Perceived Challenges Faced by Nurses in Home Health Care Setting: A Qualitative Study.

BACKGROUND: Home care has gradually become a nursing model for nursing care. The nurses' experiences of challenges they have in home care have remained unknown. The aim of this study was to explore the hidden aspects of challenges related to home care in Iran.
METHODS: This study was conducted to explore the challenges of home nursing care using a qualitative content analysis method. Purposeful and snowball sampling methods were used for sampling. The study was conducted from September 2016 to September 2017 in the provinces of Khorasan and Tehran in Iran. Semi-structured interviews were conducted on 33 nurses who were providing home care. After data saturation, the data were analyzed.
RESULTS: The data analysis led to the development of five main categories of "difficult instances ", "economic problems", "professional barriers", "social difficulties", and "bureaucratic tension".
CONCLUSION: The results of this study showed how nurses faced with a variety of challenges in home care and how they were different from hospitals. Facilitating the nursing processes, supporting home care, and recruiting nurses that had the potential to cope with the existing stressful factors and economic incentives can increase the quality of home care.

INTRODUCTION

Many countries are faced with problems about healthcare services, such as the increasing prevalence of chronic diseases, disabilities, and the elderly population.[1] Rapid changes in the population distribution have led to changes in the care environment from hospitals to homes.[2] Home care has currently become one of the alternative solutions to hospital care, because for patients, home is a place of emotional and physical associations, memories, and comfort.[3] Home care is not only patient-centered, but also cost-effective.[4,5] will gradually become a common nursing model and presents an opportunity to improve the continuity of care after hospital discharge.[6,7]

Home care involves a wide range of technical and supportive care for patients after discharge from the hospital, maintaining the health of the disabled people and the elderly at home, preventing unnecessary admission, and meeting the daily needs.[3] However, countries are faced with several technological and social challenges, which affect the supply and demand for home care services.[8,9] Previous studies have shown that home care has been faced with challenges such as caring problems, inadequate nurses’ ability, poor management, lack of adequate infrastructure, cultural difficulties, payment models, coordination and inter-professional cooperation, and lack of job satisfaction in home care.[10-14] addition, lack of job satisfaction was one of the main reasons that caused the nurses to leave the home care.[15] Nurses describe the home care environment as horrendous. Obviously, when nurses leave home care, this part of care will be provided by non-professional staff.[16]

Home care agencies officially began their activities in Iran about 20 years ago.[17] However, the dimensions of home care in Iran are still unknown.18 Therefore, the necessity of conducting qualitative studies to search, describe and obtain a deep insight into the clinical experience of home care in Iran is highlighted. Understanding the different characteristics of home care can help appropriately assess the quality of care at home. Without understanding the dimensions of home care, the nurses’ feelings, beliefs and existing difficulties, it is impossible to design appropriate care plans and strategies. The home nurses’ experiences of what challenges they have in home care have remained unknown in Iran. Given the multidimensional nature of homecare challenges, qualitative content analysis is an appropriate method for subjective interpretation of the content of the text. Therefore, this study used a qualitative content analysis method to clarify the hidden aspects of the challenges related to home care.

MATERIALS AND METHODS

The conventional content analysis approach was applied.[19] We began our study by contacting agencies in the field of home care and professional groups. We also developed a list of about 35 home care nurses. Eventually, 33 nurses were selected based on the inclusion criteria. The researcher used purposive, snowball sampling to interview the experienced home nurses. For snowball sampling, the first participant was asked to introduce the researcher to other home nurses. As study progressed, we selected the nurses using maximum variation strategies in terms of age, gender, marital status, clinical experiences as well as the provided service types (wound care, elderly care, chemotherapy, phototherapy, and general care), and home care agency (consultant and home nursing care centers, clinical care delivered at home centers, and elderly care in home centers). Inclusion criteria were having a clinical working experience of at least one year in home care, being able to share their experiences, holding a bachelor’s degree or higher in nursing, and giving their consent to participate and express their experiences. Exclusion criteria included request for leaving the study and lack of willingness to participate. Sampling was continued to the point of data saturation. Data saturation happened when no other new codes or categories appeared from the last two interviews.

Semi-structured interviews were conducted on home nurses at a time and location convenient to them. The location of interview was determined at the home care offices, hospitals and nursing faculty or wherever that was convenient for the participants. The duration of each interview was about 20- 105 minutes, with an average of 47 minutes. Additional interviews were conducted for two participants. None of the participants refused to answer the questions during the interview. All interviews were handled by the first author (Ph.D. student of nursing). The focus of the interview questions was the nurses’ experiences of challenges in home care. First, a general question such as “Can you describe one of your problems in home care? What were your challenges in home care? What is your experience, either pleasant or unpleasant, in home care? What did you do to deal with the problems you encountered?” was asked. The interview process was guided based on the participants’ responses. Afterwards, considering the participant’s answer, we formed the probing questions to be asked by the researcher. The study was conducted from September 2016 to September 2017 in the provinces of Khorasan and Tehran in Iran.

Data analysis started on the day of the in-depth interview. As a first step in the analysis, the audiotapes were transcribed. The analysis process was carried out simultaneously based on the Graneheim and Lundman’s method of analyzing the qualitative data.[19] In this study, the whole interviews were defined as the unit of analysis. Sentences and/or paragraphs were considered as the units of meaning. Each meaning unit was summarized to a condensed meaningful unit and then primary codes were obtained. Codes were compared with each other in terms of similarities and differences and were grouped into subcategories. By comparing the similar subcategories with each other, and deep contemplation about the latent contents of the data were introduced as the main categories of the study. The interviews were analyzed by MAXQDA 2010.

For rigor, four criteria of credibility, dependability, confirmability and transferability were used according to Lincoln and Guba. [20] The researchers made an attempt to increase the credibility of the research through long engagement, participation, and interaction with the interviewees, as well as collecting valid data, doing member check and verifying the data. Also, feedback from the participants was employed to ensure that they were in line with what they stated.

Two expert professors in qualitative research reviewed the data to enhance their confirmability. The entire process was later described to the supervisors and external researchers to make the findings verifiable. If there were any discrepancies between the researchers in coding, we discussed and resolved it. To further verify the reliability of the findings, we collected the data at various times and places.

Dependability was also achieved through systematic recording of the research process based on the consideration of the researcher’s impartiality, peer debriefing (approving examples of coded data by skilled and expert qualitative researchers) conducted, and member checking (participants confirmed the samples of codes). Analysis was done under the supervision of the professors and experts. For the transferability, researchers used purposeful sampling and selected nurses with various experiences and the type of home care. Also, the research team attempted to accurately report the process of the study and data analysis in order to enhance the clarity of the study findings.

Ethical Issues

This study was approved by the local research ethics committee of Mashhad University of medical sciences (IR.MUMS.REC.1395.307). All the participants were justified about the aims of the study and a voluntary written consent was obtained from the participants before the interviews. It was mentioned that the participants had the right and were able to quit in any stage of the study whenever they wished. Moreover, they were also told that their information would remain confidential during and after the research.

RESULTS

In this study, 33 nurses (20 men and 13 women) participated with the clinical nursing experience of 2-32 years (mean=16.9±9.2 years) and job experience in homecare nursing (mean=7.2±5.9 years) (Table 1).

Table 1

The participants’ characteristics (n=33)

Characteristics		n (%)
Gender	Female	14 (42.4)
	Male	19 (57.6)
Education level	Bachelor	27 (81.8)
	Master	6 (18.2)
Marriage status	Married	30 (90.9)
	Single	3 (9.1)

The data analysis led to the development of five main categories of “difficult instances”, “economic problems “, “professional barriers”, “social difficulties” and “bureaucratic tension”. The developed categories and subcategories are listed Table 2.

Table 2

An overview of the categories (n=5) and subcategories (n=14)

Category	Subcategory
Difficult instances	Stress factors of home care
	Job burnout
Economic problems	Disproportion between income and expense
	Close competition
	Lack of specific tariffs
Professional barriers	Threating quality of home care
	Lack of professional cohesion
	Human resources’ issues
	Role ambiguity
Social difficulties	Power status change
	Lack of social security
	Reduction of social status
Bureaucratic tension	Extreme bureaucracy
	Ineffective supervising

1. Difficult Instances

Difficult instances were reported by home nurses. They were experiencing physical and mental stress that was one of the main reasons for their reluctance to work at home care (Table 3).

Table 3

Category development for “difficult instances”

Category	Subcategory	Code	Quotation
Difficult instances	Stress factors of home care	Stress due to being alone at the patient’s home	This is a stressful job. Now, while I have 30 years of clinical experience, I still have stress for patient care, because I am alone. (p.27) (nurse, manager of home care center)
	Job burnout	Reduced power and physical exhaustion	When I returned, I had a bad feeling. I was in shock. I remembered what happened to that boy during the injection. For a few days, I could not work. (p.8) (nurse, 20 years of clinical experience)

1.a. Stress Factors of Home Care

The specific characteristics of home care made the nurses to struggle and deal with stresses that were rarely seen during their work in the hospital.

“A simple injection that I easily administered in the hospital without stress, I need to review the doctor’s prescription several times in patients’ home! It causes stress, even for me that have thirty years of job experience in the hospital.”(p.27) (nurse, woman, 30 years of clinical experience)

The presence of family members at home and working alone and lack of provision of help by colleagues caused more stress in the nurses:

“Family members have a higher level of expectations of nurses for homecare …, the expectation level is higher, I feel much stress when I provide care …, certainly it is harder for me to work there and my work quality may suffer”(p.33) (nurse, man, 5 years of clinical experience)

“Working alone, and lack of support, such as liability insurance, puts a lot of stress on the nurse at home. It creates a completely different work condition for the nurse.”(p.2) (nurse, woman, 24 years of clinical experience)

1.b. Job Burnout

Nurses described their feelings of being overloaded, so that physical and emotional exhaustion reduced their abilities to provide care:

“That means you get really tired; I am really tired; I am sick of stress; I am going to be sick. Now, work is not really interesting, especially due to related dangers and difficulties.”(p.27) (nurse, woman, 30 years of clinical experience)

2. Economic Problems

One of the major challenges for home nurses was the economic problems. Home nurses argued that the income generated by the home care industry is not enough to compensate for their routine costs. There is a severe competition in this market. This market is also threatened by the lack of official tariffs.

2.a. Disproportion between Income and Expense

Participants emphasized imbalances between their incomes and expenses, which made it hard to work at home.

“We are spending much money each month on the staff salaries, electricity and gas. Our job is not cost-effective. Home care centers are semi-active or are closed, because the cost of running the center is not covered.”(p.15) (nurse, man, 10 years of clinical experience)

2.b. Close Competition

From the home nurses’ remarks, competition in the home care market has reduced the economic viability of nurses for home care:

“A large number of outpatient clinics dispatch nurses for home care, and labs dispatch staff for blood sampling …, Unauthorized people enter the home care market, because they do not use the routine costs of formal agencies, and the cost of their services is lower. Therefore, formal agencies are pulled out of the competition.”(p.6) (nurse, man, 15 years of clinical experience)

2.c. Lack of Specific Tariffs

The lack of a clear definition of home-care tariffs has led to confusion on the part of the home nurses.

“I do not know how much I should earn as a care cost, so it is a challenge for the center. A reasonable tariff can solve the problem that has not been announced by the ministry of health.” (p.22) (nurse, woman, 15 years of clinical experience)

3. Professional Barriers

The findings indicate that home care is faced with a unique set of challenges to meet professional criteria in Iran. One of the home care problems was the lack of professional maturity in home care.

3.a Threating Quality of Home Care

One of the important neglected parts of home care is the poor quality of care, so that many unskilled and uneducated individuals provide care in this area. This aspect can profoundly endanger the wellbeing of the patients.

“I have been faced with some cases of low quality care and even dangerous activities. For example, nasogastric tube has been inserted wrongly or is placed in the mouth, or the venous catheter has been inserted upside down.”(p.8) (nurse, woman, 20 years of clinical experience)

3.b. Lack of Professional Cohesion

The lack of professional cohesion and lack of transfer of experiences among the nurses were mentioned in this study. They interacted less for organizing, following their rights, planning, and sharing information.

“Until now, we did not have a joint reflection session with our home care colleagues.”(p.15) (nurse, man, 10 years of clinical experience)

3.c. Human Resources’ Issues

Home care managers believe that for many reasons home care in Iran is not a permanent job and it is very difficult to retain the nurses’ interests. Therefore, it is very difficult to supply and employ the nurses for a long-term period.

“I worked with a lot of people in these years. Newly employed nurses came to me and I taught them how to practice. They reached the level that could practice independently and left. When they get the experience ...,. Unfortunately, it is more a fact that they leave after being taught.”(p.23) (nurse, woman Manager of Home Care Center)

3.d. Role Ambiguity

Home nurses experience ambiguity in role playing, because the nurses’ role and his/her duties have not been clearly outlined in government guidelines for home care.

“I do not know whether I am allowed or not, so I am scared that if I am asked about doing something in the future. It is not clear what nurses can do and what they cannot.”(p.14) (nurse, man, 17 years of clinical experience)

4. Social Difficulties

The role of social factors, family and community cultural structures in the home care process was described as barriers to home care by nurses.

4.a. Power Status Change

Nurses had a high power in management when they were in the hospital, but this power decreased when they worked at the patient’s home. In hospital care, the nurses had a higher position in terms of space and care environment control, but in home care the power stance was changed in favor of the family. In this new environment, the family dominated the environment and the nurses.

“It is precisely at home that you are dominated by the family; at home, the family governs, and you are surrounded by the family; you have more stress and have to act according to the family desires; you cannot decide for yourself or act independently.”(p.4) (nurse, man, 16 years of clinical experience)

4.b. Lack of Social Security

Social security was one of the main factors influencing the nurses’ motivation to home care. Nonetheless, the feeling of insecurity, especially in unfamiliar conditions was a source of concern for the nurses. The nature of home care was mixed with potential unexpected incidents.

“We go somewhere in down town areas ..., it has a bit security problem ...we do not know what is going to happen, how dare to you go there?”(p.28) (nurse, woman, 25 years of clinical experience)

4.c. Reduction of Social Status

A home nurse should deal with the inappropriate social status of its profession in society. Home nurses are more likely to be subjected to degrading reactions from the family and close relatives than in the hospital. Sometimes, these responses prevented the nurse to continue attending home care.

“There were times when I was in the patient’s home and there were some visitors. I did not feel good at all; I was worried because the name of the private nurse was considered to be the equivalent to a worker at home. I felt somehow humiliated.”(p.5) (nurse, man, 3 years of clinical experience)

5. Bureaucratic Tension

Nurses in this study explained that they often had to get involved in a vicious bureaucracy circle. They faced a lot of problems for obtaining permissions and starting work, and their work was hampered.

5.a. Extreme Bureaucracy

The results of this study showed that the current administrative bureaucracy disappointed home nurses.

“There is no ability to cope with this intense bureaucracy; the laws are difficult ...,and the interpretation of the law is different in each department, and each unit raises its own opinion.”(p. 24) (nurse, man, Manager of Home Care Center)

5.b. Ineffective Supervising

The lack of adequate and accurate monitoring and inability of supervising the organization to address the issue of nursing home care, negligence or inability to deal with unauthorized and unskilled staff led to confusion in home care.

“The secretaries of physicians who are mostly uneducated carry out home care services. The supervisory board has no supervision on them....I only hope that strong supervision will be provided on work qualification.”(p.27) (nurse, woman, 30 years of clinical experience)

DISCUSSION

The purpose of this study was to explore the challenges of delivering home care from the perspective of Iranian nurses. We categorized the various dimensions of home care challenges in five main categories including “difficult instances”, “economic problems”, “professional barriers”, “social difficulties”, and “bureaucratic tension”. In addition, the results of this study showed that the nurses in delivering home care experienced several economic, psychosocial, and bureaucratic problems, which were consistent with the results of previous studies. [10,21-23]

This study showed that home nurses often experience strains, which may lead to stress and burnout. Previous studies showed several sources of stress for home nurses including poor workplace management, loss of peer support, lack of necessities in home care settings, interactions with patients, inadequacy of perceived professional knowledge, unexpected events and care process, and working time problems.[24-27]

From the experience of our participants, stress in home care raised from the imbalance between the coping ability of the individual and the demands outweighing their ability to cope. In this situation, if unpredicted issues happened regarding the patient’s health, the home nurse had to decide about what was needed to be done and how since the participants felt lonely at home care centers. Due to the high stress related to the home care settings, most of our participants experienced physical problems. In this regard, previous studies showed that stress related to the working conditions probably contributed to the development of physical symptoms, too.[28]

Regarding the economic problems, the nurses believed that home care services were not affordable in Iran. The cost of the home care industry is high and the nurses’ income cannot compensate for these costs. There are reports that many home care agencies in Britain and the United States are bankrupt.[29] The other studies showed that the financial crisis influenced the home health care services and had led to some obstacles in the provision of care.[9,30] One of the important economic issues is that home care services in Iran are not covered by health insurance. This problem leads to limited access to home care services; instead, families receive help from unauthorized persons who provide services at a lower cost. This leads to an inability to monitor the quality of home care. Accordingly, insurance coverage is an effective factor in maintaining the quality of home care.[1,18] The lack of predetermined tariffs is another challenge for nurses, which leads to unequal and unfair competitive situations. This led to the legal gap, i.e. an unauthorized individuals can easily have access to a home care market, while licensed home care staff have many expenses in the same market. For this reason, the motivation of nurses to enter the market is reduced.

Professional maturity was another challenge of home care centers in Iran. Standards and duties of home nurses are not clearly defined. In addition, the lack of qualified staff was one of the problems that nurses described in this study. These findings are consistent with those of another study in Iran;[13] home care agencies have faced challenges in employing qualified staff. This finding is consistent with those of other studies conducted in Iran.[13,18,31]

Home nurses also face major social challenges, such as lack of a desirable social status, a change in the power position of the family in their home and social security. These findings are also consistent with those of other studies.[13,18,32] A study showed that lack of security is highly associated with depression in home care workers.[33] Another study shows that the lack of home nurses’ safety can reduce the quality of care. For example, the period of care may be shortened.[34]

Ethical issues arose when home nurses were confronted with making decisions about whether or not to provide care in high risk areas of the city, how much care they should provide, and when, where and how? This evidence suggests that fear of harm, or an actual threat or injury is a serious concern for home nurses, and might compromise the patient care. Therefore, the home nurse’s security should be taken very seriously and appropriate preventive measures should be taken.[35]

The findings of this study also showed that one of the main obstacles to providing nursing home services in Iran was bureaucratic problems. Bureaucratic problems have created tensions and contradictions and a paradox in the home care system. On the one hand, it demands the establishment of standards and quality improvement, and on the other hand, it is a barrier to the nurses’ creativity and motivation and prevents the development of home care.

Our research had some strengths and limitations. The participants had a rich experience of the phenomenon of home care and eagerly expressed their experiences as the key stakeholders and home care professionals. Due to limited studies in this field, this study is one the first studies to reveal the hidden aspects of home care in Iran. However, despite the researchers’ efforts to maintain the integrity and quality of this research, the generalization of the results of this study outside the Iranian nursing borders should be done with caution. In addition, this study could not include all the existing perspectives, including the experiences of nurses who are active in small cities or even unauthorized home care agencies, nurses with associate degree, patients, and their families. The authors recommend that more studies should be conducted with other stakeholders.

CONCLUSION

Various dimensions of home care challenges were categorized in five main categories including “difficult instances”, “economic problems”, “professional barriers”, “social difficulties”, and “bureaucratic tension”. Our results showed how nurses faced with a variety of unpredictable challenges in delivering home care. Based on the participants’ experiences, there are important gaps between home care in Iran and international home care standards, which requires Iranian healthcare policymakers to pay attention to them.