Abstract
The escalation in the number of medical devices in home care increases the demands on district nurses’ knowledge and skills. This qualitative interview study with 13 district nurses from Sweden aimed to describe their experiences of advanced medical technology in home care. The COREQ checklist for qualitative studies was applied. The results showed two categories: district nurses’ experiences of collaborating in teams and district nurses’ experiences of performing safe care. The safe use of advanced medical technology in home care required good collaboration between all the parties involved. This resulted in a certain amount of freedom and increased quality of life for the patients. District nurses needed time, continuity, practical training, and repeated education to be able to provide safe care. Distinct leadership was important at all organizational levels. The results can generate a safe and sustainable work environment for district nurses, almost independent of their technical background.
Introduction
In most European countries, people prefer to receive care in their homes rather than in long-term care institutions. 1 Home care reduces patients’ stress and provides them with a sense of control and autonomy. 2 Expectations about the possibilities for home care have grown as new technology enables distant monitoring and more complex treatments using advanced medical technology (AMT) in the home situation. 1 AMT enables specialized care to be performed in the home and is often a prerequisite for establishing home care for the patient. The development of the AMT has given rise to an escalation in the number of medical devices in the patients’ homes, thus requiring the district nurses working in home care to have a broad knowledge of how the devices are to be used in a patient-safe way. 3 There are also increasing demands on the district nurses to be technically proficient from both patients and their next of kin. 4
Background
Home care
Home care is interpreted differently worldwide, but usually involves care provided behind someone's front door and includes services that enable people to remain in their home environment. Home care may be necessary for patients after hospital discharge or to prevent hospital admission. 1 Home care requires health professionals to be able to encounter unpredictable environmental challenges and patients with different needs. It is thus not possible to predict and standardize all home care and rehabilitation processes. 5 The type of services in home care may refer to the care given only by professionals, so-called formal home care or in combination with care given by next of kin; so-called informal care. Formal home care is provided for a short or long period of time after the completion of a formal assessment of the patients’ needs. Informal home care often differentiates between patients staying at home or being hospitalized. Living alone at home with a serious illness 24 hours a day is a complicated experience that requires access to support, often provided by informal caregivers. 1
In European countries, it is common to work together in teams consisting of community care professionals including a general practitioner (GP) and a social worker. 1 In Sweden, home care is staffed around the clock with community nurses, who are accompanied by different health professionals such as assistant nurses, occupational and physiotherapists, GPs, and other care professionals who perform work on the delegation of the registered nurses. 6 The best possible home care depends on cooperation and a dialogue between patients, next of kin, nurses, and GPs. 7 Professionally trained nurses are responsible for medically oriented technical tasks, prevention, and therapeutic care. It includes help with catheterization, wound care, prevention of bedsores, oxygen administration, and intravenous injections. 1 Other tasks performed are nutrient supply via drip or tube, pain relief, blood transfusion, or other specific care that requires the use of medical devices. 6
AMT and the users
AMT is defined as medical devices and software systems that are complex, provide critical patient data, or that directly implement pharmacologic or life-support processes whereby inadvertent misuse or use error could present a known probability of patient harm. 8 AMT includes respiratory aids, oxygen therapy, hemodialysis/peritoneal dialysis, wound pumps, infusion pumps, and parenteral/enteral treatments. 3 Incidents in connection with AMT in home care are related to the failure of the product (43.6%), the organization of care (27.9%), the user (15.7%), and the environment (12.9%). 9
AMT in hospitals is mainly managed by health professionals and experienced personnel. The users in a home care context are often a non-professional group with different backgrounds of age, physical and mental condition, and experience of AMT. 4 This heterogeneous group is a challenge for designers and manufacturers of AMT when creating safe and user-friendly products for home care. 10 A certain responsibility is transferred to the next of kin when patients with AMT care move home. Educational efforts and concrete instructions must be given to them, if they want to be involved, for example, the correct use of medical equipment or emergency preparedness. 4
The use of AMT requires specialist knowledge, skills, and an understanding of the potential risks and how these can be minimized. 11 The district nurses need to be clinically and technically skilled and focus on building partner relationships with the next of kin as they take considerable responsibility for the patients’ safety in the home care. 4 A perception of vulnerability is generated for the district nurses due to the constant changing of tasks and increased demands for technical knowledge concerning technical devices, and further uncertainty is created by a lack of continuity and support in managing the devices. 9 Moreover, the district nurse is often alone and responsible for taking individual decisions in the absence of the GP involved, thus further increasing the vulnerability. 12 Safe usage of the medical devices requires a self-confidence developed during years of experience and continuous use. The district nurses can put a greater focus on the patients rather than on the performance of the task when they have gained more self-confidence. 13 The concept of safe care refers to minimizing the risk of injury and is based on collaboration with all health professions. The work of the district nurse must be based on current legislation and regulatory documents to contribute to safe and secure care. 14 Patients and their next of kin highlight the importance of the nurses’ skills in handling the medical devices correctly. They feel uncomfortable if the nurses express or show ignorance when performing the tasks.13,15
Several studies shed light on the experiences of patients and their next of kin of AMT in the home, but only a few studies focus on the experiences of nurses or other health professionals.3,16
The study
Aim
The study aims to describe district nurses’ experiences of AMT in home care.
Design
A descriptive and inductive design with a lived experienced approach was chosen to describe qualitatively different conceptions of the phenomenon AMT. 17 This approach is recommended when people's lived experiences of a phenomenon are to be elucidated and where there is a lack of knowledge about the specific field of study. Data were analyzed and interpreted with a manifest content analysis. 18
The participants
An information letter was sent via email to the nurse with medical responsibility for the municipal home care services and the managers of social care in two municipalities requesting permission to conduct interviews with community nurses. The two neighboring municipalities that were selected were considered large enough to receive the targeted participants. The managers were asked to reply with contact details for the community nurses who met the inclusion criteria. Convenient and purposeful sampling was chosen to select the participants. 17 The inclusion criteria was a grade in specialist nursing as district nurse and one year's experience in home care, regardless of gender and age. The targeted number was 15 participants. A letter with the study's aim and design together with a consent form was sent via email to 20 district nurses. Of the 20 district nurses, seven declined to participate and no reason for not accepting the invitation had to be given. Since this was a master's thesis and therefore meant a time limit, no further attempts were made to find more participants.
The 13 who participated in the study were willing and interested in verbalizing and communicating their own experiences (Table 1). They worked in home care in both rural and densely populated areas. Their experience with medical devices consisted of pumps for drugs, enteral or parenteral infusion, and wounds, as well as respiratory aids for oxygen treatment, continuous positive airway pressures, ventilators, and cough machines. Furthermore, they managed peritoneal dialysis, subcutaneous vein ports, suction of airways, various drains, and anti-decubitus mattresses.
Sociodemographic characteristics of the participants.
Data collection
Data collection started with the formulation of a semi-structured interview guide by the authors. The second and third authors worked as nurses and were students completing research for a master's thesis. The first and last authors had extensive experience in qualitative research methods and were also familiar with the context through 25–30 years of working experience with AMT in hospital and home care. Consensus and evaluation about the quality and relevance of the questions in the interview guide was achieved following a pilot interview with the first participant. The questions were considered relevant for the purpose of the study and the pilot interview was included. All the interviews were planned to be carried out by telephone and the duration of the interviews was determined in agreement with the participants.
Data collection was conducted by the second and third authors and consisted of individual telephone interviews recorded by an audio device in September and November 2020. Only one participant and one researcher were present during the interviews. The interviews began with an open-ended question: ‘What is your experience of medical devices in home care?’ Additional questions were asked, including the district nurses’ positive and negative experiences of AMT. Further they were asked about their skills, information, education, and risks when using AMT and support from management. To obtain more detailed and in-depth information, probing and follow-up questions were asked, such as ‘Could you elaborate on that?’ and ‘How did you handle it?’ A total of 13 interviews were performed, lasting 15–60 minutes. They were then transcribed verbatim by both interviewers during the weeks after the interviews.
Ethical considerations
The Declaration of Helsinki was followed, emphasizing respect for the individual, including their rights, integrity, privacy, confidentiality, and dignity. 19 Approval by an ethical review board was not needed since health professionals were interviewed, which is in accordance with Swedish research regulations. 20 The interviewers completed an ethical self-examination developed by the university before the study was performed. Essential guidelines to consider in the study are the criteria of information, consent, confidentiality, and usage. Oral informed consent was obtained from all participants in connection with the interviews. All data were de-identified, coded, and saved on data devices. Quotations in the text were labelled as participants 1–13, and the data were only used for research purposes. The data collected were password encrypted, and access was limited to authorized persons only. The authors’ previous knowledge and experiences have been utilized in this paper, giving special attention to reflexiveness and avoiding preconceived ideas and interpretations.
Data analysis
The data were analyzed and coded by all authors using inductive qualitative content analysis. The data consisted of complete interviews and were analyzed at a manifest level where the focus was towards the prominent and visible information in the text. 18 The interviews were read through several times to gain an overall view and to discern different meaning units. The meaning units that responded to the purpose were selected and marked with different colors according to their meaning. They were subsequently condensed into smaller units without changing their main contents. Each condensed meaning unit was marked with a code to increase the level of abstraction. The analysis proceeded, and similar contexts were combined and sorted into six subcategories, and similar subcategories were sorted into two categories representing the manifest content of the data. Data saturation was experienced after the analysis of 12th interview; thus, no new information emerged. Subsequently, one further interview was conducted to confirm this. 17
Rigor
In order to ensure scientific quality in qualitative research, an assessment is required based on the five terms: credibility; authenticity; dependability; confirmability; and transferability. Credibility and authenticity refer to how data are obtained and interpreted. 17 This was achieved by finding suitable participants with varying experiences of the phenomenon. Most participants had extensive experience of working as a district nurse in home care and handling different types of medical devices. Credibility was also strengthened using a semi-structured interview guide, which guaranteed that the participants received the same overall questions. In total, 13 individual telephone interviews were conducted. The amount of data required to answer a research question in a credible way varied depending on the complexity of the phenomenon and the data quality. 21 Thirteen interviews were conducted, which was considered sufficient to be able to obtain a reliable result. The interviews were considered to add sufficient satiety and more interviews would not contribute with more variety. This is considered a strength in the study. There are no rules on how many interviews a qualitative study should contain if participants provide content-rich reflections on their experiences. 17 Data were analyzed at a manifest level and there was judged to be a congruence between the level of abstraction of the subcategories and the categories.
Dependability refers to the trustworthiness and the stability of data over time and the authors’ consistency in data analysis. 17 The interviews were recorded digitally, and transcripts and texts were reread during the analysis, allowing the authors to remain close to the content. By listening and transcribing interviews simultaneously, the interview situation is repeated, creating a better basis for understanding. 17 All the authors collaborated throughout the analysis process, confirming the reliability and dependability of interpretations, being aware and open to pre-understanding, and agreeing on the outcome.
Confirmability is the value of the data and can be compared to objectivity. A clearly described analysis process increases the confirmability of the study. 17 Confirmability was assured since citations were included in the result, making it possible for the readers to act as co-examiners.
Transferability refers to the generalizability and implies that the choice of method and selection of data collection are appropriate to identify and study the experiences referred to. 17 A qualitative design was the natural choice, and data collection through interviews was the most appropriate method. Transferability was also established by the selection of experiences from both men and women. Although the sample comprised 13 participants, the purposive selection is considered varied in terms of gender, age, and experience. Since women are overrepresented in the district nursing profession, it is not considered a weakness for transferability that two out of 13 participants were men.
Findings
The study participants consisted of 13 district nurses (age range = 28–66 years) and had a Postgraduate Diploma in Specialist Nursing. All worked in home care in rural and densely populated areas. Two categories and five subcategories emerged in the analysis of district nurses’ experiences of AMT in home care (Table 2).
Categories and subcategories of the district nurses’ experiences of AMT in home care.
Note. AMT: advanced medical technology.
District nurses’ experiences of collaborating in teams
The district nurses considered that AMT in home care had become increasingly common in the last decade. The use of AMT made it possible to provide more advanced home care, and more patients with pharmacologic or life-support processes could be treated at home instead of the hospital. The district nurses meant that the patients also gained a certain amount of freedom and increased quality of life with their AMT. The use of the medical devices required collaboration between all parties involved. When the district nurses were not certain about using various medical devices, they asked their colleagues for help. Co-working with the specialist care was considered necessary, and a wish for improved communication and long-term planning before the patient's discharge to home care.
Working colleagues are important supportive members in the team
The district nurses emphasized the importance of collegial support for exchanging information about the medical devices and solving problems together that may arise. This support was critical when the district nurses had not used a particular medical device for a long time and needed to update their knowledge. If you are unsure about something, we talk to each other and help each other. We have also lined up and taken extra shifts and extra evenings if there are something extra special so we can be the two of us and help each other. (Participant [P] 9)
It was also an openness to share their experience with less experienced colleagues. … some have never been there before… new colleagues and newly trained. We are quite helpful that way, if there anyone who says I want to join this. (P1)
Specialist healthcare colleagues are important co-workers in the team
The district nurses considered it essential to cooperate with the specialist healthcare services. They usually called and consulted the specialist healthcare for more information and/or advice on the usage of the medical devices that the district nurses were less familiar with. Sometimes they went to the hospital for education and practical training on the prevailing technology. I can go to the hospital… it could be a pleural or abdominal drain that you haven’t done in a while… then you can go there and practice how to do it… it is very important. (P4)
The district nurses received particularly satisfying support from doctors who were responsible for patients receiving late-stage palliative care. Sometimes the palliative counselling team can do this, and you go through the different steps in peace and quiet and maybe the first time you go home to the patient together. (P4)
The district nurses desired better communication and forward planning from the hospital's departments when discharging patients requiring AMT. This often happened too quickly and before they had received sufficient practical training and felt confident with the current AMT.
Information about the transferal between specialist care and home care usually took place via the digital medical record systems, but oral reports were of great importance, especially if children were to be cared for at home. When children come home and have to receive different injections, then it‘s very good to be able to talk directly to them. (P3)
District nurses’ experiences of performing safe care
In order to handle medical devices in home care safely, district nurses needed to maintain the level of their medical skills, which they usually did by regular use and practical training of the various medical devices. AMT in the home entailed some risks due to it not being possible to monitor patients around the clock. The district nurses thus considered that risk awareness was a significant factor. AMT also entailed a great deal of liability when delegating to other health professionals as well as trust that the patient and their next of kin could raise the alarm or remedy any errors themselves if some problem occurred.
Maintenance of medical technical competence in home care
The district nurses emphasized that great demands were placed on their technical skills. They expressed that it could sometimes take several months or years from when they were trained or last worked with the products, resulting in an uncertainty in the usage. In addition, there may be new and completely unknown AMT depending on whether the patients had received care in another health authority with a different type of AMT. It can be long time between the use of them… then you have to read again and refresh your knowledge… read the instruction manual or user manual… so that you update yourself every time. (P11)
The district nurses considered it to be their personal responsibility to search for current information to keep their knowledge up to date. The employer sometimes provided them with the opportunity to attend manual training or lectures that could take place in hospitals or the companies’ salesmen came and informed about their products. These training sessions occurred infrequently, and structured and regular updates or the opportunity to visit hospitals were desired. The district nurses implied that the managers lacked the understanding that repeated education and practical training generated increased patient safety. The managers, who frequently lacked medical expertise, expected the district nurses to have the knowledge about how to use all the medical devices available for home care. They always think that when you’re a district nurse you can do this; they think it’s obvious that we can manage it… you want more support from managers and management. (P2)
The staff who worked evenings and at night perceived that they were often forgotten as they did not have the opportunity to gain the same information and practical training as the district nurses who worked during the day. The training sessions were usually suited to the schedules of the day health professionals. It was particularly difficult if problems arose when the district nurses started their night shift lacking information about the management of the medical devices. It‘s completely impossible to get the same information as those who work during the day, when working night and evening. (P8)
Awareness about risks when using AMT in home care
The district nurses considered that there were several risks with AMT in the home. There could be defective pumps, people who changed important settings on the devices, or sudden losses of power. If the devices were user-friendly and easy to manage, it facilitated the management and reduced the risks of making mistakes. Therefore, an increased patient focus in the manufacturing process was desired. From my perspective, I see that it is a change, we get better products that are easier to handle, they are minor and sounds less and are more flexible in many ways. (P5)
The district nurses also considered it dangerous to handle medical devices about which they did not have sufficient knowledge. Conducting regular risk assessments and establishing routines if something unforeseen could occur was pointed out as vital. If you handle something that you may not feel safe doing, you can physically harm the patient… it’s a risk for my own credentials if I take care of something that could be harmful. (P9)
The district nurses meant it was a risk that the patients were not under the constant supervision of the health professionals in their homes. They thus had to trust the patients or next of kin to contact the home care services if they needed help. A certain amount of time to make their journey to the patients was also needed because the latter were often spread out in the community, which could also mean a risk in emergency situations. They may live 20–30 kilometers away and just when they call I may be working with another patient who takes half an hour to complete… we need more time as we do not have the patients living close to each other. (P4)
The district nurses also expressed that the need of medical devices and all the associated materials also risked turning the home into a hospital environment. But they (medical devices) are a prerequisite for being able to care at home. But the negative is that it becomes a hospital environment at home and many of our patients find it difficult. (P5)
Responsibility in connection with AMT in home care
The district nurses were responsible for planning AMT in the home, which required both time and good forward planning. This included everything from ordering materials and ensuring that these were in place at the home to ordering medicines for various treatments. Some AMT was delegated to other health professionals. The district nurses who did not handle the medical devices very often could thus become uncertain. Many times, we delegate these tasks to the assistant nurses… The more we delegate the less we have to do with it, but still we have the ultimate responsibility. (P12)
The district nurses sometimes experienced situations when the AMT did not work as intended. They worked alone at the patient's home most of the time and had to take responsibility for solving the problem. It was thus necessary to be professional to ensure that the patients could feel safe, even if the district nurse did not feel completely confident in performing the task. It can be a great insecurity for those living in their home, especially when we show our insecurity. I think it’s important that even if you feel insecure that you don’t really show it when you’re there. (P9)
AMT contributed to the patients and their next of kin being more involved in the care and taking more responsibility for the AMT. This facilitated the opportunity to live as normal a life as possible in their own homes. However, there was a risk that the patients and their next of kin undertook a responsibility they perhaps did not feel secure about. They may not always be asked if they feel safe with the responsibility… it’s a lot to keep an eye on for them… it's easy that they sometimes get disregarded. (P6)
Working alone at someone's home involved great personal responsibility and was different from having other colleagues nearby to consult. The district nurses wanted someone to call in case of unforeseen emergencies during the on-call time. Despite the great personal responsibility and rapid increase in AMT, they considered working with AMT developing and stimulating. There's a big difference if you’re at a short-term accommodation with a lot of staff around, then when you are alone in a home… you want to possess a high level of competence because you’re very dependent on it as you’ve no one to ask on the spot. (P10)
Discussion
The results regarding district nurses’ experiences of AMT in home care were twofold, collaboration in teams and the performance of safe care.
It was considered vital to have a close relationship and cooperation with the colleagues and the specialist healthcare services. Forward planning in the delivery of care was necessary, especially when considering not to discharge the technology-dependent patients to their homes too quickly. Good cooperation and communication between the hospital and home care create conditions for a smooth transfer of care. 22 The district nurses often have insufficient time to plan interventions no matter how complex these are. This includes the reporting from the specialist care services not occurring in time, and the information about the patient's care being limited and lacking essential details. 23 The district nurse is responsible for organizing, planning, coordinating, and managing nursing together with others in the team for people with multifaceted and intricate healthcare needs. 24 This process is not always easy as it is well-known that the use of medical devices in home care requires preparation and planning, and all the equipment needs to be in place at the patient's home, and the district nurses should receive education and practical training on how to use the products.
The use of AMT in home care placed great demands on the district nurses to be technically savvy. The requirements placed on the district nurse's specialist knowledge are increased due to the complexity of the tasks required to use AMT. 11 New medical devices are constantly being introduced, and the district nurses working in home care must have a broad knowledge of how the products should be used. 13 There is a need for special training for the nurses through collegial instruction, practical training, and theoretical knowledge. 11 Patients and their next of kin also place greater demands on the district nurse to be technically knowledgeable. 4 Regular practical training and education for all district nurses should take place systematically so that sustainable and safe care can be ensured for the patients.
It was a challenge for the district nurses to keep their knowledge up to date as there could often be a long gap between the times they used the various devices. Uncertainty is created in the professional work of district nurses when AMT is only used sporadically. 3 Patients and next of kin feel uncomfortable when district nurses cannot or are unsure about using the products. Sometimes they have more knowledge about how to use the medical devices than the district nurses. 15 The district nurses considered themselves responsible for seeking relevant information and updating their knowledge, which was often time-consuming. District nurses need to be continuously updated in their knowledge and regular practical training to conduct safe person-centered care when using AMT. 11 They need to be prepared before visiting the patients, although there is often little time and resources to ensure this. 13 Quality and patient safety are created in organizations with a good work environment, psychological security, and permissive culture. 14 Safe use of medical devices requires self-confidence, and with greater self-confidence, district nurses can focus more on the patients than on the actual task they perform, which positively impacts the care relationship. 13
Patients and their next of kin sometimes took on a responsibility they did not feel comfortable with when AMT was brought into the home. The next of kin perceive themselves as the district nurse's assistants for monitoring medical devices and other practical commitments, which means they can never relax from this responsibility. 13 It is necessary to build partnerships and collaborate with the next of kin since they take on responsibility and thus contribute to safety in home care. 4 It is crucial to create trust, good relationships, and to involve the patients and their next of kin in the care based on their needs and wishes. The involvement of the patients and their next of kin in the care must thus be based on their possibilities and conditions, together with the awareness and receptivity of the health professionals about what the patients and the next of kin want to take responsibility for.
The district nurses were concerned about incidents that may occur when they were not present in the patient's home. It is a risk factor when patients are not observed around the clock. 13 Being dependent on technical devices can be experienced as a tiring and strenuous situation, despite the alarms on the devices. The risk of medical devices with sounds can lead to alarm fatigue, which increases the risk of the product being turned off or ignored and has resulted in severe injuries and even death. 25 Adverse events in connection with AMT in home care are related to failure of the devices in 43.6%. 9
It could sometimes take a long time to reach the patients if an error with the AMT occurred. Long journeys can be both time- and energy-consuming and create stress for everyone involved. 12 The district nurses should have access to support during on-call times to provide good and safe care, as it is impossible for them to always correct defects in the medical devices. Patients and their next of kin also need to be trained in handling the medical devices to be able to solve problems when the district nurses are not on site. 15 District nurses emphasize that being available and on hand when needed is a crucial factor when creating and maintaining security care. 16
It is known that patients and next of kin experience that their home changes into a more hospital-like environment when AMT is introduced into the home. AMT affects the private sphere of the patients and their next of kin since it can lead to more home visits by health professionals and require a large space for storage, preparation, and waste management. 13 District nurses need to adapt the patient's home from a work environment point of view and create space for the technology devices and associated materials. 12 District nurses should be aware of how medical devices affect both patients and their next of kin in their home environment and be attentive and adapt the care to their wishes. It is of great importance to avoid too much visual material in the home to reduce the feeling of a hospital environment.
Limitations
Transferability can be considered if district nurses working in various settings can recognize the descriptions and interpretations as their own. Sweden's healthcare system may differ from that in other countries, and it is thus difficult to transfer the result internationally. The author's preconceptions of AMT in home care may have had an impact on the findings. This has been considered through careful discussions throughout the analysis process.
Conclusion
This study provides information about the importance of practical training and experience of using AMT for district nurses. This resulted in an increased competence and technical skill, which improved self-confidence in the use of AMT, leading to safe and secure care. The AMT generated freedom for patients and enabled participation in self-care. However, district nurses should be sensitive to what patients and next of kin want to take responsibility for due to AMT in home care. The specialist healthcare services need to plan forward before the patient with AMT being discharged to the home in order to provide the district nurses with the opportunity to update their technical knowledge. Collaborating and creating a relationship with patients, next of kin, working colleagues, and co-workers from specialist care is essential. Clear leadership is important at all organizational levels and should strive to assemble guidelines for regular risk assessments, generating a better working environment, and safer care.
Footnotes
Acknowledgements
We are grateful to the participants for generously sharing their experiences.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article
