• acute care referrals;
  • community care;
  • decision making;
  • older people;
  • staff interviews


• The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides.

• In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision.

• Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role – a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence.

• Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished.

• Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear.

• If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.