The district care can no longer cope: does the family want to help with the care?

Elly Westendorp (76) from Breda lifts her foot into a steel frame and slides it towards the yellow spheres at the bottom. In one movement she pulls up the frame – and with it the support stocking that has been hooked over the yellow balls. With the help of a kind of plastic cone attached to a large elastic band, she also pulls thick socks over it. “So, the day can begin.”

Westendorp can no longer bend over. Thanks to the ‘donning aid’, she can still put on and take off her own support stockings. And that saves the district nursing two visits a day to Westendorp.

Using assistive devices (technical or otherwise) and only making essential visits to clients: this is what the future of district nursing looks like. Because every minute less with one client means more time to help another, says district nurse Emma Bloemendaal (28). With the acute staff shortage, there are simply too few care providers to meet the increasing demand for district nursing. There is a shortage of more than sixty thousand employees in nursing, care and home care.

Bloemendaal works at home care organization Thebe, which offers neighborhood and residential care in 23 municipalities in the west and center of North Brabant. The organization has 127 vacancies for district nursing. The Bloemendaal team will manage, she says, “but not many clients should suddenly be added. We need a balance between inflow and outflow.” While more people are now knocking on the door: the Netherlands is ageing, it is expected that in 2040 there will be more than 2.6 million over-75s. In 2018, there were still 1.4 million. Half of people aged 75 and older have two or more chronic diseases.

Earlier this year, Thebe sent all community nursing clients and their relatives a letter asking if relatives could help, it said. AD. The letter asked for help showering and dressing. The Amsterdam care organization Amsta sent a similar letter.

A spokesperson for interest group MantelzorgNL says that informal carers are increasingly called upon. During corona, regular care was scaled down to meet acute care and family and loved ones had to help. “That is still not back to the old level.”

For example, people who used to be cared for four times a week are now only twice a week. Not all informal carers can continue to do the extra tasks. “It is good to let the family know when the schedule does not come around, but be careful who you ask what. An elderly partner or someone with a busy job and young children may not be able to take on those extra tasks at all.” MantelzorgNL advocates more ‘collaboration’ between professionals and family.

At Thebe in Breda, the clients are now at the door. A few weeks ago, a gentleman on a scooter rang the doorbell. He could no longer put on his support stockings himself, whether he could get help with this from now on. District nurse Emma Bloemendaal: “He was standing there with his mobility scooter in the hallway. You don’t send them away.” The district nursing was deployed for him for a short time, “until he was self-reliant”.

Five minutes less scheduled

This Tuesday in November, Bloemendaal treats wounds on Elly Westendorp’s leg. On arrival, Westendorp is already sitting in her stand-up chair. Leg up, trouser leg rolled up and gauze over the place of the wounds. “I know how busy they are, so I try to prepare as much as possible.”

That indeed makes a difference, says Bloemendaal: as a result, Westendorp has five minutes less scheduled. Doesn’t Westendorp regret that? “It’s more fun when she’s there, it’s that simple. But I am realistic and know that they need time.” That’s the right attitude, Bloemendaal nods, while she disinfects the scissors to cut a bandage.

Although Westendorp had to ask for some extra time two weeks ago, for a good conversation. She had fallen, in the house, where she was alone. Daughter didn’t answer, son didn’t answer, neighbor did not answer. “I felt very alone.” It took her 45 minutes to get up on her own, meanwhile she saw her knee swell. “The wounds were healing, now they have opened again due to the pressure on my leg.”

It was frightening. Westendorp: “Then I said: Emma, ​​I want to leave.” To a nursing home, she means. Westendorp herself is not eligible for this, because she is ‘too independent’ thanks to the home aids. “I have a number of defects”, she keeps her hands far apart, “but thanks to my slip lift and donning aid I can still dress myself. It is a blessing and a curse.” Because her husband went to the nursing home five months ago, Westendorp can also go there. “I can ride with him.”

The new, effective approach sometimes leads to difficult conversations, says Bloemendaal. “It used to be like this: if you want care, you get it. Now we have to say ‘no’ more often. Just make a sandwich or take out the trash when you’re on a home visit? That takes an extra five minutes. If you do that for every client, you lose an hour a day. In that hour you can also help three or four others.”

Social contact, that must be during the ‘care moment’, so during medical care or help with getting dressed, for example.

It is emphatically no longer the intention that a client receives district nursing for years – unless there is absolutely no other option. “We help people become independent. We provide the care that is needed at that moment, but we also reduce that where possible. By getting someone used to a support stocking aid.” According to Bloemendaal, preventive use of occupational or physiotherapy also ensures that clients can remain self-reliant for longer.

Some clients have difficulty letting go after they are independent again, according to the nurses. That is why district nurse Marsha van Eijk (26), from the same district team, tries to ‘prepare people mentally’ from the start. “I specifically mentioned that we will eventually phase out. Then it is already in the head and someone is less surprised when we say: dude, I think you can do it yourself.”

‘We are always in a hurry’

Not all colleagues easily switch to the other approach. Rianne van Beek (55), for example, also from the same neighborhood team, finds it “difficult”. “I belong to the generation that was taught at school: when you close the door, you should feel good. That doesn’t always work anymore.”

This morning, for example, she was with a woman with dementia, she says at the office. The client went to day care for the first time, but due to her dementia she no longer knows how to get down from her flat. It was therefore arranged that the taxi driver would come upstairs. “That gave the family peace of mind. But not me! I wanted to wait for the cab to arrive to make sure she came down. There was no time for that.” The most important thing, says Van Beek, is that you never convey to clients that you are in a hurry. “But we’re always in a hurry.”

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Colleague Marsha van Eijk attended an intake interview this morning with a 76-year-old man who had just left the hospital “to determine the need for care”. It was clear that the man needed care, she says when she returns to Thebes’ office. He has dementia and was recently diagnosed with cancer. His health problems weigh heavily on his wife, who can no longer handle the care. Van Eijk, against Bloemendaal: „We are really going to be able to make a difference here. That is so nice.” And, she says: “In the media you mainly read how hard our work is. It is, but above all it is very beautiful.”

Beep, beep, beep. “That’s how I hear that my blood value is good.” Bernedine (78) is holding a device next to her arm, into which district nurse Sharmila Sahai (49) has just placed a sensor. The sensor, a kind of large round cap, measures her blood sugar. Because it concerns her private situation, Bernedine does not want to use her last name NRC. Bernedine has diabetes, is very visually impaired (“I only see shadows”) and does not move easily anymore. Thanks to the sensor with sound, the ‘FreeStyle Libre’, she can still monitor her own blood sugar.

While she can measure her own values, she can no longer do many other things. For eye drops, for example, she needs help: “I can’t raise my arm anymore – it shoots right back.” The district nurse visits three times a day.

That dependence makes her “sad”. “If only I could do it myself.”

Sahai: “You find it difficult to accept help, don’t you.”

Bernedine: “People say I laugh a lot, but it’s hard inside me.”

“You laugh your worries away.”

“But I can lose my egg with you.” She laughs.

And Elly Westendorp? The choice for the nursing home is difficult for her. On the one hand she likes to go to her husband – “now I have no one to say good night to” – and she does not feel safe in her own home, on the other hand it means giving up a last bit of freedom. “The nurses come in there seven times a day for my husband’s medicines. And you have to eat what is served. I like to prepare something myself.” Then she bounces up a bit. “It is also quite cozy, you know, sometimes they play handball there.”

In any case, she will be missed in the district team: the nurses have built up a strong bond with her – they have been coming over for about five years. Bloemendaal: “That makes her really an exception, especially now that we are trying to help people become as independent as possible.”

A version of this article also appeared in the newspaper of November 30, 2022