The Effect of Graduates' Opinions and Experiences on Home Care Practices in Undergraduate Education on Postgraduate Nursing Interventions: A Qualitative Study.

AIM: The purpose of this study is to evaluate the opinions of nurses who completed the public health nursing internship program and are currently working in the clinic about the home care interventions they apply during nursing education and to evaluate the effects of these practices on the clinical studies.
METHOD: The descriptive qualitative research was conducted in May-June 2016. The sample number determined by the criterion sampling method, one of the purposive sampling methods, is 14 nurses. In the interviews, an introductory information form and an interview form consisting of open-ended questions were used. The data were collected via e-mail and evaluated by content analysis. The data were reported according to COREQ. Ethics committee approval was obtained.
RESULTS: Readiness to the profession was revealed with four themes including personal development, understanding the importance of home care practice, evidence-based and holistic care, and related sub-themes.
CONCLUSION: Opinions of the graduates about the home care interventions they applied during their education and the effects of these practices on the clinical studies were multidimensional and positive.

Introduction

The change of the demographic structure in Turkey and in the world has led to considerable differentiation of the factors related to health (Koc et al., 2010). It is predicted that the rate of the population over the age of 60 years in the world would increase from 12% which was 8.8% in 2018, in Turkish population would rise to 10.2% in 2023, and to 25.6% in 2080. This demographic change will increase the incidence of diseases in old age and the requirements for home care service (Turkey Statistics Institute [TSI], 2020).

The purpose of home visit programs is to maintain the health of individuals in their own living spaces, to help them to gain autonomy related to health, and to prevent disability and repeated hospitalization and can be served primarily to risky groups (pregnant women, children, elderly individuals, etc.) (Avellar & Supplee, 2013; Huss et al., 2008; Stoltzfus & Lynch, 2009). For example, in a meta-analysis study reviewing randomized controlled trials, it was revealed that home visit practices based on system identification along with clinical examination reduced the disability burden of elderly individuals (Huss et al., 2008). Home visits enable especially the parents who delay or neglect to use health services, to access to healthcare services they need, and also health care professionals to monitor and assess the growth and development of the child (Schmit et al., 2015; Stoltzfus & Lynch, 2009).

The studies have presented the cost and clinical efficacy of home care practices provided by the nurses, and it has been observed that the independence of patients could be increased with these practices (Cengiz & Bahar, 2017; Lewin et al., 2013; Tappenden et al., 2012). The studies have reported the effect of home visits conducted within the scope of public health nursing practices during nursing education on the students and families who were visited through home visits (Aryuwat et al., 2019; Kinsey, 2019; Nies & McEwen, 2015; Tavares, 2019). In addition, it was also determined that the opinions of the families, who were visited by nursing students through home visits, about health services they received were affected by the variables such as previous home visit experiences of the families, their perceptions about the institutions of the students who came to visit, theoretical backgrounds, and practical skills and personal characteristics of the students (Nies & McEwen, 2015). Students often described particularly their first home visit experience as anxious (Tong et al., 2007). However, Aryuwat et al. (2019) determined that home visits improved nursing students’ analysis, synthesis, problem-solving, and critical thinking skills. Tavares et al. (2019) emphasized that home care practices allowed students to provide health training specific to family’s requirements by including innovative learning and teaching processes. Another study conducted for a similar purpose stated that students’ home visits in poor areas within the scope of public health practices improved their holistic approach, critical thinking, and problem-solving skills and increased their professional satisfaction (Kinsey, 2019).

In the literature, it is seen that there are studies examining the effect of home care practices conducted during the education process on the professional skills and development of nursing students (Aryuwat et al., 2019; Kinsey, 2019; Tavares, 2019). However, no study was found examining the reflection of home care practices of students before graduation on their nursing interventions in their professional lives after graduation. Home visits made within the scope of public health nursing in nursing education have an important place among home care practices and are significant for students to exhibit the independent roles of nursing related to different fields. The aim of this study is to evaluate the opinions of nurses, who completed the public health nursing internship program and are currently working in a clinic, about home care interventions they applied during their education and their effects on their clinical trials. It is thought that the study results would contribute not only to the curriculum studies for nursing education and practice fields but also to the effectiveness of home care services to be offered to the society.

What are the opinions of nurses on home care practices they carry out within the scope of public health internship program during their education?

What are the opinions of nurses on the effect of home care practices, they carry out within the scope of public health internship program during their education, on their clinical works after graduation?

Method

Study Design

In the study, a descriptive qualitative study design was used. The data were reported according to Consolidated Criteria for Reporting Qualitative Research checklist proposed for qualitative research (Tong et al., 2007).

Sample

In sample selection May-June 2016, criterion sampling method from purposeful sampling methods was used. The sample of the study consisted of 14 nurses who experienced the home visit process within the scope of public health nursing internship program in a nursing faculty of a public university.

Data Collection

The data collection was carried out via e-mail on the internet. In order to test the clarity of the problems and their compatibility to the purpose of the study, a preliminary interview was held with a participant. The purpose of the research and the importance of giving detailed answers to the questions for in-depth analysis were explained in the mail. Data collection process was terminated when data saturation reached.

The inclusion criteria of the study were determined as being voluntary to participate in the study, having experienced the home visit process during the undergraduate program within the scope of public health nursing internship program, working as a nurse in the clinic, and having access via e-mail.

Data Collection Tools

In the study, as a data collection tool, an introductory information form and an interview form consisting of open-ended questions were used. The interview form was prepared by the researchers based on the qualitative research method and in accordance with the related literature (Esmaeili et al., 2014; Huss et al., 2008; Ildarabadi et al., 2013). The questions prepared by the researcher were arranged in line with the opinions of three experts who had experience in a qualitative study. Questions of the interview form are as follows: During your public health nursing internship,

Can you explain your home care intervention process?

Can you tell us how home visits make you feel?

Can you explain the effects of home care practices on your professional education?

How do you think the home care practices have an effect on your postgraduate nursing practices?

How do you think the home care practices affect your communication with patients?

Validity and Reliability of the Study

For the validity and reliability of the study, the criteria proposed by Lincoln and Guba (1985) were taken into consideration.

Statistical Analysis

Data were analyzed by using the content analysis method. The content analysis steps used in the study were as follows: coding data, finding themes, editing codes and themes, and defining and interpreting the results. Four female researchers who have doctoral degree and are experienced in home care and qualitative research analyzed the data obtained via e-mail, created main themes, and sub-themes were created and reached consensus with expert researchers.

Validity

Credibility: All data obtained via e-mail were recorded, and data collection process was terminated at the time when no new information was received. For investigator triangulation, four researchers who have experience in qualitative research had broadly similar views on the creation of themes and sub-themes and explanation of data but agreed on common themes. On the other hand, for data triangulation, the studies conducted in different people and places were compared with the present study (Guler et al., 2013).

Detailed description method and purposeful sampling were used. Detailed and accurate information about all stages of the study was provided. The interview data were described in detail and rearranged according to the concepts and themes, the obtained themes were exemplified to the reader by making direct citations, and the interview data were transferred as much faithfully as possible to the original ones.

Reliability

All data were collected by using the same interview form and delivered to the participants by the same researcher. The analyses were evaluated by more than one researcher.

A confirmation review was carried out. All stages of the study were evaluated by the group of researchers experienced in qualitative studies, and the compatibility of judgment, comment, and suggestions reached to raw data were confirmed. Data collection tools, raw data, coding made during analysis, and all other materials are kept confidential for confirmation.

Ethical Considerations

In order to conduct the study, ethical approval was obtained Koç University Social Sciences Research Ethics Committee (Ethic committe desicion number: 2016.117.IRB3.071, Date: 17.05.2016) and informed consents of the individuals to be included in the study were obtained through e-mail.

Results

The mean age of the nurses interviewed was 25.2 ± 1.12 years (min = 25, max = 27), 85.7% were female, and 78.6% were single. The nurses who participated in the study graduated in 2013 (35.7%), 2014 (35.7%), and 2015 (28.6%). The mean time of starting to work after graduation was 2.2 ± 1.06 months, and their total working duration was 1.9 ± 0.77 years on average. Of the nurses, 57.2% are still working in internal medicine–surgery–pediatrics services and 35.7% are still working in intensive care units. In addition, 64.3% changed their department and half of the nurses stated that they previously worked in internal medicine–surgery–pediatrics services.

The participants’ opinions about the home visit process and their effects on clinical trials were collected under 4 main themes and 12 sub-themes (Figure 1). Illustrative quotes from the interviews are presented in Table 1.

Figure 1.

Themes and Sub-themes Were Created in Line with the Opinions of the Participants About Home Care Processes.

Table 1.

Illustrative Quotes from Patients’ Experiences

Themes	Sub-themes	Illustrative Quotes from Patients
Readiness to profession	Increase in professional satisfaction and motivation	“I discovered a different dimension of nursing. May be, I felt more active and productive than we could feel in the clinical environment.”
	Development of professional values	“Taking care of patients in their own environment made it easier for me to understand patient psychology and improved my empathy ability.”
	Encouragement to specialize in profession	“Reaching many people with my home care practices helped me achieve professional satisfaction. After graduation, I pursued my master’s degree in this field.”
Maintaining independent roles	“Reaching many people with my home care practices helped me achieve professional satisfaction. After graduation, I pursued my master’s degree in this field.”
Personal development	Communication skills	“Home visits developed my communication skills the most. Although we saw how to communicate in many cases theoretically and practically in communication lessons, I had a hard time at first when I faced this situation in real life. I understood better how to get close over time. Maybe that’s why I didn’t have a hard time in communicating with people in my professional life.”
	Development of the sense of responsibility	“Visiting them every week in their environment helped me to take the sense of responsibility.”
Increased self-confidence	“Before the first trainings, you have a feeling that no one will believe or trust you as a nurse who has not started the profession, yet. At least I was. However, I saw later that the families applied the training given exactly. At that time, my confidence increased.”
Understanding the importance of home care practices	Making behavioral change in the individual	“We aimed to develop a behavioral change by gathering the family data in the home environment, making correct determinations and informing them about the appropriate issues. I had the anxiety of being able to do it or not. Contacting with the families over time and observing the changes in the family made me very happy.”
	Including the patient in the care process	“As a nurse who came to the family’s home and tried to diagnose their health status, I realized that individuals were feeling safe. The feeling of trust given by going to their houses every week and following the training given encouraged them to involve in their own health care.”
Giving importance to the feelings of the patients/individuals	“While the treatment process of individuals is at the forefront in the hospital environment, I saw the family roles and how other family members were affected by the current health problem.”
Providing evidence-based and holistic care	Gaining holistic approach	“…The most important part of home visits for me was seeing the individuals in their living spaces and realizing most of the factors affecting them. This made me think that we were able to apply the holistic approach we always talked about.”
Ability to transfer theoretical knowledge to practice	“I encountered many chronic diseases in this practice and got detailed information about their management at home. Now, I am giving trainings to the individuals I met on the subjects that need to be paid attention at home besides the treatment applied in the hospital in these days when I just stepped into my profession.”

Readiness to Profession

Under the readiness to profession theme determined as a result of the interviews made with the participants, four sub-themes including “increase in professional satisfaction and motivation, development of professional values, encouragement to specialize in profession, and maintaining independent roles” appeared.

Increase in Professional Satisfaction and Motivation

All of the participants expressed their home visit process they experienced with public health nursing practice as a different experience than the clinical environment. Besides, they stated that recognizing different working areas of the nursing profession supported their professional motivations.

Development of Professional Values

The participants stated that they realized the importance of themselves and their profession as a nurse in the intervention process of public health nursing internship. They expressed that they felt ready for working life by developing in the instructive role of the profession, approach to the patient, and empathy.

Encouragement to Specialize in Profession

While the participants emphasized that the intervention process they experienced supported professional satisfaction, some said that this process directed them to specialize in the profession.

Maintaining Independent Roles

The interns who presented their nursing knowledge gained through undergraduate education to the individuals and their families in their own houses expressed their satisfaction by stating that this process enabled them to achieve the independent functions of nursing.

Personal Development

Under the personal development theme, three sub-themes appeared, namely, “communication skills, development of the sense of responsibility, and increased self-confidence .”

Communication Skills

The interns who reached many individuals and families with home care practice stated that this process contributed significantly to improving communication skills. In addition, the interns who have all started their working life importantly emphasized that experiencing repeated communication processes throughout the home care practice facilitated the adaptation process to the working life.

Development of the Sense of Responsibility

Health trainings were planned by determining the specific goals for individuals and their families through home visits made periodically by public health nursing interns. Repeating the home visits made regularly by the participants in the environment where the individual and his/her family were living ensured to take responsibility for the health of that family.

Increased Self-Confidence

Home care practice process gave the interns who took the responsibility of the individual and the family the opportunity to manage the processes of planning home visits, prioritizing the trainings, and developing positive behavior by using training and consulting skills. Overcoming all these processes in the course of time supported the development of personal and professional self-confidence of the interns.

Understanding the Importance of Home Care Practices

Under the theme of understanding the importance of home care practices, the sub-themes of “making behavioral change in the individual, including the patient in the care process, and giving importance to the feelings of the patients/individuals ” appeared.

Making Behavioral Change in the Individual

The participants who determined the needs specific to the individual and family during the home visits said that the process of developing behavioral change caused anxiety in themselves at the beginning but they were happy when the individuals or their families exhibited the desired behavior or their awareness about the subject increased as the home visits progressed.

Including the Patient in the Care Process

The participants stated that repeated home visits to the individuals and their families in their safe environment played a supportive role in establishing trust relationship with the health care professional and taking their own individual health responsibilities.

Giving Importance to the Feelings of the Patients/Individuals

Some of the participants emphasized the superiority of home visits over the hospital environment for the individuals to see their domestic roles and responsibilities and plan individual care for this.

Providing Evidence-Based and Holistic Care

As a result of the interviews, two sub-themes as “gaining holistic approach and ability to transfer theoretical knowledge to practice” appeared under the theme of providing evidence-based and holistic care.

Gaining Holistic Approach

Most of the interns found home care practices in the quality to be supportive for holistic approach targeted by nursing undergraduate education since it offers the opportunity to address the individual and all family members in their environment.

Ability to Transfer Theoretical Knowledge to Practice

The interns who used evidence-based practices during their home visits throughout the public health practice emphasized that this process also supported them to deal with both hospital and home care processes of the patients and their families in an evidence-based way in their working life, as well.

Discussion

Professional Readiness

Professional satisfaction and motivation levels of the nurses in individual and organizational contexts affect the quality of care services provided (Tilev & Beydag, 2015). It was concluded in this study that job satisfaction levels of nurses did not differ according to gender and age group but differed according to the unit they work and working hours. Positive motivation and having positive perception about the profession are important in terms of the development of profession in order for the nursing students to adapt to the profession, achieve the academic success, and maintain a productive working life (Cerit & Coskun, 2018). In this context, the experiences of the nurses who participated in the study during the training process appear as a factor affecting the job satisfaction.

It was determined in the study by Al Jarrah (2013) that the students’ perceptions on nursing were affected by many factors but they were positive. In a qualitative study examining the expectations from clinical practice, students stated that they were not satisfied with the components of this stage of their education. It was stated that the lack of knowledge regarding the care of different patients in the clinical environment, feeling insufficient about nursing skills, and experiencing anxiety related to the clinical environment negatively affected the students (Esmaeili et al., 2014). It was revealed that the professional motivation level of the nursing students continuing their education in a university located in the Western Black Sea Region in Turkey affected their professional perception and emphasized that the internal and external motivations of the students should be supported (Cerit & Coskun, 2018). When it is evaluated from this perspective, it will be appropriate to emphasize that public health nursing practices are a complementary element in nursing education. In a qualitative study on public health nursing practices of nursing students using the grounded theory, it was emphasized that students’ perceptions about practice affected professional productivity and quality service provision; planning activities such as group study, project preparation, and so on, to increase the attention of students to the subject is recommended for those who are responsible for public health nursing lesson and practice (Ildarabadi et al., 2013).

Home care services from the important practices of public health are provided after evaluating the individual according to the criteria of benefiting from home health care services in the Netherlands, for instance. These criteria include medication follow-up, dressing, injection, wound care with a medical report; aging, chronic disease, disability, or requiring continuous medical follow-up and control due to an accident, or the individuals’ inability to cope with the chronic health problems on condition that it is confirmed with a committee report (Danis, 2014). In Turkey, home care practices are carried out according to the Regulation on the Provision of Home Health Services by the Ministry of Health and Its Affiliated Institutions coming into force in 2015, the services are provided after the decision of the evaluation commission and written request to the related unit by a relative of the individual who needs to receive home health services (Republic of Turkey Ministry of Health, 2015). In addition, family physicians can also visit home in some cases (Republic of Turkey Ministry of Health, 2013). Besides, home visits carried out within the scope of public health nursing practices in the nursing undergraduate education curriculum in Turkey help students not only to gain professional experience and the development of readiness to profession levels but also to provide health care easily to the individuals. The scope of the health service offered is presented in a very comprehensive way in subjects ranging from meeting the daily hygiene needs of the bedbound patient, nutrition during pregnancy, peer bullying to family planning. Since public health nursing practices provide the opportunity to practice the independent roles of the nurse, it is thought to diversify the students’ tendency to specialize in the profession.

Communication skill is vital since it involves individuals understanding each other and covers a process that can be developed instead of personal talent (Kumcagiz et al., 2011; Sen et al., 2013). In the study conducted with nurses in Samsun, it was found that undergraduate and higher education positively affected the behavioral dimension of the communication skills of nurses (Kumcagiz et al., 2011). In another study, it was determined that nurses mostly used passive communication styles (counterparty-focused and message-receiving) and their non-verbal communication use levels were at medium levels (Onay et al., 2011). In their study, Şahin and Özdemir (2015) determined that the communication and empathy skills of the nurses were related. In another study, it was found that the communication skills of the nursing students were at moderate level and there was a correlation between the variables of establishing relationship with friends, having difficulty in establishing communication with the patient while applying nursing care, and thinking themselves as a social individual (Sogut et al., 2018). When similar studies in the literature were examined, it was seen that the studies on the development of communication skills, sense of responsibility, and self-confidence during the undergraduate education of nurses have gained importance. In this study, it was determined that home visit practices affected students’ effective communication skills and personal development positively.

In a study evaluating the effect of the home visit process on students, it was determined that nursing students’ skills of analysis, synthesis, and effective solution generation, and therefore, critical thinking skills developed (Aryuwat et al., 2019). In a study evaluating home care practices with nursing students in Brazil, it was determined that students’ personal and professional skills developed, they had an opportunity to transfer their theoretical knowledge to practice, they could provide health education for the care needs of families, and this process made contributions to innovative learning and teaching (Tavares, 2019). In another study, it was emphasized that public health nurses were able to find solutions to the critical problems and increase professional satisfaction in line with the characteristics of the family especially in the poor regions with home visits with a holistic perspective (Kinsey, 2019). In accordance with the literature, in this study, it was thought that nursing students develop their experiences about leading to behavioral change in individuals with home care practices, including them in the care, and developing experiences about awareness of individual characteristics.

Holistic nursing care is defined as a specific nursing practice that evaluates the social and cultural aspects of body, mind, spirit, emotions, environment, relationships, and life by considering the individual as a whole (Bayindir & Bicer, 2019). However, physical needs in care can come to the fore due to reasons such as work density and time constraints. In fact, American Holistic Nurses Association (AHNA) also emphasizes that holistic care should be provided in every environment (AHNA, 2020). It was stated in a study evaluating the nursing students’ definitions about the holistic care that a facilitating environment specific to holistic care should be provided (Kalb & O’Conner-Von, 2019). In this study, the students stated that they recognized the importance of reflecting physiological problems of individuals along with other components (psychological, social, and spiritual) to the care in an environment different from the hospital through home visits.

Evidence-based practices are an indispensable element for nurses at undergraduate and graduate levels, and it is recommended to transfer current evidence to care (Mackey & Bassendowski, 2017). Ruzafa-Martínez et al. (2016) recommended to transfer the use of evidence-based practices in nursing education to students. It was emphasized in another study that nurses cared about the use of evidence-based practice, but scientific studies are needed in order to develop and evaluate their competencies, and it is important to teach especially nurses how to integrate evidence-based practice into the clinical decision-making process (Saunders & Vehviläinen-Julkunen, 2016). In this study, graduated nursing students stated that they experienced that supporting nursing interventions with evidence-based practices was effective in solving individuals’ problems, which is in parallel with the information in the literature.

Study Limitations

The fact that the participants were working in different clinics after graduation may have affected their perspectives and views on public health practices. This can be regarded among the limitations of the study.

Conclusion and Recommendations

It was found that the opinions of the nurses, who participated in the study and completed the public health nursing internship program, about home care interventions they applied and the effects of these practices on clinical studies were multidimensionally positive. Public health nursing practices that adopt the holistic approach in providing care and using planned and evidence-based practices during nursing undergraduate education emerge as a process that develops students’ individuals and professional skills. Thus, the education processes of the students are supported and the home care needs of the society are contributed.

In addition, in this study, only the education processes of students studying at a public university were evaluated. It is thought that the achievements related to the public health nursing practice evaluated may also contribute to the curricula of other nursing departments. In fact, in accordance with the obtained results, it is recommended that nursing students make definitely a home visit and involve in home care processes during their undergraduate education. Opportunities should be provided for the nursing students to transfer their home visit experiences to their peers, and studies should be planned in evaluating the students’ opinions about home care practices and supporting these learning experiences through students’ feedback.