Nordic homecare nursing from the perspective of homecare nurses-a meta-ethnography

Digital ethical reflection in long-term care: Leaders' expectations

BACKGROUND

Healthcare leader support and facilitation for ethics work are of great importance for healthcare professionals' handling of ethical issues, moral distress, and quality care provision. A digital tool for ethical reflection in long-term care was developed in response to the demand for appropriate tools.

RESEARCH AIM

This study aimed to explore healthcare leaders' expectations of using a digital tool for ethical reflection among their home nursing care staff.

RESEARCH DESIGN

A qualitative research design with vignettes and focus group interviews was used. The data were analyzed using reflexive thematic analysis.

PARTICIPANTS AND RESEARCH CONTEXT

The sample comprised ten healthcare leaders from municipal long-term care in Norway.

ETHICAL CONSIDERATIONS

Participation was voluntary and based on informed consent. The Norwegian Agency for Shared Services in Education and Research approved this study.

FINDINGS

The analysis resulted in the development of three themes representing leaders' expectations of the tool: (i) giving staff a voice, (ii) revealing ethics in practice, and (iii) keeping the pot boiling.

DISCUSSION

Leaders must be informed about the ethical issues experienced to engage in supportive measures for their staff. Digital channels can increase the democratization, safety, and efficiency of communication between employees and leaders and increase awareness of ethical aspects in daily care work. The leaders had positive expectations of employees' activities and benefits from using the tool for ethical reflection. However, they admitted that realizing the tool's potential to ensure continuity in ethics work requires considerable organizational and leader involvement.

CONCLUSIONS

This study shows that healthcare leaders are open to digital solutions for managing ethics work in home nursing care. Both opportunities and important prerequisites for successfully implementing the digital tool were identified.

Exploring Norwegian homecare healthcare professionals' perceptions of risk and the link to high-quality care: a qualitative multiple case study

OBJECTIVES

Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience.

DESIGN

The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted.

SETTING

The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case.

PARTICIPANTS

Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups.

RESULTS

Four themes were identified: 'professionalism is constantly prioritising and aligning care based on here-and-now observations' 'teamwork feels safe and enhances quality' 'taking responsibility for system risk' and 'reluctantly accepting the extended expectations from society'.

CONCLUSIONS

To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients' condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Exploring homecare leaders' risk perception and the link to resilience and adaptive capacity: a multiple case study

BACKGROUND

Home-based healthcare is considered crucial for the sustainability of healthcare systems worldwide. In the homecare context, however, adverse events may occur due to error-prone medication management processes and prevalent healthcare-associated infections, falls, and pressure ulcers. When dealing with risks in any form, it is fundamental for leaders to build a shared situational awareness of what is going on and what is at stake to achieve a good outcome. The overall aim of this study was to gain empirical knowledge of leaders' risk perception and adaptive capacity in homecare services.

METHODS

The study applied a multiple case study research design. We investigated risk perception, leadership, sensemaking, and decision-making in the homecare services context in three Norwegian municipalities. Twenty-three leaders were interviewed. The data material was analyzed using thematic analysis and interpreted in a resilience perspective of work-as-imagined versus work-as-done.

RESULTS

There is an increased demand on homecare services and workers' struggle to meet society's high expectations regarding homecare's responsibilities. The leaders find themselves trying to maneuver in these pressing conditions in alignment with the perceived risks. The themes emerging from analyzed data were: 'Risk and quality are conceptualized as integral to professional work', 'Perceiving and assessing risk imply discussing and consulting each other- no one can do it alone' and 'Leaders keep calm and look beyond the budget and quality measures by maneuvering within and around the system'. Different perspectives on patients' well-being revealed that the leaders have a large responsibility for organizing the healthcare soundly and adequately for each home-dwelling patient. Although the leaders did not use the term risk, discussing concerns and consulting each other was a profound part of the homecare leaders' sense of professionalism.

CONCLUSIONS

The leaders' construction of a risk picture is based on using multiple signals, such as measurable vital signs and patients' verbal and nonverbal expressions of their experience of health status. The findings imply a need for more research on how national guidelines and quality measures can be implemented better in a resilience perspective, where adaptive capacity to better align work-as-imagined and work-as-done is crucial for high quality homecare service provision.

Nurses' professional discretion in the purchaser-provider split in home care in Norway

AIM

To explore how nurses' professional discretion is operationalized in home care services that follow a purchaser-provider organization in Norway.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured interviews with open-ended questions were used, and data were collected from in-depth interviews with 15 registered nurses working in home care in four Norwegian local authority areas between April and November 2020. Braun and Clark's six-step analysis was used to analyse the empirical data.

RESULTS

The analysis yielded two main themes, namely 'The purchaser's instructions: facilitating and constraining care' and 'Professional discretion meets the purchaser-provider organisation of healthcare,' with five associated codes.

CONCLUSION

Nurses are dependent on an organizational framework due to the complexity of health care services and the number of tasks involved. At the same time, they perform considerable compensatory work and need the ability to be flexible to enable this work and to perform actions related to the unforeseen needs of individual patients or those involving professional discretion.

IMPACT

The purchaser-provider model both facilitates and constrains nursing practice and professional responsibility in home nursing. Home nursing services need to be well organized because of their complexity and the wide variety of tasks they involve. In this context, the element of constraint is associated with the need for flexibility and professional discretion. Despite a strict framework, the nurses perform additional and compensatory tasks. Reforms inspired by 'New Public Management,' such as the purchaser-provider split, limit the workload for nurses; however, there is still a need to exercise discretion. The findings of this study may help home care managers and health policy-makers understand the interaction between management logic and health care logic, leading to a more appropriate organization of health care services where the nurses, as actors, gain more trust.

IMPLICATIONS

This study highlights home care nurses' opportunities to exercise discretion in an organizational framework that strives towards standardization. The nurses' ability to exercise discretion is important for individual and holistic patient care. At the same time, an organizational framework is needed because nurses cannot attend to all the needs the patients may have, as this will overload both home health services and the nurses.

What about the fundamentals of nursing-its interventions and its continuity among older people in need of home- or facility-based care: a scoping review

AIM

This scoping review investigated and descriptively summarised previous research about fundamental nursing, its focus (what care needs are described, how is it described and by whom is it described), continuity of care (is it described in relation to fundamental nursing) and possible nursing interventions or activities targeting older people's fundamentals of care needs in home- or facility-based care.

METHODS

This scoping review was carried out following the steps of Arksey and O'Malley's methodology and PRISMA-ScR reporting guidelines. Searches were conducted in PubMed via NIH, CINAHL via EBSCO and PsycInfo via ProQuest for the time period between January 2002 and May 2023.

RESULTS

Forty-two studies were included where the majority had been conducted in a facility-based care context. Nutrition-or rather nutritional care activities targeting eating and drinking-was the most frequently described fundamental care needs addressed. After this came personal care such as cleansing, dressing, oral care, skin, and foot care. Few studies addressed more than one fundamental care need at the time. The nursing staff described fundamental nursing as complex, comprehensive, and demanding. Older people and relatives described a gap between the fundamental nursing provided and their perceived need for support. Less attention was given to older peoples relational and psychosocial needs. Identified nursing interventions mainly targeted physical care needs. Our findings also implied that interventions focusing on fundamental nursing were described as feasible in practice with favourable or moderate results, while long-term effects were difficult to detect. No studies were identified focusing on fundamental nursing in relation to outcomes such as continuity of care.

CONCLUSION

Fundamental nursing was mainly described in relation to physical care needs, which were essentially conducted within facility-based care contexts. Interventions and activities primarily focused on one fundamental need at the time, mainly within the physical domain. No nursing interventions were identified focusing on relational and psychosocial needs where continuity of care can be viewed as a relevant outcome. Such limited focus are especially concerning as research has highlighted the importance of that older people with complex care needs can benefit from a holistic and person-centred approach i.e. fundamental nursing.

TRIAL REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/XJ39E Protocol: http://dx.doi.org/10.1136/bmjopen-2022-069798.

Barriers to clinical nurse participation in the internet-based home visiting program: a qualitative study

BACKGROUND

Home visits are an important part of home care. With increasing demand and the rapid development of information technology, an increasing number of regions are experimenting with the use of information technology in home visits, hoping to meet the needs of more patients through technological interventions. However, most of the current studies have focused on patient health improvement through home visits, neglecting to consider the actual experience of nurses as service providers in participating in Internet-based programs. Thus, the purpose of this research is to explore what is holding nurses back from participating after the Internet has been added to traditional home visiting programs.

METHODS

This research was designed with an exploratory-descriptive qualitative analysis method. Semistructured interviews were used to collect information on barriers to nurses' participation in the Internet-based home visiting program. Participants included 16 clinical nurses working in various hospitals in Nanjing, China. The thematic analysis method was used to analyze the information.

RESULTS

This research identified three themes and twelve subthemes that hinder clinical nurse engagement in the Internet-based home visiting program. The three themes included multiple barriers to individuals, different service modes, and emerging organizational problems.

CONCLUSIONS

As a new form of traditional home visiting program in information society, Internet-based home visiting has many shortcomings in the overall program design and service management specifications. For more patients living at home to receive quality care services, it is necessary to take more effective measures to encourage nurses' participation at three levels: nurse demand, service process, and organizational management.

Historiographic and biographic accounts of Faroese nurses' training and health-promoting work from 1910 to the end of the 1930s

The Nordic country Faroe Islands consists of 18 mountain islands situated in the North Atlantic Sea. In the late 1800s, nursing in the Faroe Islands was behind international standards. A transition towards organised nursing commenced when Danish deaconesses arrived in 1897; their missions were to serve as nurses and train Faroese women in nursing. The overall aim of this research is to add to the history of Faroese nurses' training and work during the first decades of the 1900s, decades when Faroese nursing became visible through the presence of deaconesses and trained nurses. With historiographic and biographic approaches and in the context of Faroese history and nursing theory and research, we present accounts about four Faroese nurses' living, training and work during the three first decades of the 1900s. These years were progressive for Faroese nursing in hospital care and public health around on the islands, and a struggle to combat tuberculosis took place. We conclude by emphasising the importance of considering the beginning of professional nursing in a small faraway country where resilient nurses worked with ingenuity and often exceeded geographic and professional boundaries to help and support sick and injured compatriots, promoting their health and well-being.

Registered nurses' challenges and suggestions for improvement of their leadership close to older adults in municipal home healthcare

BACKGROUND

Worldwide people are living longer. The need for healthcare for older adults is increasing. The trend is towards advanced home healthcare, where registered nurses are key figures. This implies challenges for municipal home healthcare, as well as for registered nurses' leadership. The aim is to explore registered nurses' perceptions of challenges and suggestions for improvements in their leadership close to older adults in municipal home healthcare.

METHODS

The present study is part of a larger web-based questionnaire survey with a cross-sectional design. The design is inductive, analysing data using qualitative content analysis and descriptive statistics. A questionnaire with open-ended and closed-ended questions was used. A total of n = 70 registered nurses leading close to older adults participated in seven municipalities in two geographic areas in Sweden.

RESULTS

The results show registered nurses' perceptions of challenges as leaders close to older adults in terms of 11 categories. The categories are motivating for care, adjusting and coordinating nursing care to the older adult, relating to next of kin, managing communication difficulties, relating to social situations in the home, managing demands, working alone, having lack of time, collaborating with physicians, and care staff having low competence. The registered nurses suggested improvements for their leadership close to older adults in terms of nine categories. The categories are adjusting the work to the older adult, clarifying registered nurses' responsibility, balancing demands and resources, setting time aside, improving staffs' competence, ensuring staff's competence development, improving the work environment, and cooperation between professions in the municipality, as well as between healthcare organizations.

CONCLUSION

The results show that registered nurses' leadership in municipal home healthcare implies a wide range of challenges. There is a need for strategies to improve the organizational preconditions to reduce challenges in registered nurses' leadership in order to promote positive patient outcomes for safe and quality care.

'Sometimes you need an eye-opener': A qualitative study on nursing assistants' experiences of developing communication skills through an educational intervention on person-centred communication

AIM

To explore nursing assistants' (NAs') experiences of developing communication skills while participating in an educational intervention on person-centred communication.

DESIGN

A descriptive qualitative study was conducted.

METHODS

Data were collected from interviews and written assignments before, during and after an educational intervention on person-centred communication targeting NAs in home care services. The data were analysed using a phenomenological approach. A total of 25 NAs participated in the study.

RESULTS

The findings describe NAs' experiences concerning the communication skills needed for building relationships with older persons and handling emotionally challenging situations. The educational intervention increased their knowledge and awareness of the importance of communication skills and how such skills are developed and refined.

Who cares?-The unrecognised contribution of homecare nurses to care trajectories

BACKGROUND

Organisation of patients' trajectories is a critical element of nursing practice. However, nursing practice is mainly expressed in terms of direct patient care, while the practices through which care is organised have received little attention, are poorly acknowledged and lack formal recognition.

AIM

To examine the management of care trajectories as provided by homecare nurses.

DESIGN

We conducted focus group interviews with 29 Danish homecare nurses. The analysis drew on the evidence based and theoretically informed framework care trajectory management. Care trajectory management is conceptualised as comprising of three organisational components: (1) Trajectory awareness, (2) Trajectory working knowledge and (3) Trajectory articulation.

FINDINGS

The organising work of homecare nursing is both complex and unpredictable requiring advanced organisational, collaborative and clinical competences to secure concerted actions in alignment with the needs of the individual patient. Without having any formal obligation homecare nurses took on the responsibility for the coordination of the different activities of the professional actors, and for securing concerted actions. Care trajectory management as provided by homecare nurses reflected a high degree of commitment for patients and illustrated that this type of organising work was driven by the values of the humanistic ethos of nursing.

CONCLUSION

The study highlights the strength of the invisible and ongoing organising work of homecare nurses. Care trajectory management in homecare reflects the moral foundation of nursing. Consequently, the professional logic of nursing reflected as direct patient care alone is too narrow. We need to acknowledge the organising work of patients' trajectories as a core task equal to direct patient care. Our study highlights the need for articulating the organising work of homecare nurses and for presenting problematic organisational structures to policymakers and managers. If not, the important organisational work of homecare nurses is at the risk of remaining invisible.

Exploring home-based care nurses' mindset for nursing practices: a phenomenological study

Background

Home nursing is an essential aspect of healthcare and can address future health challenges. The nature of nursing and its practical applications are of particular interest, as nursing involves technical knowledge, rational procedures, and diverse skills. It is consequential to explore nursing practices in context to understand how nurses navigate their work. This study aimed to explore the characteristics of home care nurse practices and how nurses solve tasks in the context of nursing in home care.

Methods

This is an exploratory qualitative research study using a descriptive phenomenological approach. We reported following the COREQ guidelines. Fifteen in-depth interviews with nurses from four Norwegian municipalities were conducted and analysed according to stepwise inductive analysis.

Results

The analysis revealed three main patterns that characterise nursing practices in home care: ‘To be vigilant’, ‘To be an all-rounder’, and ‘To act with independence’. The content and distinction of these patterns are discussed through a theoretical framework of ‘clinical mindlines’. There are multiple mindlines and complex realities for home-based care nursing. The nurses displayed great sensitivity in their practice, were knowledgeable about where they focused their attention, adapted their actions to the context, and demonstrated their independence as professionals.

Conclusion

Nurses’ vigilance and contextual insight are critical to their practice approach and task-solving abilities. These professionals need to manage emergent organisations and exercise independence and professional judgment when adapting their work to the context of home care patients. Future health policy should not strictly be based on standardised guidelines; depending on the context, it is also appropriate to focus on nurses’ practical knowledge and the importance of mindlines.

The experience of dependence on homecare among people ageing at home

Being dependent on homecare potentially threatens a person's integrity and autonomy, particularly when people are dependent on help to manage basic bodily functions that involve intimacy and nudity, making the person vulnerable despite being in his or her own home. As the population continues to age and live longer, more people are expected to be dependent on homecare. The aim of this study was to investigate the phenomenon of dependence on homecare among people ageing at home. Individual in-depth interviews were used to explore 15 Danish and Norwegian homecare receivers’ experiences of dependence on homecare. Interview records were transcribed and analysed in a hermeneutical phenomenological process described by van Manen. First and foremost, the experience of dependence on homecare is a question of adaption. The older people in this study struggled to get used to their deteriorating body and at the same time they continuously had to negotiate to get care in accordance with their values. Being dependent on care could be experienced as being reduced to a task or a problem to be solved though the participants had a significant need for undivided mental attention. The presence of homecare staff in the participants’ homes could entail a change where the participants experienced that they lost control over the surroundings. According to the voices of the older people in this study, future homecare should be accommodated in an organisational set-up that gives priority to stability and continuity in the relation between the homecare receiver and the homecare staff. Also it is significant that homecare staff do not have a task-oriented approach to their job and are sensitive to the values of the homecare receivers.

The Experiences of Home Care Nurses in Regard to the Care of Vulnerable Populations: A Qualitative Study

Home care nurses have become the main references in home care for vulnerable patients. In patients' homes they offer comprehensive and continuous care to both the vulnerable population and their families. The aim of this qualitative study was to explore experiences and perspectives of home care nurses regarding the care of vulnerable patients in Spain. We conducted in-depth semi-structured interviews with 15 home care nurses working with a vulnerable population. From a data analysis, two themes and four subthemes emerged: (1) "barriers to providing home care to vulnerable populations", with the following subthemes: "the particularities of the patient and their home caregivers" and "perceived barriers for the involvement of home care nurses in the care"; and (2) "the emotional cost of home care" with the subthemes "home care is draining for caregivers" and "the impact of home care on the home care nurses". These findings show us that nurses face a number of difficulties in home care for vulnerable patients. The training of nurses in certain competencies and skills by the social health services would enhance the quality of care offered to these patients.

Changes in home care clients' characteristics and home care in five European countries from 2001 to 2014: comparison based on InterRAI - Home Care data

Background

Policymakers advocate extended residence in private homes as people age, rather than relocation to long-term care facilities. Consequently, it is expected that older people living in their own homes will be frailer and have more complex health problems over time. Therefore, community care for aging people is becoming increasingly important to facilitate prevention of decline in physical and cognitive abilities and unnecessary hospital admission and transfer to a nursing home. The aim of this study was to examine changes in the characteristic of home care clients and home care provided in five European countries between 2001 and 2014 and to explore whether home care clients who are most in need of care receive the care required.

Methods

This descriptive study used data from two European research projects, Aged in Home Care (AdHOC; 2001–2002) and Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care (IBenC; 2014–2016). In both projects, the InterRAI-Home Care assessment tool was used to assess a random sample of home care clients 65 years and older in five European countries. These data facilitate a comparison of physical and cognitive health and the provided home care between countries and study periods.

Results

In most participating countries, both cognitive (measured on the Cognitive Performance Scale) and functional ability (measured on the Activities of Daily Living Hierarchy scale) of home care clients deteriorated over a 10-year period. Home care provided increased between the studies. Home care clients who scored high on the physical and cognitive scales also received home care for a significantly higher duration than those who scored low.

Conclusion

Older people in several European countries remain living in their own homes despite deteriorating physical and cognitive skills. Home care services to this group have increased. This indicates that the government policy of long-term residence at own home among older people, even in increased frailty, has been realised.

Person-centered dementia care in home care services - highly recommended but still challenging to obtain: a qualitative interview study

BACKGROUND

Dementia is one of the main causes of disability and dependence in older people, and people with dementia need comprehensive healthcare services, preferably in their own homes. A well-organized home care service designed for people with dementia is necessary to meet their needs for health- and social care. Therefore, it is important to gain knowledge about how people with dementia experience the home care service and if the service responds to their wishes and needs. The aim of this study was to explore the experience of home care services among people with dementia, to understand the continuity in services, how the service was adapted to people with dementia, and how the patient experienced person-centered care and shared decision-making.

METHODS

We used a qualitative, exploratory design based on a phenomenological-hermeneutic approach and performed individual in-depth interviews with persons with dementia. A convenience sample of 12 persons with moderate to severe degrees of dementia from four Norwegian municipalities participated in the study. The interviews were conducted in February 2019.

RESULTS

The findings identified that the participants appreciated the possibility to stay safely in their own homes and mostly experienced good support from staff. They expressed various views and understanding of the service and experienced limited opportunities for user involvement and individualized, tailored service. The overall theme summarizing the findings was: "It is difficult for people with dementia to understand and influence home care services, but the services facilitate the possibility to stay at home and feel safe with support from staff."

CONCLUSION

The participants did not fully understand the organization of the care and support they received from the home care services, but they adapted to the service without asking for changes based on their needs or desires. Although person-centered care is recommended both nationally and internationally, the participants experienced little inclusion in defining the service they received, and it was perceived as unclear how they could participate in shared decision-making.

Home-Care Nurses' Experiences of Caring for Older Adults With Type 2 Diabetes Mellitus and Urinary Incontinence: An Interpretive Description Study

Introduction

A third of older adults with diabetes receiving home-care services have daily urinary incontinence. Despite this high prevalence of urinary incontinence, the condition is typically not recognized as a complication and thereby not detected or treated. Diabetes and urinary incontinence in older adults are associated with poorer functional status and lower quality of life. Home-care nurses have the potential to play an important role in supporting older adults in the management of these conditions. However, very little is known about home-care nurses’ care of this population.

Objective

The objective of this study was to explore how nurses care for older home-care clients with diabetes and incontinence.

Methods

This was an interpretive description study informed by a model of clinical complexity, and part of a convergent, mixed methods research study. Fifteen nurse participants were recruited from home-care programs in southern Ontario, Canada to participate in qualitative interviews. An interpretive description analytical process was used that involved constant comparative analysis and attention to commonalities and variance.

Results

The experiences of home-care nurses caring for this population is described in three themes and associated subthemes: (a) conducting a comprehensive nursing assessment with client and caregiver, (b) providing holistic treatment for multiple chronic conditions, and (c) collaborating with the interprofessional team. The provision of this care was hampered by a task-focused home-care system, limited opportunities to collaborate and communicate with other health-care providers, and the lack of health-care system integration between home care, primary care, and acute care.

Conclusion

The results suggest that nursing interventions for older adults with diabetes and incontinence should not only consider disease management of the individual conditions but pay attention to the broader social determinants of health in the context of multiple chronic conditions. Efforts to enhance health-care system integration would facilitate the provision of person-centred home care.

The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Purpose

The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions.

Design/methodology/approach

The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality.

Findings

Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews.

Originality/value

Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.

Zwischen Anspruch und Wirklichkeit - Perspektive von fallverantwortlichen Pflegefachpersonen zur Rationierung in der spitalexternen Pflege

Between demand and reality - Perspectives of case-leading nurses on rationing in home care Abstract. Background: The demand for home care services in Switzerland (Spitex) is growing at an annual rate of 8 %. With increasingly complex client situations, lack of time and professional resources, the risk of rationing care is rising. Objective: This study explores how case-leading nurses (CLNs) experience rationing of care and how they deal with this in their daily practice. Methods: We chose a qualitative approach with an interpretative description. Between September and December 2018, we conducted semi-structured interviews with 12 CLNs from seven Spitex organisations in the German-speaking part of Switzerland. The data were analysed according to the thematic analysis of Brown and Clarke. Results: CLNs often experience not having enough time to fully oversee a client's care plan from the assessment to the evaluation of care needed. They show a high level of commitment to providing good quality of care, but have to walk a tightrope between demand and reality. Additionally, they are under pressure to defend the financing of needed services from health insurance companies. Conclusions: Rationing is an everyday experience of CLNs' practice and they invest a lot of effort in reducing its effects for their clients. CLNs work under pressure, thus targeted measures are necessary both at the political and Spitex organizational level, to reduce rationing of care.

Home-care nurses' distinctive work: A discourse analysis of what takes precedence in changing healthcare services

Ongoing changes in many Western countries have resulted in more healthcare services being transferred to municipalities and taking place in patients' homes. This greatly impacts nurses' work in home care, making their work increasingly diverse and demanding. In this study, we explore home-care nursing through a critical discourse analysis of focus group interviews with home-care nurses. Drawing on insights from positioning theory, we discuss the content and delineation of their work and the interweaving of contextual changes. Nurses hold a crucial position in home healthcare, particularly in ensuring care for sicker patients with complex needs. Assessing health needs, performing advanced care, and at the same time, providing customized solutions in various homes were identified as distinctive for home-care nurses' work. Changes have made nurses' work become driven by comprehensive tasks and acute medical needs that require much of their competence and time. Urgent care seems to take precedence in nurses' work, leaving less time and attention for other tasks such as conversations and support for coping with everyday life. This underlines the need to investigate and discuss the content and scope of nurses' work to help shape the further development of home-care nursing.

Struggles with infrastructures of information concerning hospital-to-home transitions

Homecare nurses play a unique role in providing care during the follow-up after hospital discharge and in preventing readmission. The aim of this study was to explore the key challenges faced by homecare nurses in relation to caring for discharged patients. Data were collected through five focus group interviews with 29 Danish homecare nurses and subjected to inductive content analyses. The key challenges faced by homecare nurses fell into three themes: struggling to see the bigger picture, caring for patients from a distance, and compromising on professionalism. The findings demonstrated a paradox between the need for information and the struggle to access this information due to complicated infrastructures of information-sharing. Homecare nurses took on a substantial responsibility in providing the best possible care despite having limited information. Ironically, by taking on this responsibility, they implicitly contribute to covering up the problems of organisational and professional information flow.