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Correspondence: Address correspondence to Bo Malmberg, Institute of Gerontology, Box 1026, SE-551 11 Jönköping, Sweden. E-mail: bo.malmberg{at}hhj.hj.se
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Abstract |
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Key Words: Home care • Community long-term care • Alternatives to institutionalization
Although it is possible to address some needs during ordinary working hours, older people may require assistance during the evening or night. To meet this need, the Swedish Home Help and Primary Health Care have collaborated to develop a program of evening and night patrols. The two authorities jointly manage the patrols, which are composed of staff members from each program. These patrols provide both social care and medical care from 4 p.m. to 11 p.m. (evening patrol) and from 11 p.m. to 7 a.m. (night patrol). The patrols are typically composed of a nurse or an assistant nurse (equivalent to an LPN) teamed with a Home Help aide. It is hard to pinpoint the differences between the staff categories and the different tasks they perform because they work together as a team. Each team is responsible for cases located within a particular geographic area or district. The service is offered to all persons in need, including younger multihandicapped people or people receiving terminal care at home. Most of the cases, however, involve older people. In this study, for example, 75% are aged 60 years or older.
Clients start using evening and night patrol in two different ways. The most common path into the program is that the client already has Home Help during the daytime and a need for help during evenings or nights has been identified. The other main pathway is when a person is leaving the hospital to go home but still needs some help during the evening and night.
When a person is referred for evening and night patrol, assessments are made by a Home Help Supervisor and by the Visiting Nurse, who has the responsibility for the area in which that older person lives. The Home Help Supervisor makes an assessment of how much and what type of social assistance is needed. When the person has medical needs, the Visiting Nurse is involved in the care planning (every client must have a Care Plan) and sometimes will serve on an evening or night patrol team. The Home Help Supervisor also works as a team leader and organizer.
Evening and night visits are usually planned, but can also be a response to an acute or emergency situation. Planned visits often concern medication, helping someone to the bathroom, or prophylaxis for pressure sores, but may also address social needs (loneliness or depression). There are no available data showing how long patients receive the service, but some patients use it for years and others just for a short period of time. Emergency or acute visits are responses to personal alarms of some of the people receiving planned visits, as well as other older people in the community. These acute visits address many different problems, ranging from falls to heart problems and anxiety. For older people living in the community, the knowledge that they can get help if something happens is often enough for them to feel safe at home and hence they seldom use the alarm.
Evening and night patrols have been available in almost half of Sweden's municipalities since the beginning of the 1980s (Statistiska Centralbyr
n, 1986). The service has grown rapidly and by 1990 approximately 90% of Sweden's municipalities offered the service (Statistiska Centralbyrn, 1991). Official statistics are available for several years in the 1990s, showing the number of people who get help during evenings and nights. In 1997, the most recent year for which information is available (Socialstyrelsen, 1998), it is estimated that almost 50,000 people get at least occasional assistance in the evening or night, a gradual increase from approximately 40,000 people in 1990.
Despite their wide acceptance in Sweden, evening and night patrols have not been studied to examine how they work and whether they are successful in supporting people in their home. There is even a lack of information about the specific tasks that evening and night patrols perform during a shift. As a first step toward an evaluation of evening and night patrols, we will examine how staff members view their work and the specific work content of their jobs.
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Methods |
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In Jönköping, the number of people who received regular planned visits during evenings and nights doubled between 1990 and 1997 from 100 to 200. Over 500 more people have alarm equipment, which some use occasionally.
To collect data, we developed two questionnaires. We designed one to be answered jointly by the patrol teams. The second, more conventional, questionnaire was to be completed by each individual member of a team. We sent the team questionnaires to each of the 33 evening and night patrols in the municipality of Jönköping, and the 76 staff persons who made up those teams received the individual questionnaires. (Some of the teams included three persons, although only two typically work on a shift.) Twenty-four team questionnaires (73%) were returned, including 9 from evening patrols, 10 from night patrols, and 5 from patrols that worked an overlapping shift. Forty-eight individual questionnaires (63%) were returned.
The team questionnaire addressed the organization of the patrol, the professional training of the staff that made up the patrol, and the type of clients the patrol served. The individual questionnaires asked about work content, typical clients served, and work satisfaction. We asked the staff to describe five of their typical patients in order to obtain information about the kind of tasks the patrol performed and what they did on a shift. Descriptions of clients included their age, gender, marital status, whether they lived alone, their primary health problems, and what specific tasks the patrol performed for them. We used this technique to elucidate the breadth of problems the staff dealt with.
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Results |
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The mean age of the patrol staff was 43.5 years. As in all Swedish old-age care, evening and night patrols are composed primarily of women. Respondents included 47 women and 1 man.
The number and type of visits made by patrols are shown in Table 1. On average, evening patrols made 14.6 visits each shift, whereas night patrols made almost 21 visits each shift. In part, this difference was due to the longer shift worked by night patrol (9–10 hours compared to 6–7 hours for evening patrol). The majority of visits were planned, but each shift could expect an average of nearly four unplanned, acute visits. It is possible to serve this large number of individual persons as the districts are geographically rather small, and the teams split up sometimes to visit one person each. Reports are written only if something special has happened during a shift, otherwise paperwork is minimal.
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The staff reported that the length of typical visits varied from being as brief as 5 min to as long as 2 hr, depending on what kind of help the patient needed.
Tasks that the evening patrol performed for the typical cases are shown in Figure 1. The most frequent kind of help involved personal care (help with toileting, changing incontinence aids, or changing position in bed). Frequent medical tasks were helping with medications and injections, assisting with a urine-catheter, and giving intravenous infusions. These medical tasks were less frequent than personal care, yet were mentioned in 10% to 20% of the typical client cases.
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The range of the work that the teams perform is exemplified in comments they made about their work: "We work with all human needs, from floor scrubbing to being a nurse, a doctor, and a priest, we support relatives, give advice and so on." "At night we do almost everything, we are very flexible. We think that problems are for solving." "The variation in the visits, the tasks and the time that every visit takes, is so large that it is hard to describe. One night does not look like any other."
Figure 2 shows the variation of patients' primary illnesses in the typical cases as described by the staff. The most common disorders among typical patients were neurological and muscle disorders, cancer/palliative care, arthritis, diabetes, gastrointestinal disease, ophthalmologic disease, "health problems" (pain and infirmities of old age), mental illness/dementia, pulmonary disease, and skin disease.
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One of the tasks of these patrols is to care for people who are dying. It is becoming more common for people with terminal illnesses to try to remain at home. When these individuals need help in the evening or night, they become the responsibility of the patrols. The number of terminally ill people seen by the patrols varies from one month to the next, ranging from 0 to 5 to 10 cases.
We asked the staff in the patrols what kind of services they provide to people who are dying or in palliative care. The most common tasks were to keep watch over the patients and provide companionship. Being available to give medical treatment was also mentioned. Several staff members expect that terminal and palliative care will increase in the future: "The patient can stay at home if they wish to die in their home. We can provide the care they need till the end and support their relatives, so they have the strength to carry on."
The contacts between the patrols and the relatives of patients are mostly very positive. The patrols mainly interact with the patient's spouse. Staff members meet relatives face to face or keep in touch by telephone, if the relative does not live with the patient. In a terminal illness, the patients receive intensive care/help (e.g., more regular visits and more advanced medical care) from the patrol, and the patients' relatives receive ongoing support and comfort.
Half of the staff members reported that the work situation had changed recently in that they performed more tasks and that the number of patients with psychiatric disorders had increased. Staff members mentioned that they thought that they did not have sufficient training to assist some patients and that they sometimes felt insecure and stressed as a result. About one third of the staff reported that the patrols now were doing more skilled and palliative care.
Two thirds of the staff desired an interest in continuing education in pain relief, palliative care, and psychiatric care. They were also interested in receiving further training in conversational techniques and how to approach people with different kinds of problems.
The staff members also answered questions about improvements they wanted in the organizational and work content of the patrols. The evening patrol staff wanted improved interplay between the social services operated by the municipality and the medical services run by the county council. That would mean, for example, improved cooperation between the hospital and patrol shifts. It also would mean better communication of information between the daytime home care staff and the patrols. The night patrols were more interested in improved technical and advanced nursing skills (e.g., care of patients with drip in central venous catheter or oxygen treatment) to increase the possibilities for patients to stay at home when they are seriously ill instead of having to go to the hospital.
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Discussion |
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The aim of this study was to provide preliminary information about the structure and work tasks of these patrols. In our study sample, tasks for the evening and night patrols vary from helping people go to bed and changing diapers to advanced therapeutic medical and terminal care. Another common form of care is to support and relieve relatives. This is often done in combination with other efforts like medicine distribution or blood sampling. Only rarely is the sole purpose of the visit to relieve relatives. Nonetheless, many of the relatives would not receive any form of respite care, except through the visits of the patrols.
There are many different diseases and disabilities described in the typical cases. Younger patients seen by the patrols have illnesses like multiple sclerosis, cancer, and diabetes. The older cases have illnesses like heart disease and leg ulcers or have suffered disabilities resulting from a stroke.
The results also indicate some differences in tasks performed by evening and night patrols. Night patrols perform more medical care activities compared with evening patrols and combined patrols, perhaps as a consequence of staff composition. The combined patrols are not very well known (we did not know of their existence until they returned the questionnaires). These patrols also do not include nurses, something that perhaps can explain some of the differences compared with the other evening and night patrols.
The staff members think they are being asked to handle increasingly difficult medical cases and are increasingly involved in palliative and terminal care. Their patients are diagnosed with multiple physical illnesses and often have psychiatric diagnoses as well. After a reform of psychiatric care in Sweden, an increasing number of people with psychiatric problems live in their own homes, and some of them need help from the evening and night patrols. Many of the staff members feel they need support and supervision to handle the great variety of problems they meet in these cases. It is difficult to take care of these problems through brief contacts during the evening or night. Many of the staff members also feel they need more education about medical problems and how to handle them practically, particularly, pain relief and palliative care. These areas reflect the fact that patrols must care for increasingly frail people.
Although the staff indicate an interest in continuing education, they identify as an obstacle the different professions and different employers of the members of a team. Putting together people from the social and medical care systems is a strength of the team, but staff indicate it is sometimes difficult to organize educational programs that are of interest to everyone at the same time. Another problem is that the working hours of the teams make it more difficult to participate in continuing education programs that are offered to Home Help or Primary Health Care staff with ordinary daytime work hours. The patrol staff members describe feeling a bit neglected and want further education. The demands of caring for patients with severe medical and sometimes also psychiatric problems can cause stress for the staff. Although team members often support and help one another, it is not always sufficient. In periods when the patrols are managing to meet very sick persons in their homes, the patrol members might require comfort from extra support (e.g., through a therapeutic group that meets every week or fortnight).
Results from our description of the evening and night patrols should be interpreted with several limitations in mind. First, we describe the work of the patrols in only one community in Sweden. Second, the clinical characteristics of the patients served are based on the staff's judgment about typical cases, rather than on a systematic review of the agency records. It is possible that the staff chose to describe the more interesting and challenging cases, and therefore the more routine cases may be underrepresented in this description. Less dramatic tasks like providing companionship or just being around to provide reassurance are probably underestimated by our method of descriptions of typical cases. No effort to teach cohabitants to perform the tasks is mentioned.
In conclusion, the evening and night patrols are an important part of old-age care in Sweden. The patrols are of necessity very flexible, work autonomously, and take great responsibility for the welfare of many old and disabled persons in their homes. According to patrol staff, without this service many patients would have to leave their homes to go to institutions, while others would stay home with far less security and a lower quality of life. More research is needed to understand the role of the patrols in supporting home care and what changes are needed to improve the care provided, as well as the morale and working conditions of staff who provide this important care.
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Footnotes |
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2 Department of Biobehavioral Health, and
3 Gerontological Center, The Pennsylvania State University, University Park.
Decision Editor: Laurence G. Branch, PhD
Received for publication March 18, 2002. Accepted for publication September 20, 2002.
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