Relationships between nurses and older people within the home: exploring the boundaries of care

The perceptions and experiences of community nurses and patients towards shared decision-making in the home setting: An integrative review

AIM

To explore patients' and community nurses' perceptions and experiences of shared decision-making in the home.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, British Nursing Index, Psycinfo, Medline and Social Services Abstracts were searched for qualitative, quantitative and mixed methods papers published between 1 December 2001 and 31 October 2023.

REVIEW METHODS

A systematic search of electronic databases was undertaken using defined inclusion criteria. The included papers were appraised for quality using the Joanna Briggs Institute critical appraisal checklist for qualitative research. Relevant data were extracted and thematically analysed.

RESULTS

Fourteen papers comprising 13 research studies were included. Patients attached great importance to their right to be involved in decision-making and noted feeling valued as a unique individual. Communication and trust between the patient and nurse were perceived as fundamental. However, shared decision-making does not always occur in practice. Nurses described tension in managing patients' involvement in decision-making.

CONCLUSION

The findings demonstrate that although patients and community nurses appreciate participating in shared decision-making within the home, there are obstacles to achieving a collaborative process. This is especially relevant when there are fundamentally different perspectives on the decision being made. More research is needed to gain further understanding of how shared decision-making plays out in practice and to understand the tensions that patients and nurses may experience.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This paper argues that shared decision-making is more than the development of a relationship where the patient can express their views (though of course, this is important). Shared decision-making requires acknowledgement that the patient has the right to full information and should be empowered to choose between options. Nurses should not assume that shared decision-making in community nursing is easy to facilitate and should recognize the tensions that might exist when true patient choice is enabled.

IMPACT

This paper demonstrates how the idea of shared decision-making needs to be explored in the light of everyday practice so that challenges and barriers can be overcome. In particular, the tensions that arise when patients and nurses do not share the same perspective. This paper speaks to the potential of a gap surrounding shared decision-making in theory and how it plays out in practice.

REPORTING METHOD

The reporting of this review was guided by the 2020 guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

This review was carried out as part of a wider study for which service users have been consulted.

Home care nurses lived experiences of caring relationships with older adults: A phenomenological study

BACKGROUND

This paper describes registered nurses' lived experiences of caring relationships in the context of homecare provision for older adults living in Denmark. With the growing ageing population throughout Europe, more older adults will require complex care solutions within already overburdened care systems. This development places demands on the competencies and organisation of homecare nurses, as they become key players in healthcare systems. Fostering caring relationships in homecare is a rewarding and valuable process that enhances the holistic and humanising aspects of caring for older adults. For a caring relationship to be truly caring, we must understand not only the subjective experience of such a relationship but also how it is experienced in relation to and shared with others.

AIM

This study aimed to describe the essential meaning of the phenomenon of caring relationships in homecare for older adults based on the lived experiences of homecare nurses.

APPROACH AND METHODS

Registered nurses working in homecare for older adults were interviewed, and a phenomenological analysis was conducted according to the methodological principles of the reflective lifeworld research approach.

FINDINGS

The essential meaning of the phenomenon is described as creating an existential and embodied space in which each patient's world is the foundation of caring. The constituents are as follows: caring for the whole person, a sense of 'at-homeness' through trusting 'the other', experiencing continuity as caring and prioritising the time to care.

CONCLUSION

Caring competence in homecare for older adults relies on a nurse's ability to intertwine physical and existential care needs and articulate them in their daily work. A focus on the phenomenon of caring relationships brings value to and adds an extra layer to the discussion on caring competence.

"Friend-ish": Home Care Workers, "Social Labor" and Managing the Boundaries of the Carer Relationship

We examine how changes in home care work, with greater emphasis on social support, have led to corresponding changes in the forms of labor performed by home care workers. Drawing on interviews with fifty older adults, we find in addition to physical and emotional labor, workers may be increasingly expected to engage in a form of labor we term "social labor," in which they actively manage the boundary between the professional services they provide and the personal relationships that may develop. We find examples of such expectations include (1) following the lead of clients who set out terms of the relationship and degree of sociality, (2) managing the potential dual role of "support worker" and "friend," and (3) meeting social needs of clients vulnerable to isolation. As Government acknowledges the value of social support and companionship, greater attention is needed to this aspect of care work, with implications for workers and clients.

The experiences and needs of frail older people receiving home health care: A qualitative study

BACKGROUND

Due to the rapid ageing of the population, there is increasing demand for long-term care in the people's home environment. Such care aims to allow the people to stay at home and avoid hospitalisation or other institutional care. In home health care, care must be provided at the highest possible quality, with the focus on the people's needs and experiences.

OBJECTIVES

This study explores the experiences and needs of frail older people receiving home health care.

DESIGN AND METHODS

An exploratory descriptive qualitative approach was chosen. Audio-taped semi-structured interviews were conducted with fifteen older people receiving home health care. A content analysis was used to analyse the data collected.

RESULTS

The content analysis identified one main theme, three categories and seven subcategories related to frail older people's needs and experiences of home health care. The main theme was quality of care. The first category, Safe and Secure Care, consisted of three subcategories: Education and Experience of Nurses, Information, and Continuity of Care in terms of personnel continuity and regular care. The second category, Autonomy, contained two subcategories: Decision-making and Self-sufficiency. The last category, Relationship with Professionals, consisted of two subcategories: Personality of Nurse and Partnerships.

CONCLUSION

Older people are able to express their satisfaction or dissatisfaction with home health care. The results of this study revealed that the quality of care is crucial for frail older people.

IMPLICATION FOR PRACTICE

The provision of home health care is inherently highly specific; home care nurses should work to provide the highest possible quality of care. In particular, nurses should focus on ensuring that the care they provide is safe, effective, timely, efficient and person-centred.

The needs of older people receiving home care: a scoping review

BACKGROUND

Most people in a state of illness or reduced self-sufficiency wish to remain in their home environment. Their physiological needs, and their psychological, social, and environmental needs, must be fully met when providing care in their home environment. The aim of this study is to provide an overview of the self-perceived needs of older people living with illness or reduced self-sufficiency and receiving professional home care.

METHODS

A scoping review of articles published between 2009 and 2018 was conducted by searching six databases and Google Scholar. Inductive thematic analysis was used to analyze data from the articles retrieved.

RESULTS

15 articles were included in the analysis. Inductive thematic analysis identified six themes: coping with illness; autonomy; relationship with professionals; quality, safe and secure care; role in society; environment.

CONCLUSION/DISCUSSION

Older home care patients living with chronic illness and reduced self-sufficiency are able to express their needs and wishes. Care must, therefore, be planned in line with recipients' needs and wishes, which requires a holistic approach.

Striking a balance: Health care providers' experiences with home-based, patient-centered care for older people-A meta-synthesis of qualitative studies

OBJECTIVE

The aim of this article was to synthesize research findings about health care providers' experiences of patient-centered care in the home setting.

METHODS

This is a meta-synthesis of qualitative findings using the analytical method of meta-ethnography developed by Noblit and Hare. We performed a systematic literature search in seven databases and assessed potential studies against eligibility criteria and quality. Subsequently, 10 primary studies were included for analysis.

RESULTS

The core theme "being a balance artist" emerged from the synthesis, incorporating the participants' experiences when faced with conflicting and competing responsibilities and needs. Two subthemes-"balancing the older clients' needs against organizational demands" and "balancing the older clients' needs against professional standards"-further elaborated on this core theme.

CONCLUSION

Health care providers' experiences indicate that organizational factors play a crucial role in shaping the conditions for patient-centered care for older people in the home setting.

PRACTICE IMPLICATIONS

To motivate and facilitate health care providers to move to a more patient-centered practice, it is important to expand the values of patient-centered care beyond the clinical encounter into the organization.

Determinants of the quality of care relationships in long-term care - a systematic review

BACKGROUND

The quality of a care relationship between a client and a care professional is seen as fundamental if high-quality care is to be delivered. This study reviews studies about the determinants of the quality of the client-professional relationship in long-term care.

METHODS

A systematic review was performed using the electronic databases of Medline, Psycinfo, CINAHL and Embase. The review focused on three client groups receiving long-term care: physically or mentally frail elderly, people with mental health problems and people with physical or intellectual disabilities. Included studies concern clients receiving inpatient or outpatient care and care professionals who provided recurring physical and supporting care for a long period of time. The studies we included contained primary empirical data, were written in English and were published in peer-reviewed journals. Data extraction was carried out by two researchers independently.

RESULTS

Thirty-two studies out of 11,339 initial hits met the inclusion criteria. In total, 27 determinants were revealed, six at the client level, twelve at the professional level, six between the client and care professional levels and three at the contextual level. The data analysis showed that most determinants were relevant in more than one client group.

CONCLUSIONS

This is the first review that looked at determinants of the quality of the care relationship for three large client groups receiving long-term care. It suggests that the current client group-specific focus in research and quality improvement initiatives for care relationships might not be needed. Care organisations can use the findings of this review as guidance on determinants to look for when mapping the quality of a care relationship in order to get a picture of specific points of attention for quality improvement.

The need for flexibility when negotiating professional boundaries in the context of home care, dementia and end of life

Professional boundaries may help care staff to clarify their role, manage risk and safeguard vulnerable clients. Yet there is a scarcity of evidence on how professional boundaries are negotiated in a non-clinical environment (e.g. the home) by the home-care workforce in the context of complex care needs (e.g. dementia, end-of-life care). Through analysis of semi-structured interviews, we investigated the experiences of home-care workers (N = 30) and their managers (N = 13) working for a range of home-care services in the South-East and London regions of England in 2016–17. Findings from this study indicate that home-care workers and their managers have clear perceptions of job role boundaries, yet these are modified in dementia care, particularly at end of life which routinely requires adaptability and flexibility. As a lone worker in a client's home, there may be challenges relating to safeguarding and risk to both clients and workers. The working environment exacerbates this, particularly during end-of-life care where emotional attachments to both clients and their family may affect the maintenance of professional boundaries. There is a need to adopt context-specific, flexible and inclusive attitudes to professional boundaries, which reconceptualise these to include relational care and atypical workplace conventions. Pre-set boundaries which safeguard clients and workers through psychological contracts may help to alleviate to some extent the pressure of the emotional labour undertaken by home-care workers.

Telemedicine follow-up facilitates more comprehensive diabetes foot ulcer care: A qualitative study in home-based and specialist health care

AIMS AND OBJECTIVES

To investigate the application of a telemedicine intervention in diabetes foot ulcer care, and its implications for the healthcare professionals in the clinical field.

BACKGROUND

Contextual factors are found to be important when applying technology in health care and applying telemedicine in home-based care has been identified as particularly complex.

DESIGN AND METHODS

We conducted field observations and individual interviews among healthcare professionals in home-based care and specialist health care in a diabetes foot care telemedicine RCT (Clin.Trial.gov: NCT01710774) during 2016. This study was guided by Interpretive Description, an inductive qualitative methodology.

RESULTS

Overall, we identified unequal possibilities for applying telemedicine in diabetes foot ulcer care within the hospital and home care contexts. Different circumstances and possibilities in home-based care made the application of telemedicine as intended more difficult. The healthcare professionals in both care contexts perceived the application of telemedicine to facilitate a more comprehensive approach towards the patients, but with different possibilities to enact it.

CONCLUSIONS

Application of telemedicine in home-based care was more challenging than in the outpatient clinic setting. Introducing more updated equipment and minor structural adjustments in consultation time and resources could make the use of telemedicine in home-based care more robust.

RELEVANCE TO CLINICAL PRACTICE

Application of telemedicine in diabetes foot ulcer follow-up may enhance the nursing staff's ability to conduct comprehensive assessment and care of the foot ulcer as well as the patient's total situation. Access to adequate equipment and time, particularly in home-based care, is necessary to capitalise on this new technology.

A purposeful Yet Nonimposing Approach: How Japanese Home Care Nurses Establish Relationships With Older Clients and Their Families

Relationship development is crucial to nursing practice with families. However, little is known about the process of building relationships with multiple family members in home care settings and in various cultures. The objective of this study was to explore the experiences of home care nurses about how they established relationships with older clients and their families in Japan. Grounded theory was used to guide the research. Twenty-three expert home care nurses participated in semistructured interviews concerning their family nursing practice. The establishment of relationships with clients/family members was based on a purposeful yet nonimposing approach composed of four aspects: keeping a mindful distance from the family, not being a threat to family life, being a comfortable neighbor, and gaining trust as a competent nurse. Through a purposeful nonimposing approach, Japanese home care nurses promoted and nurtured nurse-family relationships and became involved in the life of the family. These findings provide a useful foundation to guide practice with families and grow knowledge about the process of establishing relationships with multiple family members in home settings.

Reinstating district nursing: A UK perspective

As policy directives gather pace for service provision to be delivered in primary care, district nursing has not been recognised as a valuable asset to facilitate this agenda. Investment in district nursing and specialist district nursing education has fallen. This is concurrent with an ageing district nursing workforce, a lack of recruitment and growing caseloads, as district nursing adapts to meet the challenges of the complexities of contemporary healthcare in the community. The district nurse role is complex and multifaceted and includes working collaboratively and creatively to coordinate care. Redressing the shortages of specialist district nurse practitioners with increased numbers of health care support workers will not replace the skill, knowledge, experience required to meet the complex care needs of today's society. District nursing needs to be reinstated as the valuable asset it is, through renewed investment in the service, research development and in specialist practice education. To prevent extinction district nurses need to be able to demonstrate and articulate the complexities and dynamisms of the role to reinstate themselves to their commissioners as a valuable asset for contemporary practice that can meet current health and social care needs effectively.

Caring for Clients and Families With Anxiety: Home Care Nurses' Practice Narratives

This study elucidated Japanese home care nurses’ experiences of supporting clients and families with anxiety. We interviewed 10 registered nurses working in home care agencies and analyzed the data using grounded theory to derive categories pertaining to the nurses’ experiences of providing care. We conceptualized nurses’ approaches to caring for anxiety into three categories: First, they attempted to reach out for anxiety even when the client/family did not make it explicit; second, they tried to alter the outlook of the situation; and third, they created comfort in the lives of the client/family. The conceptualizations of nurses’ strategies to alleviate client/family anxiety may reflect Japanese/Eastern cultural characteristics in communication and their view of the person and social care system, but these conceptualizations may also inform the practice of Western nurses by increasing awareness of skills they may also have and use.

Home health care nurse perceptions of geriatric depression and disability care management

PURPOSE OF THE STUDY

Psychosocial interventions alone or combined with antidepressant medication can effectively treat mild to moderate geriatric depression. However, most home health care patients with depression and disability do not receive these interventions. Moreover, relatively little is known about home health care nurse views about depression management. Therefore, our research purpose was to provide a deeper understanding about how home health care nurses perceive and experience depression detection and evaluation within the context of caring for geriatric patients with disabilities.

DESIGN AND METHODS

This qualitative descriptive study involved 2 focus groups and 16 semistructured interviews with nurses providing care to geriatric home health care patients followed by observation during 25 nurse home visits to geriatric patients who had depression and disability.

FINDINGS

Nurses demonstrated confidence in caring for elderly patients with disabilities. However, they expressed different views about the nature of depression and the integration of depression and disability care in daily practice. Evidence points to a need for advanced training that supports an enhanced role for generalist homecare nurses in providing depression care management for this vulnerable geriatric population.

IMPLICATIONS

Policy challenges are associated with ways in which home health care is fiscally organized primarily to address patients' physical and acute skilled care needs and not depression.

Client involvement in home care practice: a relational sociological perspective

'Client involvement' has been a mantra within health policies, education curricula and healthcare institutions over many years, yet very little is known about how 'client involvement' is practised in home-care services. The aim of this article is to analyse 'client involvement' in practise seen from the positions of healthcare professionals, an elderly person and his relative in a home-care setting. A sociologically inspired single case study was conducted, consisting of three weeks of observations and interviews. The study has a focus on the relational aspects of home care and the structural, political and administrative frames that rule home- care practice. Client involvement is shown within four constructed analytical categories: 'Structural conditions of providing and receiving home care'; 'Client involvement inside the home: performing a professional task and living an everyday life'; 'Client involvement outside the home: liberal business and mutual goal setting'; and 'Converting a home to a working place: refurnishing a life'. The meaning of involvement is depending on which position it is viewed from. On the basis of this analysis, we raise the question of the extent to which involvement of the client in public home-care practice remains limited.