-K, Johansson B & Dahlin-Ivanoff S (2009) Multi-component health promotion and disease prevention for community-dwelling frail elderly persons: a systematic review. European Journal of Ageing 6, 315–329.


Care for community-dwelling frail older people Hamaker ME, Jonker JM, de Rooij SE, Vos AG, Smorenburg CH & van Munster BC (2012) Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncology 13, e437–e444. Hulscher MEJL, Laurant MGH & Grol RPTM (2003) Process evaluation on quality improvement interventions. Quality & Safety in Health Care 12, 40–46. Hyland D (2002) An exploration of the relationship between patient autonomy and patient advocacy: implications for nursing practice. Nursing Ethics 9, 472–482. Janssen BM, Van Regenmortel T & Abma TA (2011) Identifying sources of strength: resilience from the perspective of older people receiving longterm community care. European Journal of Ageing 8, 145–156. Janssen BM, Abma TA & Van Regenmortel T (2012) Maintaining mastery despite age related losses. The resilience narratives of two older women in need of long-term community care. Journal of Aging Studies 26, 343–354. Lacas A & Rockwood K (2012) Frailty in primary care: a review of its conceptualization and implications for practice. BioMed Council Medicine 10, 4. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R & Sibbald B (2005) Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews, Issue 2, Art. No. CD001271. Lloyd L (2006) A caring profession? The ethics of care and social work with older people. British Journal of Social Work 36, 1171–1185. Lowenstein A (2000) A case management demonstration project for the frail elderly in Israel. Care Management Journals 2, 5–14. Mathoulin-Pelissier S, Bellera C, Rainfray M & Soubeyran P (2013) Screening methods for geriatric frailty. Lancet Oncology 14, e1–e2. Metzelthin SF, van Rossum E, de Witte LP, Hendriks MR & Kempen GI (2010) The reduction of disability in community-dwelling frail older people: design of a two-arm cluster random-

ized controlled trial. BMC Public Health 10, 511. Metzelthin SF, Van Rossum E, de Witte LP, Ambergen AW, Hobma S, Sipers W & Kempen GI (2013) Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial. British Medical Journal 347, f5264. Murphy F (2006) Loneliness: a challenge for nurses caring for older people. Nursing Older People 18, 22–25. Nes F, Abma T, Jonsson H & Deeg D (2010) Language differences in qualitative research: is meaning lost in translation? European Journal of Ageing 7, 313–316. OECD (2011) Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing, doi: 10.1787/9789264122314-en. Paes M (2009) Double actorship in community health work from the perspectives of presence and empowerment. Journal of Social Intervention: Theory and Practice 18, 6–22. Polit DF & Beck CT (2008) Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th edn. Lippincot Williams & Wilkins, A Wolters Kluwer Business, Philadelphia, PA. Ponterotto JG (2006) Brief note on the origins, evolution, and meaning of the qualitative research concept “thick description”. The Qualitative Report 11, 538–549. Slaets JPJ (2006) Vulnerability in the elderly: frailty. The Medical Clinics of North America 90, 593–601. Stake RE (1980) Program evaluation, particularly responsive evaluation. In Rethinking Educational Research (Dockrell WB & Hamilton D eds). Hodder and Stoughton, London. Steverink N, Slaets JPJ, Schuurmans H & Van Lis M (2001) Measuring frailty. Development and testing of the Groningen Frailty Indicator (GFI). Gerontologist 41, 236–237. Stijnen MM, Duimel-Peeters IG, Jansen MW & Vrijhoef HJ (2013) Early detection of health problems in potentially frail community-dwelling older people by general practices–project [G]OLD: design of a longitudinal,

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J Bindels et al. quasi-experimental study. BMC Geriatrics 13, 7. Tronto JC (1993) Moral Boundaries. Routledge, New York, NY/London. Van Haastregt JC, Diederiks JP, Van Rossum E, De Witte L & Crebolder HF (2000) Effects of preventive home visits to elderly people living in the com-

munity: systematic review. British Medical Journal 320, 754–758. Wilhelmson K, Duner A, Eklund K, Gosman-Hedstrom G, Blomberg S, Hasson H, Gustafsson H, Landahl S & Dahlin-Ivanoff S (2011) Design of a randomized controlled study of a multi-professional and multidimen-

sional intervention targeting frail elderly people. BMC Geriatrics 11, 24. van der Zwet J, Koelewijn-van Loon MS & van den Akker M (2009) Lonely patients in general practice: a call for revealing GPs’ emotions? A qualitative study. Family Practice 26, 501–509.

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