Nurses' experiences of the ethical values of home care nursing: A qualitative study.

Objective: Considering the importance of out-of-hospital services, the emergence of home care nursing, and the need for an ethical framework in nursing practice, the present study aimed to explore the nurses' experience of ethical values of home care nursing.
Methods: The data of the study was collected using face-to-face individual interviews. Through purposive sampling, 20 nurses who worked in the home care centers in four cities of Iran in 2020 were interviewed. They shared their experiences of the ethical values of home care nursing. Then, the interviews were analyzed based on the content analysis approach and using Graneheim and Lundman method.
Results: In the present study, 416 codes were extracted. Merging these codes based on the similarity, seven main themes, and 16 sub-themes were extracted. The themes included perception of the professional identity, respect for the client's autonomy, respecting privacy, establishing human interaction, maintaining mutual safety, observance of justice, and cultural-religious competence. The sub-themes included responsibility, development of professional and inter-professional interactions, maintaining the professional status at home, providing the holistic artistic care, patient's privacy, nurse's privacy, and maintaining the confidentiality of information, respect for the client's choice, honestly informing, empathetic interaction, adjusting the power positions, client's safety, nurse's safety, establishing justice, respect for the religious beliefs at home and cultural sensitivity.
Conclusion: The participants stated that due to entering the patient's privacy in the home care cases, the ethical values such as perception of the professional identity, privacy, family interactions' management, mutual security, and cultural-religious competence became doubly important compared to the hospital caring.

What is known?

The nurses provide a wide and complex care range during home care. They provide care through long-term engagement with the clients; hence they encounter many ethical challenges.

Recognizing ethical values is an important part of the performance of the nursing profession. Values, beliefs, and culture in Iran, which has a specific context, strong religious beliefs, and family-oriented values, may be different from other countries.

Because ethics depend on the cultural and social values and norms, and nurses work in different cultures, there is a need to adapt their performance to the service recipients’ value systems and cultural beliefs.

What is new?

This article describes the experiences of Iranian nurses who provide care from the ethical values while caring at home.

Although nurses have more freedom of action at home than in the hospital, this autonomy is very satisfying for them; however, family and clients at home are in a position of power compared to the hospital. This could affect the quality of the care provided at home, and the need to respect the privacy and dignity of the client could be felt more at home.

Nurses need an ethical understanding to maintain the integrity and continuity of their relationship with the client and his family. The relationship between the client and the nurse plays an essential role in making ethical decisions when providing care.

Introduction

Ethics is one of the most important issues that has always been discussed, and it is defined as the value dimension of human decision-making and behavior. Today, the ethical approach has become doubly important in the health system, and it has been mentioned as a factor in maintaining public health [1]. Nursing Practitioners confront more ethical issues due to close contact with the patients [[2], [3], [4]]. The social and structural changes in the nursing profession have caused nurses to increasingly work out of the hospitals and deal with home care [5]. In this type of service delivery, the nurses’ personal and professional responsibility is doubled [6,7].

When caring at home, the nurses provide comprehensive and complex care to people with disability and chronic illnesses. As they provide care through long-term engagement with the clients, they experience many ethical challenges [8,9] such as the patient autonomy, dignity [[10], [11], [12], [13]], creating a sense of trust, empathy, honesty, attention to the patient’s authority and competence, conscious satisfaction [12], justice, and disagreement among the caregivers [[14], [15], [16]]. In addition, there are end-of-life issues such as difficulty in deciding on the hospitalization, keeping on or eliminating the maintenance treatments, coercion [[14], [15], [16]], and physical abuse [12]. Also, the necessity to accept different perspectives of patients and families who may have different cultures, spaces, and home atmospheres could create the context for emerging the ethical challenges for the nurse’s privacy, especially when trying to provide nursing care [10,[17], [18], [19]]. Policies related to the limited payments and lack of time and resources allocated to home care can affect the provision of ethical nursing services and the extent to which the individuals have access to the care services. Thus, the home care nurses may be in constant conflict between the principles of professional ethics to provide the best care and the policymakers’ policies [20,21]. Therefore, it is felt that these nurses need structured support such as guidelines and codes of ethics for caring as an ethical framework when they are making decisions [[11], [12], [13], [14], [15], [16],18,22]. Also, commitment to social and cultural values is of fundamental importance. In addition to being considered the standard and guide for practice, they also play a role in professional identification [23].

In Iran, home care includes the provision of nursing care by nurses with different specialties, based on the needs of the society regarding the caring-counseling, education, treatment, and rehabilitation, with emphasis on increasing the health and reducing the disability, especially in patients with the chronic diseases (incurable, cancers, specific diseases, etc.) and the elderly.

This system of care can provide services ranging from supplying and teaching a patient and/or caregivers how to use mobility aids to more complex services, such as physical and mental assessments, medical interventions such as wound care, medication education, and monitoring as well as pain management and speech, physical, and occupational therapies [24].

The traditional features of the Iranian context, i.e., the religious beliefs and sensitivity to the issue of hijab and the religious rituals for the dying patient, makes Iran a country quite different from the other countries. There are also cultural and gender stereotypes such as the inappropriateness of entry of women into the home for care, the availability of formal and traditional medicines, the use of conventional Iranian arbitrary treatments, the family-oriented feature of the Iranian society, the emotional dependency among the family members and the cultural diversity of the Iranian society where the different ethnic groups live together (each one having its own identity with its particular customs).

This difference in the values necessitates developing an ethical guide for the nurses based on the ethical values and standards accepted by the country to provide ethics-based nursing care [25]. Considering the importance of providing out-of-hospital services, the emergence of home care nursing, and the need for an ethical framework to care for these patients, this study aimed to explain the nurses’ experiences with the ethical values of home care nursing.

Methods

Research design

As part of a larger research project, the qualitative inductive content analysis was used to get in-depth information from the experiences and understanding of the participants. The present qualitative content analysis study was conducted with the conventional inductive approach to explore the nurses’ experience of the ethical values of home caring.

Participants and sampling procedure

The research sample consisted of 20 nurses working in the home care centers in four cities of Iran in 2020, who were chosen through the purposive sampling method. Thus, the nurses having at least five years of experience working in a hospital setting and one year of experience in the area of home care who were willing to participate in this study were selected.

Data collection

After finding the qualified participants, presenting the letter of introduction, explaining the purpose of the research, and obtaining their written consent, the researcher collected the data through individual interviews in Persian. The interview site was determined by each participant in the nurse’s workplace or the researcher’s workplace. The sampling continued until the data was saturated and the new codes did not appear.

The participants were interviewed with prior coordination. Sample questions that served as the interview guides were: “What is the difference between caring for patients at home and caring for them in the hospital? Describe how to take care at home for one day. What do you pay attention to when caring for a patient? Have you experienced situations at home where you had difficulty deciding whether or not to take care of somebody or how to do it?” Probing questions were used based on the participants’ answers. Notes were taken from the conditions during the interview to help complete the findings whenever it was necessary. Events and behaviors that reflect the ethical values of caring for patients at home were also recorded as the field notes.

Data analysis

Each interview was conducted for 40–60 min, and they were recorded using a voice recorder. The content of the interviews was immediately analyzed using the Granheim and Lundman method. Hence, while collecting the data, the researcher analyzed them after each interview [26]. All the conversations were entered into word 2010 and MAXQDA software, word by word, and the nurses’ experiences related to the ethical challenges at home were transcribed and coded.

Data were analyzed through the five-step conventional content analysis method Graneheim and Lundman (2004) proposed [26]. In the first step, each interview was transcribed word by word. In the second step, the interview transcript was reviewed several times to understand the whole. In the third step, each interview transcript was considered the unit of analysis, and the meaning units were identified and coded. The first author analyzed the total data, while the second author analyzed half of the textual data. The two authors then compared the codes and settled the minor disagreements through discussion. The codes were grouped into subcategories according to their conceptual similarities and differences in the fourth step. In the fifth step, the subcategories were compared, and the latent data content was identified and presented as the main categories. The final categories were reviewed by all authors to ensure a clear difference between the categories and subcategories and fit the data within each category [26]. Parts of the audiotape were translated from Persian into English by an independent translator, blind to the study, to check for consistent translation.

The resulting codes were compared with the previous ones, and the conceptually similar codes were placed in the same category. Finally, the categories that were similar in terms of meaning and content were considered the main categories.

Trustworthiness

The following standard criteria of the qualitative studies were used to confirm the credibility of the data: selection of the participants who had different experiences in the area of the phenomenon under investigation, having maximum diversity in terms of age, sex, level of education, socio-economic status, and geographical location, the researcher’s long-term engagement with data, peer monitoring, participant monitoring and, if necessary, modifying the resulting codes. The researcher reported the research steps in full detail to achieve the confirmability criterion. Also, to check the accuracy of the coding process, the transcript of some of the interviews and the extracted codes and categories were presented to some experts in the areas of qualitative research and nursing ethics. The researcher described the research procedure in detail to make the data more reliable. Also, she presented the initial codes obtained by interpreting the participants’ experiences, examples of the extracted themes, and excerpts from the interview transcripts for each of the codes. The researcher tried to publish the results through a detailed description of the research process and characteristics of the research population to ensure the transferability of the findings so that others could follow the research path and evaluate the applicability of the data of this study.

Ethical considerations

This study was conducted by obtaining the ethical code number IR.MUI.RESEARCH.REC.1398.423 from the Biomedical Ethics Committee of Isfahān University of Medical Sciences. The informed written consent was also obtained from the participants, and they were explained that they were free to leave the study at any stage of the research.

Results

Participant’s demographic information

Participants of this study were 20 nurses (11 males and nine females) working in the home care area with a minimum of 4 and a maximum of 20 years of working experience in this area. The demographic characteristics of the participants have been presented in Table 1.

Table 1

Demographic characteristics of nurses.

Number	Position	Age (years)	Gender	Location	Degree of education	Working experience (years)	Working experience at home (years)
1	Supervisor	49	Female	Tehran	B. Sc. in nursing	26	18
2	Supervisor	48	Female	Sari	M.Sc. in nursing	24	10
3	Nurse	35	Male	Sari	B. Sc.in nursing	12	8
4	Nurse	29	Male	Babol	B. Sc.in nursing	6	5
5	Nurse	30	Male	Sari	B. Sc.in nursing	6	4
6	Nurse	47	Male	Tehran	PhD in nursing	24	7
7	Nurse	45	Male	Tehran	B. Sc.in nursing	20	16
8	Nurse	44	Female	Tehran	B. Sc.in nursing	19	5
9	Nurse	55	Male	Tehran	B. Sc.in nursing	30	5
10	Nurse	43	Male	Isfahan	B. Sc.in nursing	19	12
11	Nurse	32	Female	Sari	M.Sc. in nursing	9	6
12	Nurse	31	Male	Tehran	B. Sc.in nursing	9	5
13	Nurse	47	Male	Isfahan	M.Sc. in nursing	23	8
14	Nurse	43	Female	Isfahan	B. Sc.in nursing	18	4
15	Nurse	34	Female	Sari	B. Sc.in nursing	9	6
16	Nurse	53	Male	Isfahan	B. Sc.in nursing	30	10
17	Nurse	50	Male	Tehran	B. Sc.in nursing	26	20
18	Nurse	35	Female	Isfahan	PhD of nursing	7	4
19	Nurse	55	Female	Babol	B. Sc.in nursing	30	7
20	Nurse	29	Female	Tehran	B. Sc.in nursing	6	4

Note: B. Sc. = Bachelor of science; M.Sc. = Master of science.

Themes and subthemes

After analyzing the data, 1,250 primary codes were extracted (see Table 2). After removing the duplicate and similar codes, 416 codes were finally obtained. Then, 16 sub-themes and seven main themes were obtained by merging these codes based on their similarity. The main themes include perception of the professional identity, respect for the client’s autonomy, respecting privacy, establishing human interaction, maintaining mutual safety, observance of justice, and cultural-religious competence. The results of this step are presented in the table below.

Table 2

The main and sub-themes that emerged based on the experiences of nurses.

Main theme	Sub-themes
Perception the professional identity	• Responsibility
	• Development of professional and inter-professional interactions
	• Maintaining the professional status at home
	• Providing the holistic artistic care
Respect to privacy	• Patient’s privacy
	• Nurse’s privacy
	• Maintaining the confidentiality of information
Respect for the client’s autonomy	• Respect for the client’s choice
	• Honestly informing
Establishing the human interaction	• Empathetic interaction
	• Adjusting the power positions
Maintaining the mutual safety	• Client’s safety
	• Nurse’s safety
Observance of justice	• Establishing justice
Cultural-religious competence	• Respect for the religious beliefs at home
	• Cultural sensitivity

Perception of the professional identity

Based on the experiences of the participating nurses, it was inferred that while providing home care, one of the most important ethical values for the nurses is “the perception of the professional identity,” which means understanding oneself as a nurse. They considered the sense of responsibility, development of professional and inter-professional interactions, maintaining the professional status at home, and providing comprehensive artistic care to form this professional identity.

Responsibility

All participants acknowledged that they have more responsibility when providing home care and have to make many decisions alone at home. When stating their experience, a participant says:

“The hospital is different from home. However, at home, there is another world. It is not the hospital where you could immediately page or call someone to come and help. You have all the responsibilities. You should not forget or neglect anything.” (Participant 6)

Development of professional and inter-professional interactions

As a health team member, the nurse could provide qualified care through participation and coordination with the other co-workers. This performance is manifested in the context of interaction with them. The nurses stated that the co-workers should develop professional home care skills through cooperation and participatory planning while providing the context for presenting the best care for the clients. One participant described their experience as follows:

“The topic of wounds is broad and complex. Sometimes it is necessary to use the experience of the co-workers. It has happened to me many times that I tell the family to wait until I ask my co-worker who works in a burn hospital and he has expertise in these types of wounds to know what is better.” (Participant 3)

Maintaining the professional status at home

Another valuable issue to the participants was the nurses’ effort to improve their professional performance and gain the personal and professional competencies defined as maintaining their professional status. Home care providers need to acquire scientific competence, professional performance, and up-to-date knowledge. They should develop clinical skills to behave professionally in complex and challenging home care situations.

“It is very important to me that when the nurse works at home, he/she has the same prestige as if he/she is working in a hospital and looks at it as a job. Finally, when you go to a house as a caregiver, you become the representative of nursing. You are the representative of this profession, and the nursing profession would be known through your work.” (Participant 2)

Providing the holistic and artistic care

The concept of “providing holistic and artistic care” refers to the clinical skills of the caregiver, the managing conditions such as the lack of home care facilities, and the person’s creativity while providing care, time management, controlling the critical conditions, and providing the holistic and appropriate professional care, so that all the physical, mental, and social dimensions of the patient and the family would be considered. One participant stated:

“In my opinion, when I want to find the vein of a patient, if I am in the hospital, I feel comfortable that if I could not do it, there are my co-workers, or there is the open catheter. However, in the home environment, I know that I should work with the only catheter that the family has paid for and bought.“(Participant 20)

To provide quality care to the patient, it is also necessary to pay full attention to the family’s needs. The participants recounted their experiences as follows:

“We may need to plan not only for the patient but also for her children and her husband. When I feel how upset this spouse or child is right now, I cannot ignore her and just care for the patient.” (Participant 14)

Respecting the privacy

This theme includes three sub-themes entitled “patient’s privacy,” “nurse’s privacy,” and “maintaining the information’s confidentiality.” They refer to privacy in all physical, psychological, social, cultural, and religious aspects for both the client and the nurse. It also refers to maintaining the confidentiality and safety of information at home.

Patient’s privacy

Providing a private environment and respecting the patient’s privacy, keeping the client’s secrets, avoiding inappropriate intimacy, and the home environment as the client’s personal space are examples of observing the privacy at home.

“When we enter a house, we only think about what we went for and ignore the other things. I should not be curious about the house’s environment or the relationship among the family members because I have access to the patient’s secrets when we enter his/her home.” (Participant 17)

Nurse’s privacy

At the same time, the participants emphasized that the caregiver should try to maintain the communication boundaries at home so that the nurse’s privacy is also not compromised.

“Some people think that because you enter their house, they can be very intimate or make any jokes with you and utter any word. That is why it is difficult to communicate with such families.” (Participant 20)

Maintaining the confidentiality of information

Keeping the patient’s secrets was stated as an important aspect of the experiences of home care nurses, and the caregivers emphasized the need to respect the patient’s right to confidentiality and privacy.

“Under no circumstances should the nurse quote the words outside the home, whether it is about the illness or the patient’s issues.” (Participant 10)

Respect for the client’s autonomy

This value includes the two sub-themes: “respect for the client's choice” and “honestly informing.”

Respect for the client’s choice

This value means respecting the ability of individuals to make the decisions that are recognized by considering the client's interests and his/her participation in the decision-making. Providing accurate, precise, and correct information about the care programs would lead to the right decision-making and a sense of worth in the client, and ultimately it makes the home care more effective.

“For example, to take care of a patient, I always ask him/her how I can do it for you. We try to guide the patient. We tell them about our experiences, but we leave the choice to them. In any case, the final decision maker is the patient.” (Participant 6)

Honestly informing

The participants emphasized that the caregivers should communicate clearly with the client and explain the benefits and risks of the interventions. Also, they should explain the actions that could be done to minimize the risks to people who can make decisions. They should provide the possibility of informed choice for the individuals.

“Often, the patient is not aware of his illness, and he/she cares at all. We must inform them about their condition. The patient must be aware of his/her condition. The patient is dying, but he/she still does not know clearly what condition he/she is in. Maybe he/she didn’t work, or maybe he/she has a will.” (Participant 13)

However, the home care nurses said that sometimes they had difficulty establishing an ethical balance between the patient’s right to choose the care and benefiting the patient to maintain his/her health. The patient has the right to demand and determine the care, and the nurses have difficulty making decisions when they see the patient’s wishes are inconsistent with their way of caring.

“Several times, it has happened to me that the patient disagrees with my care. I remember a patient who said it was hard for me to have an NG Tube. He/she was not satisfied with everything I did, while he/she could not have good nutrition. This situation makes working very difficult. I get very upset at this time.” (Participant 11)

Establishing human interaction

This theme has consisted of two sub-themes, “empathetic interaction” and “adjustment of the power positions.”

Empathetic interaction

“Empathetic interaction” is characterized as understanding the client/family and their circumstances, being gentle when communicating, managing emotions at home, and creating peace.

“I feel that it is annoying for the patient’s family to see that there is a patient, they pay for the equipment, and they see the patient’s bad status. So, when we enter the person’s home, we try to calm the atmosphere; we invite them to calm down because they need to be understood and treated with kindness, patience, and gentleness, as much as possible.” (Participant 8)

Adjustment of the power positions

The participants stated that one of the most important ethical values at home is adjusting the power positions to provide the best care. The nurse must establish clear boundaries with the family to prevent the threats of the presence of family, such as family domination, arbitrary interventions, insistence on doing the wrong work, and putting the nurse under pressure.

“When the nurse enters the home environment, he/she is usually under the control of the family and the patient. They put you under pressure: ‘We asked you to come to the home. So, whatever we want, you have to do, and you should do them under the conditions we have, you must do anything we say’, and the nurse must obey.” (Participant 18)

Maintaining the mutual safety

This theme consists of the two sub-themes, i.e., “client safety” and “nurse safety,” which refers to protecting the nurse and the client against the uncertain conditions and dangers that may arise in the home environment. Nurses and clients must be protected from physical, psychological, sexual, and economic harm.

Client safety

Providing safe care at home is very important. Participants stated that the nurses must do their best so that the client’s health would not be endangered by anything.

“The nurse should be alert, and the patient and caring for him/her must be important to the nurse. For example, we had a case where the nurse was asleep during the night shift while he/she was caring for a critically ill patient. You should spend time for the patient and do your work carefully, not just do the duty, because it’s very easy to do so at home.” (Participant 1)

One of the issues raised by the participants in the client safety area was the request for euthanasia. Talking about their experiences, the nurses stated that the caregivers are not allowed to perform euthanasia for the client.

“I went somewhere to take care. When I was going out, the patient’s spouse told me, away from the eyes of his/her children: Can’t you do something that he/she could die easily?” (Participant 9)

Nurse safety

All the participants commented that the client is also obliged to create a safe environment for the nurse to work at home, and the nurse should be safe from any abuse and harm so that he/she could provide the standard care safely.

“There were shameless suggestions to our nurse from the patients’ children or the patient himself. Also, you have to take care of yourself and your pocket. We had many cases where the nurse takes care of the patient, and then he/she realizes that there is not her wallet, but the opposite is true as well.” (Participant 1)

Observance of justice

Establishing the justice was another value that the participants pointed out. Justice means recognizing the equality of human beings in terms of value and avoiding discrimination among the clients based on their cultural, social, economic, ethnic, and racial status. In addition, it also covers providing conditions for fair access to the services at home for all of the clients, including the male and female, young and old, poor and rich ones.

“The nurse has learned that having the role of a therapist, he/she should do his/her duty. Care should not be recommendatory. Nobody could say that this patient is poor so that I could work less, or this patient is acquaintance or rich so that I could work better. It is not right. Whether the killer or murderer, who the patient is, does not matter to the nurse; he/she should take care of the patient.” (Participant 4)

Cultural-religious competence

Another value inferred from the nurses’ experiences participating in this study was “cultural-religious competence.” This theme consists of two sub-themes: “cultural sensitivity” and “respect for the religious beliefs at home.”

Cultural sensitivity

The caregiver who enters the home must know the diversity of the clients’ cultural, religious, and social backgrounds, along with being aware of his/her values. The caregiver should be informed of the client’s background through effective analysis of his/her cultural and religious background and provide the home care while respecting the client’s beliefs as much as possible. Participants referred to Iranian society’s cultural characteristics and religious backgrounds, and its traditional context in their statements.

“When you enter patients’ homes, you have to take care of everything twice. The home is reverenced. The owner of the home is respected. It is disrespectful to enter the home with shoes. Iranians are very complimentary. I remember early in my work when a patient’s family brought me fruit and complimented me. I thanked and said that I had just eaten food. I took nothing, and they became very upset and told me, ‘they are clean; please eat them.’ (Participant 19)

Respect for the religious beliefs at home

Nurses should avoid the behaviors that hurt the beliefs and values of the client and his/her family, such as insulting the religious beliefs, disregarding, and ridiculing the beliefs. Another participant commented about “respecting the religious beliefs at home”:

“For example, I saw a family who put some Turbah on the patient’s back. They put some money under the patient’s pillow to donate to a charity or closed a green cloth to his/her finger. Here we should not say, Oops, collect this garbage and throw them away.” (Participant 12)

Discussion

The nurses participating in this study considered the ethics observance as the basis of home caring. Their perception of the ethical values of home caring was formed into the seven main themes: the perception of the professional identity, respect for the client’s autonomy, respect for privacy, establishing human interaction, maintaining mutual safety, and observance of justice cultural-religious competence.

According to the participants, nursing would be professional when it has the power to observe the ethics. Professional identity and ethics are necessary for each other, and this is a necessity for nursing in any environment, including the hospital or at home. Milton (2010) believes that the professional identity is a kind of professional power [27]. Since the nursing personnel is considered the ethical leaders in the health care systems, maintaining and strengthening this group’s ethical and professional identity is essential both in hospitals and at home [28]. Nurses who have the necessary knowledge and experience to care at home are proud of providing good palliative care and could provide the conditions for a good death at home [29]. In addition, acquiring up-to-date knowledge, developing clinical skills through continuing education courses, and promoting competencies have been mentioned to maintain professional status.

Gágyor et al. found that the nurses felt powerless if there was no good collaboration between the physicians and home care nurses. In most cases, the nurses did not discuss the care issues with the physicians because they feared it would affect their subsequent collaborations [11]. Karlsson et al. claimed that the presence of confident and responsible individuals alongside the client and family could lead to their greater trust in the home care provider [30]. Öresland also stated that the responsibility of the nurses at home is much more because they are alone with the patients and have to make many decisions [17,31].

The present study’s findings also showed that due to being in the private environment of the home and lack of monitoring at home when providing care, the nurse is required to have a higher sense of responsibility to provide timely, correct, and qualified care to the client. A holistic approach to providing patient care involves considering all of the client’s mental, psychological, social, and spiritual needs. In line with the findings of this study, Reed et al. stated that the nurse should not only deal with the stereotypical role of the physical care but also, he/she should become a part of the patient world and should provide the holistic patient-centered care [32]. In addition, the present study’s findings showed that while considering the key role of the family members in the home care practice, they should be regarded as a client along with their supportive role. Also, by developing a close relationship with them, the holistic approach should assess the different dimensions of their potential and actual needs.

In line with the present study results, Karlsson et al. stated that when the participants felt that the patient autonomy was not respected, nursing home care was experienced by the nurses as a serious ethical problem [10]. For the nurses, increasing the patient autonomy means seeing the patient as an individual with his/her own needs, values, and preferences. According to the nurses’ comments, patient care should be a two-way decision, depending on the person’s wishes and capacities as well as the contextual factors such as the presence of informal support and care [33].

Providing accurate, concise, and correct information about the care programs to the client leads to the right decision-making and a sense of worth in the client. However, some home care nurses commented that when they saw the patient’s wishes inconsistent with their caregiving style, they had difficulty making decisions and establishing the ethical balance between the patient’s authority in choosing the care and the benefit of the patient to maintain his/her health. Karlsson’s study also stated that the client and his/her family need knowledge and information about the disease status to be involved in the decision-making regarding end-of-life care at home [30].

The participants’ statements showed that privacy at home is doubly important because the nurse enters into the patient’s privacy which requires the nurse’s skill in defining the boundary between the professional work and the patient’s private life. In various studies, loss of privacy at home, disruption of the family routines, and change in the family interactions due to the presence of a nurse at home have been reported [[34], [35], [36]].

Garcia showed that keeping the client’s secrets within the confines of the job, respecting the client’s wishes for maintaining the privacy of the health issues, and the families’ lack of information are the important aspects of home care that must be considered [37].

The nurse must maintain the communication boundaries at home so that the nurse’s privacy would not be compromised, which was less addressed in the previous studies. Participants in the present study believed that the solution to maintain this value was to clarify the boundaries of the nurse’s professional work and private life.

One of the important values was empathetic interaction. Considering the traditional Iranian society, family-oriented culture, and the role of the family members in the home care, the nurse’s interactions with the patient and his/her family at home significantly impact the quality of care. As a result, competent and powerful caregivers lead to respect for the client when trying to communicate. The lack of proper communication with the client wastes more time and energy at home. This value is known for understanding the client/family and their circumstances, being gentle when communicating, managing the emotions at home, and developing peace. Lack of sincere communication with the client and his/her family could lead to ethical problems for the nurses. It makes the nurses unable to perform their professional duties regarding the clients’ real needs [10,14]. The skills of listening, accepting, and speaking about the emotional issues that the family is involved in, could lead to a reduction in their fear and development confidence. Also, ignoring the client and his/her family’s perspective and weakness in communication could lead to dissatisfaction with the services [10,32].

Also, the present study participants stated that the family’s strong presence during providing care at home, the feeling of more power, and the comfort of the families due to the presence at home’s personal space and atmosphere could affect the nurse’s care. One of the most important ethical values at home reported by the nurses was the adjustment of the power positions. In line with the present study, in Öresland’s study, the nurses believed that in the hospitals, they are powerful; however, at home, the patient and his/her family are in a power position. Nurses at the patient’s home act more as guests to minimize the negative consequences of their work [17]. Therefore, the caregivers should set clear boundaries with the family to prevent threats due to the family’s presence, such as the dominance of the family, arbitrary interventions, insistence on doing the wrong thing, and putting the nurse under pressure.

Given the fact that the usual protections that the personnel have in the hospital (e.g., co-workers, security guards, alarm systems) are not present in the home care, in the absence of the employer safety policies and programs, the home care personnel could be exposed to the abuse and violence [38]. The issue that the participants in this study have repeatedly pointed out is that all those involved in home caring should be protected from verbal, physical, or sexual harassment and intimidation. Also, they stated that the nurses should avoid the behaviors that could lead to physical, psychological, emotional, sexual, and financial harm to the client. Evidence suggests that the nurse and family/client’s sense of insecurity at home prevents the trust and even causes the nurse to appear unreliable in presenting his/her caring roles [10].

The observance of justice was another value mentioned by the participants. Respect for the individual values and sensitivity to the existing differences is essential for optimal patient care. Fair distribution of the resources is the goal of the caregiving system, and the observance of equality is a key factor in the equitable distribution of the resources, including equal access to the services and, as far as possible, equal treatment for the similar cases. Consideration of the weakest members of the society is also recognized as a value in the society [39,40]. Petosa stated that the home care nurse should provide the appropriate service to all the patients, especially the vulnerable minority of the society, and he/she should avoid any discrimination in the care provision [41]. Nor should the provision of home care to the young patients be different from that of the older ones, and their individuality should be respected [12,36].

Cultural-religious competency was one of the most important ethical values for the nurses while providing home care. They believed that religion and religious beliefs have long been an inseparable part of the civilization of the Iranians. Therefore, the caregiver should enter the home and provide care, knowing the family’s cultural, religious, and social diversity and being aware of his/her values. We must notice that home caring is entering an environment where the client/family’s values, preferences, culture, and control are dominated. One needs to respect their culture and lifestyle and the decisions of individuals in providing the care [34].

Garcia indicated that working on certain religious days may cause problems, or blood transfusion contradicts some individual’s religious beliefs, which should be considered when providing the services [37]. Previous studies have pointed out considering the clients’/families’ spiritual beliefs as a factor for the ethical improvement and advancement in nursing [42,43]. Since Iran is a religious society and the ethical principles bind it, it is expected that people in any job position have ethical and human performance based on religious principles.

Limitations

The study’s limitations were difficulties in data collection from different cities and arranging a suitable time to interview participants due to their work busyness and lack of free time and a few probing questions in the interview guide were too general to explore the ethical issues in-home care nursing.

Conclusion

Based on the results of this study, it could be stated that the responsibilities and complexity of the tasks have been doubled under the influence of the unique home environment compared to the hospital care. Caregivers have considered the ethical values in providing home care, such as the perception of the professional identity, respecting the privacy, management of the family interaction, mutual safety, and cultural-religious competence. The provision of ethical care is one of the main goals of health care systems in the world; therefore, due to the emergence of home care nursing in line with the priorities of the Ministry of Health in Iran and the importance of out-of-hospital services, the development of an ethical framework would be very helpful to address the ethical challenges of this area and development of ethical competence in these nurses. Such a framework should be based on the ethical values identified according to the Iranian society’s society, culture, structure, and religion. Because most studies are based on qualitative research, more exploratory studies are needed to understand the specific challenges of home caring.

Data availability statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

CRediT authorship contribution statement

Masoume Arab: Conceptualization, Methodology, Investigation, Data curation, Writing-original draft. Mohsen Shahriari: Supervision, Conceptualization, Methodology, Writing-review & editing. Amir Keshavarzian: Methodology, Writing-review & editing. Abbas Abbaszadeh: Writing-review & editing. Mahrokh Keshvari: Writing-review & editing.

Funding

This research was extracted from PhD thesis and was reviewed by Research Council of , Isfahan, Iran and approved with Grant No: 398,547.

Declaration of competing interest

The authors have declared no conflict of interest.