Evaluation of an advance care planning education programme for nursing homes: A Longitudinal study

Effects of an Advance Care Planning Training Program for Certified Palliative Care Nurses in Japan

Education programs for certified palliative care nurses who promote advance care planning (ACP) for cancer patients are important, but not currently available in Japan. This study aimed to develop an educational program of ACP for certified palliative care nurses in Japan and evaluate its effectiveness. A program consisting of four modules was implemented for 60 certified palliative care nurses in the Kyushu, Chugoku, and Shikoku regions. Participants attended one training session, and 39 responded to a survey on changes in ACP practice and difficulties with cancer nursing 3 months after the intervention. The Wilcoxon signed-rank test was performed to compare data before and after the intervention. The results obtained showed an increase in dialogue on ACP among patients/families and healthcare professionals (mean before the intervention = 24.49, mean after the intervention = 27.59, p = 0.045), and a significant decrease in the sense of difficulty with knowledge of and skills for ACP (mean before the intervention = 4.85, mean after the intervention = 4.30, p = 0.001). More than 90% of the participants gave positive comments on the evaluation items such as understanding and satisfaction with the educational program and appropriateness of the contents. After attending the training program, participants' sense of difficulty with their knowledge of and skills for ACP decreased, and their practice of ACP increased. This program may promote the practice of ACP for cancer patients in the future.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

AIM

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life.

DESIGN

Systematic review, without meta-analysis, with vote counting based on direction of effect.

DATA SOURCES

Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies.

REVIEW METHODS

Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness.

RESULTS

Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result.

CONCLUSION

This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed.

IMPACT

The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Continuing Education Outcomes for Advance Care Planning: A Systematic Review of the Literature

INTRODUCTION

Advance care planning (ACP) is a process of considering future health and care needs for a time when a person may be unable to speak for themselves. Health professional continuing education programs have been proposed for facilitating patient participation in ACP; however, their impacts on participants, patient and clinical outcomes, and organizational approaches to ACP are not well understood.

METHODS

This systematic literature review examined interventional studies of education programs conducted with health professionals and care staff across a broad range of settings. Five electronic databases were searched up to June 2020, and a manual search of reference lists was conducted. The quality of studies was appraised by the first, second, and third authors.

RESULTS

Of the 7993 articles identified, 45 articles met the inclusion criteria. Program participants were predominantly medical, nursing, and social work staff, and students. Interventions were reported to improve participants' self-perceived confidence, knowledge, and skills; however, objectively measured improvements were limited. Multimodal programs that combined initial didactic teaching and role-play simulation tasks with additional activities were most effective in producing increased ACP activity in medical records. Evidence for improved clinical outcomes was limited.

DISCUSSION

Further studies that use rigorous methodological approaches would provide further evidence about what produces improved patient and clinical outcomes. Needs analyses and quality indicators could be considered to determine the most appropriate and effective education resources and monitor their impacts. The potential contribution of a broader range of health professionals and interprofessional learning approaches could be considered to ultimately improve patient care.

Nursing home staff members' attitudes regarding advance care planning: relationships with different types of knowledge

BACKGROUND

Advanced care planning (ACP) is an essential component of quality palliative care in nursing homes. Despite the benefits associated with ACP in nursing homes, completion rates are low. Staff members' knowledge and attitudes toward ACP were found to be main determinants of ACP completion.

AIMS

To assess nursing home staff members' attitudes towards ACP and their association to different types of knowledge.

METHODS

A convenience sample of 138 nursing home staff members (69% female, 53% non-Jewish, 46% nurses) who reported having heard the terms advanced directives and durable power of attorney completed a structured questionnaire assessing attitudes toward ACP, subjective knowledge, and three types of objective knowledge (declarative, legal and procedural) regarding ACP, as well as socio-demographic and professional factors.

RESULTS

Participants expressed positive attitudes toward formal and informal aspect of ACP, although their subjective and objective knowledge in the topic was moderate. Hierarchical regression analyses revealed that the three dimensions of objective knowledge improved significantly the participants' attitude scores.

DISCUSSION

There is a need to integrate different types of knowledge in educational programs provided to nursing home staff members to improve their involvement in ACP initiatives with residents and family members.

Palliative and end-of-life educational interventions for staff working in long-term care facilities: An integrative review of the literature

BACKGROUND

Given the increase in the number of deaths within long-term care facilities (LTCFs), the need for palliative and end-of-life (EOL) care education among such facilities has been increasing. As such, a systematic synthesis of global palliative and EOL care educational approaches and evaluation can aid further educational development.

OBJECTIVE

To synthesise the current literature on palliative and EOL care educational interventions for staff working in LTCFs and identify barriers to, and facilitators of, intervention implementation.

METHODS

The study used an integrative review framework wherein indexed databases, namely, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, Cochrane Library and Japan Medical Abstract Society, were systematically searched for studies published in English and Japanese between 2007 and 2019. Search terms that are related to palliative care, LTCF, and education were combined to increase search sensitivity. The quality of the papers was assessed using Joanna Briggs Institute Critical Appraisal Tools and the Mixed-Methods Appraisal Tool.

RESULTS

A total of 52 studies were included in the review. Our results suggested that although studies in this area and setting have been evolving, suboptimal developmental research and educational practices, global variability and unstandardised approaches to education and lacking viewpoints from service users have remained. Barriers to intervention implementation were also reported due to the specific characteristics of LTCFs, which include high staff turnover and considerable variation in professional skills and experience.

CONCLUSIONS

Given the different LTCF types, systems and policies across each country or region, further research on standardised educational interventions with contextual considerations using large-scale studies with robust methodology is needed to meet the increasing demand for palliative and EOL care among the global ageing population.

IMPLICATIONS FOR PRACTICE

Palliative and EOL care educational intervention for LTCF staff need to include more consideration of context, organisational culture and the user involvement throughout the process of education and research to enhance the quality of care in this complex setting.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial)

BACKGROUND

provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff.

DESIGN AND SETTING

a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC).

PARTICIPANTS

residents who were not independently mobile.

INTERVENTION

SCTP-delivered by physiotherapists to care staff.

OBJECTIVES AND MEASUREMENTS

key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety.

RESULTS

a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns.

CONCLUSION

care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

The Impact of Organizational Factors on Nurses' Knowledge, Perceptions, and Behaviors Around Advance Care Planning

The objective of this study was to understand the organizational context of nurses' use of advance care plans (ACPs). We use a modified version of Bandera's social cognitive theory model to understand relationships between organizational constructs such as experience with ACPs and satisfaction with organizational support and oncology nurses' knowledge, behaviors, and perceptions around ACPs. The sample included practicing registered nurses with a major focus in oncology who were members of the Oncology Nursing Society in the United States, and nurses at medical hospital or community care settings were included. Institutional review board approval was obtained, and permission was granted from the oncology nursing organization for online surveys. A validated ACP survey was used to measure nurses' experiences and perceptions of working with ACP. Perceptions of ACP by patients, vicarious experience with ACP, direct experience of ACP, having received training, and perceptions of organizational support for ACP were all predictive of total ACP behaviors in the workplace. The final regression model had 3 independent variables and accounted for 33% of the variance in total ACP behaviors. Both vicarious and direct experience with ACP was associated with ACP behaviors in workplaces. This implies the need for more vicarious and direct training experiences, as well as organization support, to build self-efficacy to perform ACP.

Development and implementation of an advance care planning program in Catalonia, Spain

OBJECTIVE

Implementation of an advance care planning (ACP) program for people with advanced chronic conditions is a complex process. The aims of this paper are to describe (1) the development of the ACP program in Catalonia, Spain, for patients with advanced chronic conditions and complex needs and (2) the preliminary results of the implementation of this program in health and social services.

METHOD

The ACP program was developed and implemented in a four-stage process as follows: (1) design and organization of the project; (2) selection of the professionals to carry out the project; (3) creation of four working groups to develop the conceptual model, guidelines, training program, and perform a qualitative evaluation; and (4) project implementation.

RESULT

The following deliverables were completed: (1) conceptual framework document; (2) practical guidelines for the application of the ACP; (3) online training course (3,763 healthcare professionals completed the online course, with an overall satisfaction rating of 8.4 on a 10-point scale); and (4) additional training activities (conferences, short courses, and seminars) in between 2015 and 2017.

SIGNIFICANCE OF RESULTS

This project was led by the Catalan Ministry of Health. The strengths of the project development include the contribution of a wide range of professionals from the entire region, approval by the Catalan Bioethics Committee and the Social Services Ethics Committee, and the ongoing validation by members of the community. A standardized online training course was offered to all primary care professionals and included as a quality indicator for continuing education for those professionals in the period 2016-2020. The main outcome of this project is the establishment of a pragmatic ACP throughout the region and training of the health and social care professionals involved in the care of advanced chronic patients.

[Hospitalization of nursing home residents in the last phase of life: an analysis of health insurance data]

Hintergrund

Im internationalen Vergleich versterben Pflegeheimbewohner in Deutschland häufig im Krankenhaus. Daten zu längeren Zeiträumen vor dem Tod und zu regionalen Unterschieden fehlen.

Ziel der Arbeit

Es werden Häufigkeiten von Krankenhausaufenthalten bei Pflegeheimbewohnern in verschiedenen Perioden vor dem Tod analysiert. Zudem werden Unterschiede nach Alter, Geschlecht, Pflegestufe, Demenz und Bundesländern untersucht.

Material und Methoden

Wir verwendeten Daten einer großen Krankenkasse und schlossen Pflegeheimbewohner im Mindestalter von 65 Jahren ein, die zwischen dem 01.01.2010 und dem 31. 12.2014 verstarben. Outcome war mindestens ein Krankenhausaufenthalt nach Heimeintritt in verschiedenen Phasen des letzten Lebensjahres. Vertiefende Analysen wurden für die Zeiträume 0 (entspricht Versterben im Krankenhaus), 28 und 365 Tage vor Tod durchgeführt.

Ergebnisse

Von den insgesamt 67.328 verstorbenen Bewohnern (mittleres Alter: 85,3 Jahre; 69,8 % weiblich), verstarben 29,5 % im Krankenhaus. In den letzten 28 bzw. 365 Tagen vor Tod hatten 51,5 % bzw. 74,3 % mindestens einen Krankenhausaufenthalt. Diese Werte waren in ostdeutschen Bundesländern höher. In allen Zeiträumen wurden Männer häufiger hospitalisiert. Bewohner mit höherer Pflegestufe wurden seltener stationär behandelt, besonders unmittelbar vor dem Tod. Demenz hatte keinen nennenswerten Einfluss auf die Hospitalisierungshäufigkeiten.

Diskussion

Etwa die Hälfte der Pflegeheimbewohner wird im letzten Lebensmonat stationär behandelt, und ein Drittel verstirbt im Krankenhaus, was, international betrachtet, hoch ist. Dass wir keine Unterschiede bei Bewohnern mit und ohne Demenz fanden, widerspricht ebenso internationalen Befunden. Somit besteht erheblicher Handlungsbedarf, die palliative Versorgung von Pflegeheimbewohnern zu optimieren.

Delivering an advance care planning facilitated model

BACKGROUND

Advance care planning is increasingly recognised as an integral part of achieving excellence at the end of life (EoL), but barriers still prevent individuals from having the opportunity to discuss their wishes and preferences for the future.

AIM

To describe the development and initial evaluations of an innovative facilitated ACP model, the ACP Triple E, which empowers individuals through education to engage in ACP conversations.

METHODS

This model uses a collaborative approach involving all sectors of a large university health board to equip all health and social care professionals with the knowledge, skills and confidence to engage in ACP discussion and also raise public awareness of the benefits of ACP.

CONCLUSION

This model includes recognised elements that support successful implementation of ACP. Initial evaluations of the model are extremely positive. Further analysis of the data is now needed to evaluate the model's flexibility and its ability to change practice and achieve strategic objectives.

Barriers and facilitators to palliative care education in nursing and residential homes: a rapid review

BACKGROUND

There is insufficient high-quality evidence to suggest that palliative care education can impact care home settings.

AIMS

To identify, appraise and synthesise all available evidence on the barriers and facilitators to providing palliative care education in residential and nursing care homes and to generate recommendations to increase the effectiveness of future palliative care education programmes in care homes.

METHODS

A rapid review searching CINAHL, Medline and ProQuest. One author screened full-text articles for inclusion. Any uncertainties were discussed with a second author.

FINDINGS

Twenty-two articles were included in the full review. Analysis of the included articles revealed the following overlapping themes: structural systems; cultural and personal issues; and knowledge translation issues with interaction.

CONCLUSION

Addressing the barriers and facilitators when designing palliative care education programmes for care homes will lead to more successful outcomes.

Systematic critical realist review of interventions designed to improve end-of-life care in care homes

The demand for high-quality end-of-life care is rising. Frequently evidenced concerns about the provision of end-of-life in care homes relate to inter-disciplinary communication and engagement in advance care planning. A number of interventions employing different mechanisms have been designed to address these issues. Therefore, the aim of this systematic critical realist review was to describe and explain the effectiveness of interventions designed to improve end-of-life care in care homes. Electronic searches were conducted in ScienceDirect, MEDLINE, PubMed, PsychINFO, and CINAHL from January 2000 to August 2018. Forty one studies were included in the review. While most of the evidence identified in this review was not strong, there was evidence to suggest that education and inter-professional collaboration can be effective intervention mechanisms for improving end-of-life care in care homes. High staff turnover was a significant contextual mechanism impacting on the sustainability of interventions. In terms of human agency, it is important to note a consistent finding related to the dedication and enthusiasm of care home staff who deliver end-of-life care.

End-of-life care of nursing home residents: A survey among general practitioners in northwestern Germany

AIM

To describe general practitioners' (GPs) perspectives on end-of-life care of nursing home residents.

METHODS

We carried out a cross-sectional study. A questionnaire was sent to a random sample of 1121 GPs in the German federal states of Bremen and Lower Saxony in 2018. Data were compared between GPs with a qualification in palliative medicine and those without such qualifications, and multivariable logistic regression was performed.

RESULTS

Overall, 375 questionnaires were returned (response rate 34%). The majority of GPs (71%) agreed that nursing home residents are treated too often in hospitals at the end of life, and more than half rated end-of-life care in nursing homes as "rather poor" (54%). For both questions, GPs with a qualification in palliative medicine showed higher agreements. In the multivariable analysis, a prior qualification in palliative medicine was also strongly associated with rating end-of-life care as "rather poor" (OR 1.89, 95% CI 1.10-3.23). Respondents cited higher staffing ratios and better trained nursing staff as the most important measures to improve end-of-life care. Furthermore, it was estimated that just 37% of residents have an advance directive, with only one-third including valid information on end-of-life hospitalizations.

CONCLUSIONS

This study showed that GPs tend to be critical regarding end-of-life care in nursing homes. To improve end-of-life care, better training in palliative care for nursing staff and GPs might be warranted. In addition, advance care planning can help to ensure that residents' wishes are respected. Geriatr Gerontol Int 2020; 20: 25-30.

Frailty Screening (FRAIL-NH) and Mortality in French Nursing Homes: Results From the Incidence of Pneumonia and Related Consequences in Nursing Home Residents Study

OBJECTIVES

To investigate the ability of the fatigue, resistance, ambulation, incontinence or illness, loss of weight, nutritional approach, and help with dressing (FRAIL-NH) tool to predict mortality.

DESIGN

The Incidence of Pneumonia and Related Consequences in Nursing Home Residents (INCUR) study database was used. This was an observational cohort study in French nursing homes conducted over 12 months in 2012.

PARTICIPANTS

A total of 788 residents aged 60 years or older, from 13 randomly selected French nursing homes.

MEASUREMENTS

FRAIL-NH was generated from the available variables at baseline. FRAIL-NH scores ranged from 0 to 14 and people were categorized as nonfrail (0‒1), frail (2‒5), and most frail (6‒14). Mortality data were obtained from medical charts and confirmed by the nursing home administrative documentation.

RESULTS

Mean age of the participants was 86.2 ± 7.5 years, and 74.5% were women. The prevalence of persons with FRAIL-NH score greater than 1 was 88.8%, with 54.2% and 34.6% of residents identified as most frail and frail, respectively. The mean FRAIL-NH score was 6.0 ± 3.4. Women (N = 583) were frailer (6.1 ± 3.4) than men (N = 200, 5.5 ± 3.4; P = .027). Overall, 136 residents died over the 1-year follow-up period. The FRAIL-NH score was a predictor of mortality (adjusted hazard ratios: for frail group 1.15, 95% confidence interval 0.55‒2.41; for most frail group 2.14, 95% confidence interval 1.07‒ 4.27).

CONCLUSIONS

FRAIL-NH is a predictor of mortality in nursing home residents and the score could assist with guiding appropriate care planning.

Nursing home staff members' knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes

BACKGROUND

Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries.

AIMS

To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy.

METHODS

Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants' characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents.

RESULTS

Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals' knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators.

DISCUSSION

Nursing home staff members' concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it.

CONCLUSIONS

A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.

Effects of an advance care planning educational programme intervention on the end-of-life care attitudes of multidisciplinary practitioners at an acute hospital: A pre- and post-study

BACKGROUND

Advance care planning is a crucial end-of-life care practice. However, an advance care planning educational programme for practitioners in an acute care setting has not yet been established. Consequently, we examined the effects of an advance care planning educational programme in an acute hospital in the hope of achieving increased awareness of end-of-life care.

DESIGN

A mixed-methods, pre- and post-design was employed to evaluate the change in attitudes of practitioners post-programme. The intervention programme was conducted thrice over 3 months in 90-min sessions.

SETTING/PARTICIPANTS

This study included 85 participants in the baseline assessment working at B acute hospital in Osaka.

RESULTS

Participants' scores on the 'Positive attitude for end-of-life care' subscale on the short version of the Frommelt Attitude Toward Care of Dying scale significantly increased after the 6-month intervention. A 'Positive attitude for end-of-life-care' implies that participants would not be afraid to practice end-of-life care. Further, participants' scores on the 'Death relief' subscale of the Death Attitude Inventory also significantly increased. The term 'Death relief' means that death helps in ending suffering. It means participants are not afraid of death. Qualitative results implied that participants believed advance care planning implementation and communicating with patients and patients' families were critical.

CONCLUSIONS

Six months post-intervention, participants displayed sustained positive attitudes towards end-of-life care. These results suggest that the present programme was effective at improving practitioners' attitudes towards patients' end-of-life care.

Is cancer a good way to die? A population-based survey among middle-aged and older adults in the United Kingdom

OBJECTIVES

Despite improved outcomes, cancer remains widely feared, often because of its association with a long and protracted death as opposed to the quick death that people associate with that other common cause of adult mortality: heart disease. Former editor-in-chief of the BMJ Richard Smith's view that 'cancer is the best way to die' therefore attracted much criticism. We examined middle-aged and older adults' agreement with this view and compared their attitudes towards dying from cancer versus heart disease in terms of which was a good death.

METHODS

This study was part of an online survey (February 2015) in a United Kingdom (UK) population sample of 50- to 70-year olds (n = 391), with sampling quotas for gender and education. Five characteristics of 'a good death' were selected from the end-of-life literature. Respondents were asked to rate the importance of each characteristic for their own death to ensure their relevance to a population sample and the likelihood of each for death from cancer and heart disease. We also asked whether they agreed with Smith's view.

RESULTS

At least 95% of respondents considered the selected five characteristics important for their own death. Death from cancer was rated as more likely to provide control over what happens (p < 0.001), control over pain and other symptoms (p < 0.01), time to settle affairs (p < 0.001), and time to say goodbye to loved ones (p < 0.001) compared with death from heart disease, but there were no differences in expectation of living independently until death (p > 0.05). Almost half (40%) agreed that cancer is 'the best way to die', with no differences by age (p = 0.40), gender (p = 0.85), or education (p = 0.27).

CONCLUSION

Despite the media commotion, a surprisingly high proportion of middle-aged and older adults viewed cancer as 'the best way to die' and rated cancer death as better than heart disease. Given that one in two of us are likely to be diagnosed with cancer, conversations about a good death from cancer may in a small way mitigate fear of cancer. Future research could explore variations by type of cancer or heart disease and by previous experience of these illnesses in others.

Exploring the Barriers of Home Care Services in Iran: A Qualitative Study

With increasing chronic diseases, the use of home care is rising in the world. Home care in Iran has many challenges and to improve that, we should identify the challenges and barriers of home care. The aim of this study was to identify and explore the barriers of home care in Iran. This is a qualitative study with content analysis approach that was conducted in Iran in 2015. Fourteen key informants comprising health policymakers, faculty members, nurses, and physicians as well as patients and families engaged in home care purposefully participated in this study. Data was obtained using face-to-face semistructured interviews. A focus group discussion was also used to complete the findings. Graneheim and Lundman's approach was used for analysis of data and Lincoln and Guba's criteria were used to confirm the trustworthiness of study's findings. The data were divided into three main categories and eight subcategories. Main categories included treatment-based approach in the healthcare system, cultural dimensions, and the lack of adequate infrastructure. A position for home care in the healthcare system, considering cultural dimensions in Iranian society and providing an appropriate infrastructure, can be beneficial to improve the situation of home care services in Iran.