District Nurses Ready for Complex Multimorbidity Require Structural Primary Care Support

District nurses working in Swedish primary care express a strong commitment to managing the care of older adults with complex multimorbidity, yet their ability to deliver holistic, person-centered care is hindered by organizational limitations, fragmented collaboration, and insufficient structural support. This primary conclusion emerges from a qualitative investigation conducted in Sweden by researchers Annica Lagerin, Elisabeth Bos Sparén, and Caroline Wachtler, published in BMC Primary Care. By analyzing the firsthand experiences of practicing clinicians, the research team identified an overarching central theme: district nurses stand ready to assume responsibility for older patients experiencing co-occurring physical and mental illnesses, provided healthcare systems establish adequate operational room to accommodate clinical complexity. Rather than viewing chronic conditions solely as isolated medical pathologies, the clinicians emphasized that sustainable primary care requires organizational models that permit relationship-building, protect time for cross-sectoral coordination, and formally recognize the extensive scope of advanced nursing practice within primary care centers.

The study highlights acute demographic transitions occurring throughout Sweden, where official projections indicate that the population aged 80 and older will expand by approximately 50 percent over the next decade. As life expectancy increases, older individuals are remaining in their own homes for longer periods while managing multiple chronic illnesses. In clinical literature, multimorbidity is typically defined as having two or more chronic conditions, introducing biological complexity through accumulated disease burdens alongside psychosocial complexity stemming from treatment fatigue, illness symptoms, and compromised social networks. Furthermore, individuals over 65 presenting with multiple chronic diseases encounter heightened risks for mental health disorders, including depressive symptoms, worry, sleep disturbances, and anxiety. Swedish primary care is structured to function as an accessible central hub delivering person-centered care that honors patient narratives, optimizes resource distribution, and enables safe home living. However, primary care clinicians routinely face an intense balancing act between idealized professional standards, mounting emotional demands, and practical constraints.

Within the Swedish healthcare system, district nurses occupy a specialized clinical position designed to provide comprehensive, generalist nursing care to community populations of all ages. District nurses are specialist registered nurses who undergo advanced clinical training comprising 75 European Credit Transfer System credits, earning prescriptive authority for designated medications alongside incontinence and diabetes aids. They operate as specialist providers of health promotion, counseling individuals on tobacco cessation, dietary advice, sleep, alcohol abuse, stress, and mental illness. Functioning as the initial clinical contact point for older individuals with complex multimorbidity, district nurses coordinate long-term care plans bridging healthcare institutions and municipal social services while delivering direct nursing care in patients’ homes and collaborating with general practitioners and registered nurses. Prior Swedish studies noted that structured district nursing interventions utilizing Safe Medication Assessment instruments and clinical decision support systems improved medication safety, alleviating stress and psychological confusion resulting from polypharmacy.

To examine these clinical dynamics, the research team adopted a qualitative design grounded in reflexive thematic analysis following established reporting guidelines. Methodologically, the investigators adopted a constructivist epistemological stance, conceptualizing knowledge as socially constructed through lived experience, coupled with an interpretivist ontology recognizing clinical truth as contextualized rather than strictly positivist. The authors explicitly detailed their clinical pre-understandings, noting that two researchers are experienced Swedish district nurses while the third is an American-raised primary care physician with active clinical practice. This composition provided deep contextual familiarity with primary care environments and fostered a biopsychosocial analytical lens, while prompting critical reflexivity regarding traditional power differentials between physicians and nursing staff. The data collection occurred between May and September 2023, utilizing individual and focus group interviews conducted at clinics. Semistructured interview guides explored clinician perceptions of managing physical and mental disorders, identification of high-need patients, and interprofessional collaboration, continuing until the research team established that adequate information power was achieved.

Recruitment utilized purposive sampling initiated through an established professional network of Swedish district nurses, selecting primary care centers across diverse geographic and socioeconomic environments within Region Stockholm. To ensure representative variation, the investigators evaluated neighborhood social deprivation utilizing the Care Need Index, contacting eight medical practices, five of which agreed to participate while three declined due to staffing shortages and time constraints. Across the five participating primary care centers, fifteen district nurses took part in the study, comprising fourteen women and one man ranging from 31 to 64 years of age. Professional experience as district nurses ranged from 1 to 25 years, with a median clinical tenure of 13 years, serving populations across rural and urban catchment areas characterized by Care Need Index scores between 0.53 and 1.44. Data collection yielded four focus groups and one individual interview converted due to participant illness, which were transcribed verbatim and analyzed using NVivo and Roam Research software.

The first generated subtheme underscored that district nurses perceive the complex patient as a coherent and whole person, prioritizing holistic understanding over the fragmented accumulation of discrete medical diagnoses. Participants emphasized that effective care requires shifting attention away from rigid institutional agendas to align with what the patient personally values and prioritizes. This approach proved vital when navigating intertwined medical complexities and unaddressed mental health struggles, which clinicians observed were frequently exacerbated by social isolation and acute loneliness among homebound individuals. Nurses reported that establishing longitudinal continuity was essential for building therapeutic relationships, deciphering subtle changes in disease trajectories, and engaging family members or interpreters across diverse cultural contexts. Furthermore, district nurses framed this holistic orientation as an ethical imperative for healthcare equity, observing that the most severely impaired individuals often lack the capacity to actively solicit assistance. To support this person-centered paradigm, participants advocated for dedicated Elderly Care Units, open telephone hotlines, and preventive home visits.

Under the second subtheme, participants articulated that they feel highly competent to take responsibility for assessing and resolving the multifaceted needs of older patients with complex conditions. District nurses described identifying vulnerable individuals across diverse clinical interfaces, including clinic visits, interactions with relatives, specialized elderly phone lines, and formal referrals from hospital personnel or general practitioners. Clinicians expressed confidence in their diagnostic acumen, pharmacological knowledge, and capacity to serve as patient advocates who persist until solutions are secured. However, participants observed that older adults frequently risk receiving lower quality care than younger cohorts, noting that ageist assumptions within health systems sometimes lead institutions to overlook actionable suffering. Furthermore, managing severe multimorbidity without formal mentorship or structured clinical supervision placed immense personal strain on nurses, who often relied on informal morning office debriefings. To sustain professional competency and patient safety, nurses proposed implementing strict caseload limits capping individual practitioners at 35 home healthcare patients, alongside designated care coordinators.

The third subtheme revealed that primary care cannot say no to patients, forcing district nurses to improvise individual solutions when interorganizational cooperation breaks down. Clinicians reported regular crises precipitated by acute care hospitals discharging frail patients without advance notification or preparatory communication, leaving community nurses scrambling to organize home support instantly. Collaboration with municipal social welfare agencies and external home care providers proved equally fragmented, with district nurses required to coordinate with seven to ten distinct commercial home care groups for a single patient roster. In many instances, municipal assistance administrators lacked clinical understanding regarding the medical vulnerability of homebound individuals, proposing superficial increases in home help hours rather than skilled nursing interventions. Compounding these structural gaps, current economic reimbursement formulas prioritize billable individual services while providing no financial compensation for interprofessional meetings or intersectoral dialogue. Although strong internal collegial networks and specialized chronic disease clinics offered vital operational support, nurses called for protected, paid collaborative time.

Under the fourth subtheme, district nurses stressed that their professional competencies must be recognized, visible, and bounded by clear operational limits. While participants demonstrated extensive clinical proficiency, they noted that healthcare executives lacking clinical backgrounds frequently failed to understand their comprehensive role, viewing them narrowly through clerical metrics such as telephone availability. To compensate for institutional deficits and temporary personnel, district nurses routinely absorbed non-nursing responsibilities, including tracking missed laboratory results and addressing socioeconomic crises. This blurring of boundaries created substantial ethical stress, as clinicians struggled to reconcile their desire to resolve all patient suffering against the impossibility of unlimited service delivery. District nurses explicitly recognized that managing acute psychiatric conditions, grief, and severe trauma exceeded their available time and professional training, warning that acting as informal psychologists compromises quality. Consequently, they urged leadership to establish closer multidisciplinary collaboration with general practitioners and integrate mental health professionals capable of conducting specialized home visits.

In evaluating the research, the authors noted methodological strengths alongside clear study limitations. The reflexive thematic approach, supported by focus group dynamics and purposive sampling across varied socioeconomic settings, captured rich shared perspectives and deep contextual nuance. The research team’s clinical background as practicing nurses and a physician facilitated recruitment, built peer rapport, and enriched data interpretation through insider insight; however, the authors recognized that this perspective may have introduced interpretative preconceptions, noting that including non-clinical investigators could offer alternative analytical viewpoints. Furthermore, the sampling frame did not include primary care centers operating under alternative organizational paradigms or examine direct patient viewpoints regarding home nursing experiences. Ultimately, the study concludes that while district nurses possess the advanced competence and commitment required to sustain older adults with complex multimorbidity at home, current primary care models are structurally unsustainable. Health authorities must implement reforms that define clear nursing boundaries, institute caseload caps, fund interprofessional collaboration, and establish dedicated elderly care services to safeguard nurse wellbeing.

Subject of Research: District nurses' experiences caring for older individuals with complex multimorbidity in primary care

Article Title: Here it is everything at once: a qualitative study of district nurses’ experiences caring for older individuals with multiple chronic health problems in primary care

Article References: Lagerin, A., Sparén, E. B., & Wachtler, C. (2026). Here it is everything at once: a qualitative study of district nurses’ experiences caring for older individuals with multiple chronic health problems in primary care. BMC Primary Care, 27(1), Article 370. https://doi.org/10.1186/s12875-026-03574-1

Image Credits: AI Generated

DOI: 10.1186/s12875-026-03574-1

Keywords: district nursing, complex multimorbidity, primary health care, older adults, person-centered care, Stockholm Region, reflexive thematic analysis, home healthcare, interprofessional collaboration, mental health, polypharmacy, continuity of care, Care Need Index, elderly care units, caseload limits, role ambiguity, care coordination