Symptom Management in Primary Care: An Ethnographic Study of the Community Nursing Role

Aims: Pain and other physical symptoms remain prevalent inthe palliative care population, and outcomes are not alwaysoptimal. Assessment, monitoring, medicines management,evaluation and collaboration are key nursing roles that mayhave a positive impact. Whether and how nurses enact theseroles is not well understood. This study aimed to investigatethe role of the community nurse in palliative care provision,with a particular focus on observational exploration of theirrole and practice in providing patient care.Methods: A longitudinal qualitative ethnographic design,comprising observation of community nurse/palliative carepatient/carer encounters over time, and post observationinterviews with patients, carers and nurses. Patients weresampled from 12 community team caseloads across threeprimary care organisations. Observations and interviewswere audio-recorded and transcribed. Iterative data analysiscomprised familiarisation, coding and categorisation usingtechniques of constant comparison to generate typologiesof concepts. The study received all necessary ethics andgovernance approvals.Results: 17 nurse/patient encounters were observed (n=11 patients, 8 nurses) with 23 post observation interviews(11 nurse, 12 patient/carer). The discussion of physicalsymptoms, especially pain, formed the core of eachobserved encounter. Nurses primarily focused on medicinesmanagement (dose, frequency, suitability), other approachesto symptom management were infrequent. Nurses wereskilled at using informal conversational assessment styles,but the non-use of formal assessment tools could narrowthe range of issues assessed. Nurses discussed the complexinterplay between physical, psychological and socialsymptoms, but this was not always reflected in care.Conclusion: Symptom management is integral tocommunity nurses work, but there is scope to improve theway this is conducted which could have a positive impacton patient outcomes.