Background: The aging population has led to a growing number of frail older patients in prehospital emergency care. These patients often present with complex healthcare needs, posing significant challenges for prehospital emergency nurses (PENs) when assessing the appropriateness of providing self-care advice and recommending that patients remain at home. This study, therefore, aimed to explore the experiences of PENs in giving self-care advice and referring frail older patients to remain at home when this approach is considered the most appropriate course of action.

Methods: An exploratory qualitative design was employed, which was based on individual semistructured interviews with ten PENs from an ambulance service organization in southwestern Sweden. The data were analysed via inductive qualitative content analysis, following the approach described by Elo and Kyngäs.

Results: The analysis resulted in one main category: Professional discretion and coordinated support for sustainable decision making, along with three generic categories. The findings highlight key dilemmas faced by PENs: navigating uncertainty in frail older patients' cognitive and functional abilities, balancing patient autonomy and self-determination with safety concerns, and managing the ethical tension between respecting dignity and preventing harm. PENs also highlighted dilemmas in communication, where striving for clarity and trust was hampered by language barriers. They further experienced challenges in negotiating power and responsibility with frail older patients and relatives. Limited resources, unclear care structures, and insufficient collaboration with other healthcare providers created additional organizational dilemmas, constraining PENs' ability to make confident, ethically sustainable decisions.

Conclusion: This study underscores the complexity of decision-making for PENs when giving self-care advice and referring frail older patients to remain at home. Ensuring safe and sustainable care requires thorough assessments, clear communication, clinical expertise, empathy, and interprofessional collaboration, while future research should also address patients' perspectives and the organizational factors influencing PENs' decisions.Clinical trial registrationNot applicable.