In total, 15 individuals aged 76–82 years were interviewed from six different healthcare centres. Of those 15, 11 were still participating in the programme; four had withdrawn from the study after some years of participation. Table 2 outlines the participants’ characteristics.
Motivators to participation
The perception of being ‘checked up on’ was an important reason for participation. Many liked to know whether they were doing well with regards to their physical and mental health, and hoped for reassurance and normal test results:
‘We [my wife and I] expected that we would find out how we were doing, intellectually [as well as physically]. I was rather interested in that. I wanted to know how I was doing.’
(P9, male, 77 years, living with partner, ongoing participation)
The check-up as a whole, and laboratory checks and blood pressure in particular, were regarded as useful:
‘Your blood pressure is measured and once in a while she checks the blood. […] Normally, when you don’t have any complaints, you don’t visit the doctor, right? It feels unnecessary. So I’m glad we have this now, it makes me feel very safe.’
(P5, female, 78 years, living with partner, ongoing participation)
The same was mentioned for evaluation of weight, cognition, and physical activity.
Some decided to participate because they were asked (by their GP) and saw no reason to decline the invitation:
‘I thought it’s probably something good. So why shouldn’t I do it? At the time I was some years younger, and it seemed like a good thing to do. There’s no harm in trying.’
(P10, female, 80 years, living with partner, ongoing participation)
Good accessibility facilitated participation. The programme did not seem to cause fear among participants, but rather offered reassurance that things remained well and they were being cared for.
It seemed that, for many participants, evaluation of their health status was the main reason for partaking, instead of actively making changes themselves. They also neither participated because they felt at high risk, nor because they wanted to become healthier, as was hypothesised.
Barriers and facilitators to continuation
Building a relationship
Almost all participants emphasised the importance of the relationship with the practice nurse:
‘ [The nurses] did their job very well. […] Not hurried but still goal-oriented and you can also talk about other things and get them off your mind. I can ask them anything. And I also get a decent answer. It’s excellent.’
(P2, female, 77 years, living alone, ongoing participation)
The practice nurse was viewed as a dedicated person with up-to-date medical knowledge and a sincere interest in their personal circumstances.
Participants hoped for someone who was genuinely concerned about them and their health. If this turned out to be the case, they often felt very attached to their nurse. A long-standing relationship was necessary to gain trust and, ultimately, to make changes regarding their health:
‘In this way [by frequent visits to the same nurse], you get an open relationship. For example, I can tell her everything. With others you keep more distance. But with her I know exactly where I stand as she does with me. She tries to do the right thing for me, that’s how I see it.’
(P14, male, 78 years, living alone, ongoing participation)
Reiterating the importance of the relationship, those who had decided to quit the study reported that their nurse’s approach had prompted them to do so. They felt that the intervention could have been of more value to them, but they were disappointed by the impersonal, one-way communication, and lack of detailed questioning:
‘I hoped for more personal questions, more attention and personal contact. They should be much more people-oriented if they want to keep people involved.’
(P13, female, 79 years, living with partner, discontinued participation)
In some cases, participants noticed that the development of a personal bond was not feasible, due to frequent changes of nursing staff and/or the nurse being too young or inexperienced. For example, in one healthcare centre, two participants (P7 and P12) reported that no permanent nurse was available for a period of time. One also pointed out about the relatively inexperienced substitute nurses:
‘Those youngsters, they might be nice people but not someone to begin a conversation with. Especially not when you’re past 75 [years of age]. No experience of life. […] The difference with [the former nurse] was huge; she was in really close contact with you.’
(P12, female, 81 years, living alone, discontinued participation)
For most participants the bond with the nurse, or its absence, was the main reason for continuing or quitting the programme, regardless of the identified risks or perceived benefits. Next to this personal bond, the approach of the nurse appeared to be critical.
Guarding autonomy
In general, participants wished to be involved in medical decisions, such as starting medication or getting additional diagnostic tests, but they were prepared to follow the advice of their health professional, even if they did not always fully understand the rationale:
‘If it’s reasonable, of course, I accept it from her. […] If it is medically safe and they advise it, then I’ll take it. When the wise people say: “it’s better for you” well, they know better than me, so I just take the pills.’
(P14, male, 78 years, living alone, ongoing participation)
For lifestyle issues however, participants all felt this was, and should be, entirely their own decision:
‘To live healthily, you do it or you don’t for yourself, that’s up to you.’
(P11, male, 82 years, living with partner, ongoing participation)
A number of interviewees expressed the importance of their autonomy being respected. They felt this became more pertinent with increasing age. Some interviewees clearly indicated that they were not prepared to follow any advice on specific domains at all. As one woman put it:
‘Actually, I have this point of view. I absolutely hate sports and such matters. So I will not do it. I’ll probably live for a few less years: so what.’
(P2, female, 77 years, living alone, ongoing participation)
There were similar examples for not eating breakfast, for smoking, and drinking alcohol, habits often developed several decades ago, to which participants had resigned themselves. Continued efforts to change these behaviours by nurses who were unaware of the underlying views or convictions caused resistance.
The term ‘lifestyle advice’ was generally regarded as patronising and comprised ‘things that one already knows’ (P2, P7) or things that were not relevant to the participant. Some participants felt irritated when lifestyle advice was given:
‘I know what a healthy diet is. Not that I always do what’s best for my health, but I do know what it is. […] There was no advice at all that was useful to me. They were all things that I already knew. Lifestyle advice, I think that’s meddlesome. But that’s unkind to say.’
(P7, male, 77 years, living alone, discontinued participation)
Another ex-participant felt disrespected and disregarded in the consultations in which the nurse gave advice. She had clear ideas about what approach should be used:
‘ “You have to …”, always “you have to ...”; I detest it. They don’t ask you what you want to do about it yourself. I think it’s a bit offensive for elderly people. They [the nurses] are kind, you know, but it’s just, you get older and age is a heavy burden. They should use another method actually, I think. More um … ask more questions about your constitution, how you are doing and what you can do as an older person in your home etc. And that’s often forgotten.’
(P13, female, 79 years, living with partner, discontinued participation)
Participants, therefore, wanted to be heard and respected, and able to discuss issues with the nurse as equal partners.
The coaching attitude
In contrast with the above, satisfied participants reported that they had not been advised on lifestyle and thought of this as something positive. For example, when asked ‘did the nurse give you any lifestyle advice?’, one participant answered:
‘No, no, I don’t think so. We did talk about certain things, but it was not advice but um … more like a conversation. What you can do to maintain your weight, those kind of things.’
(P3, female, 77 years, living with partner, ongoing participation)
The aversion to lifestyle advice seemed to be caused by its directive and moral nature; participants felt judged, rather than encouraged to change their behaviour. However, people generally appreciated the nurse enquiring about specific lifestyle issues and their efforts towards healthier living:
‘She asks about it, about physical activity and also ‘do you do household chores’, and if so ‘do you need help with it’ and um … because with household chores, you are being physically active too, you know. She also asks if you go walking and go outside. I don’t go cycling anymore, but I do have a home trainer, I tell her, and I use it. That’s also good, she says.’
(P10, female, 80 years, living with partner, ongoing participation)
Another woman illustrated the reflective way in which the nurse encouraged her to improve her diet:
‘She never tells us [my daughter and me] what to do, not at all. She likes it when I tell her, that’s why she’s so good. We live healthier now. We eat two pieces of fruit every day, she always asks about it. Yes, we eat very healthy as a matter of fact.’
(P1, female, 77 years, living with daughter, ongoing participation)
The positive effect of the coaching attitude described by participants was threefold:
when the nurse asked questions and listened, they gained trust;
nurses could recognise and reinforce efforts that had already been made; and, as a result; and
they were able to discuss tangible, tailor-made plans with the participant.
Ironically, in accordance with the above, participants who succeeded in making (generally small) changes reported that the nurse had been of no, or only minor, influence: they felt it had been primarily their own decision to change their behaviour. For instance, one participant started cooking with oil instead of butter and, when asked why, he said hesitantly:
‘Well, because of those conversations [with the nurse] probably, but I heard it from outside too, of course. And it’s also easier than before to get cooking oils in the shops. It used to be normal to use butter. […] It [the influence of the nurse] was only indirect, because I knew it already. No, the conversations were not the main reason [for a change in lifestyle]. I know we talked about it, and I took note of it, but I knew it already.’
(P7, male, 77 years, living alone, discontinued participation)
It seemed that, with regard to making changes, especially in lifestyle, successful nurses operated in a sharply defined area; they mainly asked questions and discussed issues in an open conversation with participants, but stayed away from giving directions or general advice. In this way, participants felt heard and respected, and were more likely to stay engaged in the consultations.
