Sjuksköterskan i primärvård med särskilt fokus på barnhälsovård

Sammanfattning: ‘The Nurse in Primary Health Care with Special Focus on Child Health Care’ The function of nurses in Swedish primary care involves health care and medical care for people of all ages, and in their health-promotion work there is a focus on child health care. Child health care in Sweden is mostly provided by nurses. The work encompasses all children from birth to school age; it is voluntary and free of charge. A newborn baby, especially if it is the first one, means a great change in the parents’ life. The child has needs which must be satisfied round the clock, and everyday life for the parents is affected in practical, social and emotional terms. The first period with a newborn baby is a sensitive time for the family. The nurse’s efforts at this time are important and must be adjusted to the family’s needs. There has hitherto been little study of which aspects parents consider important during the first months of the child’s life. The overall aim of the thesis was to study the function of nurses in primary care, specifically child health care, and to focus on aspects of importance for good child health care and the first encounter between the nurse and the family. A combination of quantitative and qualitative methods has been used, and different perspectives have been explored to arrive at as complete a description as possible and to increase the reliability of the results. In studies II and III the same random sample was used. The studies were carried out locally in a primary care district in southern Sweden between 1984 and 1989 (study I), regionally in southern Sweden in 1999 (study IV), and nationally in Sweden in 1995 and 2000 (studies II, III, and V). In study I, data from computerized records were studied over a six-year period. The data came from an individual-based computer system for the population of a geographically defined area and their contacts with health care. The data registered were: personal identity number, date of visit, type of visit, place of visit, person in charge, diagnosis, blood pressure, and actions taken. One patient record was used by all categories of staff. The study used data registered during the period by doctors, nurses, and assistant nurses. The study was a total investigation, covering all contacts with the population (approx. 21,700 inhabi-tants) in the primary care district by doctors, nurses, and assistant nurses. The results did not show that organization in care teams led to any reduction in the number of visits. The increase in the number of visits to both doctors and nurses was greatest in the area with a system of care teams. During the period of the study the nurse had retained her independent role; half of the visits was not prescribed by a doctor. The doctor mainly met middle-aged people while the nurse mainly met children and elderly people. Children mostly visited the doctor in cases of illness, while the nurse was responsible for health care among children. Home visits by nurses to elderly people greatly increased in number while visits to children decreased slightly. The second study, concerning mothers (n=676), investigated their visit patterns and ratings of formal and informal social support for simple health problems in the child. The analysis also focused on differences between mothers related to occupation, country of birth, the child’s health, and the number of children. The questionnaire covered the following topics: utilization of child health care, the age of the mother, number of children, the child’s health, the mother’s country of birth, occupation, and compliance with advice. Questions about informal and formal social support were constructed by the authors as a scenario and were hypothetically formulated. The questions concerned everyday health problems in the child: somatic problems (diarrhoea), behavioural problems (persistent crying), and preventive advice (child safety). All mothers rated the nurse’s advice and support highly for everyday health problems in the child, and the majority of the mothers followed her advice. As regards social support in solving health problems, however, there were differences in the mothers’ ratings in relation to socio-economic classification (SEC), country of birth, and number of children. Mothers of low SEC and first-time mothers valued the nurse’s advice more than mothers of high/medium socio-economic background and first time mothers, who relied more on their own competence and what they learned from literature and mass media. Foreign-born mothers turned to emergency medical care more than Swedish-born mothers, who turned to the nurse in child health care. The third study analysed and compared mothers’ (n=676) and nurses’ (n=243) perceptions of aspects of importance for good child health care. The study consisted of two nationwide postal questionnaires, one for mothers and one for nurses. Both mothers and nurses were selected at random. The questionnaire was constructed with similar questions for mothers and nurses to enable comparisons. The topics illuminated in the questionnaire were good child health care, a good nurse, forms of visits for the first encounter, accessibility, and continuity. The mothers stated 14 different factors and the nurses 13 factors which they considered important for good child health care in their responses to the open-ended questions. Mothers and nurses had largely the same views that accessibility, information/advice, support, and friendly treatment were aspects of importance for good child health care. Mothers mentioned information/advice and support to a slightly larger extent than nurses, who had a greater tendency to stress competence and continuity. Accessibility and friendly treatment were highly rated by both mothers and nurses. Time and friendly treatment was registered by both mothers and nurses, but these were not expressed in the official goals of the work. Differences between the mothers’ perceptions of good child health care emerged in relation to SEC, country of birth, and number of children. The fourth study, which was qualitative, was performed with the aid of focus group interviews with nurses (n=21). The nurses discussed in groups important factors for the first encounter with new parents. In the latent content analysis the factors “creating trust”, “creating a supportive climate”, and “creating a picture of the family’s life situation” were established. Sub-categories of “creating trust” were good contact/reciprocal relationship, listening, guest/equal roles, time/peace and quiet. The category “creating a supportive climate” comprised the sub-categories confirmation/support and individual advice. The third category, “creating a picture of the family’s life situation”, had the sub-categories the family in its environment/holistic impression and socio-cultural aspects. The general interpretation of the nurses’ statements was that they found that by listening and being sensitive to the family’s situation, a good mutual relationship was established. Obtaining a holistic impression of the family’s situation was also emphasized as important, so that in future contacts with the family they could give individual advice, support, and confirmation. Home visits were regarded as the best aid to be able to establish trust and to create a picture of the family’s situation, which in turn was essential for establishing a supportive climate. The nurses’ perception of home visits was unanimous. The nurses said that they tried to avoid the patriarchal structure of the health service and the medicalization of everyday health problems. The aim was to study the function of the nurse in primary care, specifically child health care, and investigate important aspects of good child health care and of the first encounter between the nurse and the family. Data from computerized records were used to follow the development of consultations with nurses and doctors and diagnoses over a six-year period in a defined primary care area. Nationwide postal questionnaires were used to investigate mothers’ and nurses’ perceptions of good child health care and the first encounter with the nurse in child health care and the mothers’ assessment of the nurse’s support and advice when the child had simple health problems. The chi-squared test was used to analyse differences between groups. Manifest content analysis was used to categorize open-ended questions. Focus group interviews were conducted to obtain a better understanding of nurses’ perceptions of important aspects of the first encounter with the family. The interviews were analysed using latent content analysis. A modified version of the instrument ‘Quality from the Patients’ Perspective’ (QPP) and the sense of coherence scale (SOC) were incorporated in a nationwide questionnaire to study mothers’ perceived satisfaction with the nurse in child health care. Student’s t-test was used to test the hypotheses and Pearson’s correlation coefficient was used to strengthen the association between the mothers’ ratings of the quality of care and their sense of coherence. Mothers were more satisfied with the first encounter if they received a home visit than if they visited the clinic. Mothers from a low socio-economic classification (SEC) were less satisfied with the first encounter than mothers from a high/middle SEC. There was an association between mothers’ satisfaction and their sense of coherence. Mothers and nurses had largely the same perception of important aspects of good child health care: time, personal treatment, advice and support, and accessibility. Differences in perception were seen above all between mothers depending on the number of children they had and the SEC group they belonged to. All mothers gave high ratings to the nurse’s advice and support, and the majority complied with the advice. There were differences between mothers’ ratings as regards SEC, country of birth and number of children. There was agreement in the nurses’ perception of important aspects of the first encounter: creating trust, creating a picture of the family’s life situation and creating a supportive climate. Home visits were considered a good aid to achieving the important aims. The thesis can provide a basis for future planning, prioritization, evaluation and discussion of the nurse’s activities in child health care.