The aim of this study was to illustrate how health and social care employees in municipalities and physicians in primary mobile health care manage the transfer of advanced health care services from hospitals to the home environment. The reflexive thematic analysis generated two main themes: Home—An arena in which one balances dual roles and respectfully negotiates the provision of care as a guest and Striving to fulfill expectations and requirements while simultaneously preserving professionalism. The themes are illustrated by quotes.
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Home—An arena in which one balances dual roles and respectfully negotiates the provision of care as a guest
This theme is related to the notions of consideration and respect for the home and those who live there. It describes how health and social care providers must consciously balance their dual roles as professional care providers and guests in a private home. This balancing act in the provision of care was expressed by one RN as follows: “Because you visit the patient at home. So, you are their guest... So, it is based on their terms, you could say”. The care providers occasionally needed to negotiate with the patient to establish an acceptable work environment.
Dealing with the dual roles of a health care professional and a guest in the home
The participants described the ways in which they dealt with and balanced their dual roles, as they were both health care providers and guests in the home. These dual roles required attentiveness and sensitivity to the patients and their relatives with the goal of meeting their needs for integrity and self-determination. One RN reflected on dual roles as follows: “… we are still guests in the home... but are still expected to take care of things... so that... you must have all tentacles out.” (RN 8)
The difference between hospital care and home health care was highlighted. The participants experience that while patients in inpatient care must adapt to hospital routines, the situation is quite the opposite in the home environment, such that home care providers must adapt to the routines of the home. Respect for the home and for the persons living there was described as being expressed in different ways. Contacting the patient to make an appointment before visiting, or notifying the patient in cases of delays were considered to be polite and respectful by the participants. They also highlighted the importance of providing information and explanations about necessary actions to ensure that patients and their relatives could understand why those actions needed to be performed. Always asking for permission before searching through cupboards and drawers was another way of showing respect for the home and those who lived there. As one RN noted, "[...] so, if I don't find anything, I ask[...] ‘Can I open these cabinets and have a look?’ I always ask first before doing it [...] I think that is important." (RN11)
One difference that was described between providing health care at the hospital and providing home health care with regard to these dual roles pertained to communication. In the patient’s home, the participants experienced the expectation, as guests in the home, that they would be available for conversation while providing care and performing their tasks in a professional way. One RN mentioned that in a hospital, you can go to a medicine room and prepare medicine or procedures undisturbed, while in a home, you must be polite and communicate with the patient and the relatives if they are present in the room. This situation was described as entailing the risk of making mistakes or performing improper treatments or actions, which could constitute safety risks for the patient.
Negotiation between the working environment and preserving the private arena
The participants described situations in which they were required to negotiate to transform the home into an acceptable work environment. This process entailed a balancing act between, on the one hand, the changes and resources required to provide good care and, on the other hand, the older persons’ self-determination and integrity. An example of a situation in which negotiation was necessary was described by one AN as follows:
“[…] when something happens to a relatively healthy older person […] before he understands that I have to rearrange the furniture or get another bed […] for the sake of our work environment, if nothing else, but also for his own sake [...] but you have to present that kind of thing in a good way.” (AN 6)
The materials and aids needed for home care were experienced as changing the home setting and negatively affecting the spirit of the home. These alterations constituted a reminder that the home had been transformed into a place for health care, and the participants mentioned that they tried to put such material and aids out of sight. The participants experienced that the patients and their relatives were not always prepared for the space required for storage and preparations. As one RN noted, “There is not really room for us in the home, but... that is probably something they haven't actually thought about” (RN 13). The care providers experienced that the person(s) living in the home sometimes had difficulties accepting the changes that needed to be made to provide good-quality health care. The participants described that the only thing they could do was to provide information regarding the benefits of such aids and hope that the patients and relatives would approve of them. When these aids are not accepted in the home, this situation negatively affected the working environment and sometimes made it difficult to provide good and safe care. Another problem the participants mentioned pertained to the difficulty of maintaining the hygiene required for certain tasks, such as infusions and dressing wounds. Not all homes have a dedicated place for these preparations, and the RNs described situations in which they were required to prepare an infusion on an unclean kitchen sink. As one RN mentioned, “And I am standing there thinking, this is not working; I can’t connect this to her... she will die right away... from cat bacteria" (RN 13). The RNs also described situations in which they were forced to climb into a bed to help a patient with a urinary catheter or when they were required to use the flashlight on their mobile phone to perform their working tasks because the lamplight was deficient in some homes.
Being attentive to and supportive of the establishment of trust and partnerships
Eliciting mutual trust from patients and their relatives was viewed as important aspect. The participants highlighted the importance of being available and supportive to both the patients and their relatives to give them hope and strength in the difficult situations they faced. When relatives were present in the home, consideration was given to the extent to which they wanted to be involved in the care process. Relatives were recognized as significant partners in home health care and were generally viewed positively by the participants. Moreover, the participants considered it to be important to be attentive and supportive to relatives because of the risks of anxiety and exhaustion caused by their changed life situation. One AN made the following comment:
“If you have good communication with the relatives, it usually works very well... It's very nice if they can get two minutes out of the patient's 15 minutes, so... it usually turns out very well, I think.” (AN 10)
Aspects that were identified as obstacles to such a good relationship included stress and a heavy workload. The ANs indicated that it was stressful to know that patients who lived alone were looking forward to their visit when there was no time to engage in conversation or when a patient felt unsafe and called them back as soon as they stepped outside the door. They stated that it was unethical to enter a home simply to perform the required work tasks and then rush off to the next patient. As one AN expressed, "[...] Sometimes it feels like you have to perform some of these tasks... on the way passing by." (AN 6)
The physicians described that meeting with a patient in the home contributed to more a holistic image of the person in question that could be obtained during a short encounter at the primary health care center. As one of the physicians described this situation, “It gives, it gives so much […], you see the whole life, the whole life of the patients. It's a completely different person when you come home... it's not a patient, it's... a person.” (Phys 1). Contact with relatives was experienced as more natural if they were present in the patient’s home during the physician´s visit. The physicians reported that this enhanced understanding of the patient and the corresponding closeness to relatives established a partnership that could serve as a foundation for tailored health care based on their needs, wishes, conditions and circumstances.
Striving to fulfill expectations and requirements while simultaneously preserving professionalism.
This theme is related to profession and collaboration and highlights the need for communication among care providers when providing care in the patients’ home. The significance of communication was illuminated by statements such as “It is important to have good and functioning collaboration, but that is not always the case” (AN 6). In the effort to fulfill expectations and requirements, challenges affecting the care providers’ ability to fulfill their own expectations and requirements as well as those of colleagues, patients and relatives must be addressed and managed to provide good quality care.
Communication and collaboration among professionals is a prerequisite for managing advanced home health care
The ANs described themselves as an important link between patients and RNs. The provision of health care was dependent on the ability of the ANs to communicate with the RNs, to be informed about the patient´s situation or to communicate with the patient and convey information provided by the RN. Close collaboration with RNs and the possibility of calling them when needed were viewed as ways of guaranteeing safety when caring for seriously ill patients at home. As one AN expressed, “[…] I could also wish.... that we had been allowed to call our patient-responsible nurses, that we had been allowed to... call them just as they are allowed to call us” (AN 1). This feeling of insecurity was expressed when participants were forced to call a RN who coordinated the incoming phone calls instead of calling the RN who knew the patient.
Coordinating patient health care contacts was viewed as one of the RNs’ most important tasks. However, communication channels with other health care professionals were often insufficient. The RNs experienced that it was difficult to contact physicians at the primary health care centers. On some occasions, when RNs called these centers, they talked to a RN even though they needed to talk to a physician. The RNs stated that they had already performed an assessment before they called the primary health care center and that the need to talk to an intermediary before being allowed to talk to a physician risked leading to misunderstandings. PMHC was viewed as an important partner in home health care by the RNs. They viewed the task of contacting a physician in PMHC when a patient needed acute treatment at home as easy. One RN made the following statement: "You call when you want to prevent admission... and maybe get prescriptions for antibiotics or drips at home or something like that" (RN 14).
When a RN with responsibility for patients and good knowledge of those patients was working, it was easy for physicians in PMHC to prescribe medical examinations and treatments. These physicians trusted these RNs’ reports and felt secure when they gave advise and prescribed treatments via telephone. However, it was also indicated that it was often difficult to receive correct information or provide appropriate evaluations since continuity among the RNs was lacking. In situations in which the RN responsible for the patient was unavailable, physicians could feel that “Sometimes I know the patient better than the municipal nurse . . . It's a difficulty... that I can't get... the right information at follow-ups and so on”. (Phys 1). The physicians expressed that they did not expect temporary RNs to perform their work as well as regular RNs because they did not know the patients in question. This lack of continuity among RNs was identified as problematic with regard to the provision of advanced health care at home. One physician stated that an expansion of the PMHC to include physician participation in home health care for all patients in the municipalities could constitute a solution to the issue of providing cohesive health care to the most vulnerable persons. Another physician expressed that a lack of resources in the municipalities constituted an obstacle with regard to the provision of home health care. This physician experienced that the shortage of health care professionals probably made it easier for RNs to call an ambulance instead of calling a physician in PMHC because RNs do not have sufficient time to care for all patients at home.
Challenge to meet expectations and requirements
The RNs described their work as challenging. They strived to meet the expectations and requirements that demanded that they should be available to home care personnel, patients, and relatives while simultaneously completing their own duties. The corresponding workload was sometimes experienced as overwhelming. One RN made the following observation: “You don't come home, and you work many hours overtime, and you’re behind anyway. What did I do? Did I do the right thing? Did I think right?” (RN 12)
The RNs described challenging situations that emerged when they were forced to use medical devices with which they were unfamiliar. They felt unprofessional when it became necessary for them to ask patients or relatives for the instruction manual, and they occasionally watched YouTube videos to learn these procedures to avoid such an embarrassing situation. They reported that the patients’ relatives had sometimes learned the procedures themselves because they perceived the RNs as insecure and ignorant.
The ANs had similar experiences of uncertainty when they were expected to care for seriously ill patients at home. They described difficult and challenging situations associated with feelings of inadequacy, which emerged when they were required to leave a patient who did not want to be left alone. On some occasions, the patient pressed the alarm as soon as the personnel closed the door, which led to conflicting emotions because they had to leave for the next patient. As one AN expressed, “I think that when they get really, really sick, then it's difficult to stay home [...] There's an insecurity between the visits.” (AN 2)
Additional challenges described focused on situations in which the ANs were told by an RN to monitor a patient with severe illness. This task was considered to be nearly impossible due to a lack of resources and competence. The ANs stated that patients who must be monitored would be safer in special housing where personnel are available around the clock. They described that they sometimes tried to motivate a patient to move but that doing so was sometimes difficult if the patient did not realize the risk of remaining at home.