Encountering patients in their homes: A qualitative study of home care nurses’ experiences

Abstract

Many ill people want to be cared for at home, and home care nurses face an infinite number of encounters when providing that service. Despite the rising prominence of home care organizations worldwide, little research has been conducted on the encounters between home care nurses and patients and how encounters influence the nursing care provided. The aim of the present study was to describe home care nurses’ experiences of encounters with patients in their homes. In total, 11 home care nurses were selected through purposive sampling. The data consisted of individual interviews, which were analyzed through qualitative content analysis, and reported using COREQ reporting guidelines. The results were based on two categories describing the importance of adapting to each patient's needs and collaborating with the person being cared for. Implementing the findings could enable nurses to care for the patients without reducing them to recipients of objectified care.

Keywords

collaboration home care nurse-patient relationship well-being

Introduction

Although life expectancy is increasing globally, it is not equated with concomitant increases of good health.¹ Experiencing illness might make a person dependent on other people, such as healthcare professionals, in their daily lives.² Today, an aim in many countries is to reduce the length of stay of patients in hospitals by transferring responsibilities from inpatient to outpatient care in order to improve personal health results and to minimize healthcare costs.³ Accordingly, home care has become an increasingly important facet of healthcare organizations worldwide⁴ and it is something that the healthcare sector also aims to provide in the future.⁵ The goal of home care is to provide support towards a functional and meaningful life. Nursing is a vital part of home care and can impact a person's everyday life and health.⁶ It is directed towards people who are ill, who are incapable of self-help, and who require care.⁷

Maintaining and developing one's functional abilities will enhance the possibility of healthy aging together with perceived well-being.¹ Home care nurses play a key role in helping the elderly to maintain their independence,⁸ by delivering person-centered and health-promoting care.⁹ However, receiving help and support at home might lead to an intrusion into a person's life, as the private home becomes a public arena.¹⁰ It may generate conflicting emotions since most people do not want their homes to be institutionalized,¹¹ even though most ill people want to be cared for in their own housing and to live there for as long as possible.¹²

Home care nurses face an infinite number of encounters and face many challenges to provide their service.¹³ When entering a patient's home, the public norms that the home care nurse carries intersect with the private norms that exist in the patient's home.¹⁴ A home care nurse's work is defined by the process of relating to different realities in different homes. The process is affected by their professional and personal identities and the legal framework for the provision of home care.¹⁵ Furthermore, the provision of home care is also informed by the patient's diverse needs relating to their state of health. Factors such as functional limitations and long-term illness, socioeconomic affiliation, conditions of living, and demographic profile (e.g. language barriers and older age) may all affect the home care process. Individual patient characteristics, such as personality and personality changes (e.g. dementia), must also be considered.¹⁶

As in many Western countries,¹⁷ Sweden has undergone a major transformation from institutional care to home care,¹⁸ and its municipalities are required to provide home care for people incapable of getting to a healthcare center.^14,19 Among Sweden's 10.5 million inhabitants,²⁰ approximately 379,000 receive home care today, and 310,000 are aged 65 years or older.²¹ Nurses working in Swedish home care are registered nurses (RN) responsible for the care given to patients in their homes,¹⁴ and some have a master's degree in nursing, such as district or elderly care.²² Home care nurses can encounter patients with multiple diagnoses and who are associated with a high symptom burden.²³ This makes home care a diverse and comprehensive field of work.²⁴ It involves a wide range of daily work assignments, from intimate nursing care to technical, preventive, and psychosocial nursing care for various long periods.²⁵ Encounters with patients in home care contain an ethical dimension, as nursing care is based on an asymmetrical relationship based on the patients’ need for help from the nurse. It is a call for care by seeing others in their subjectivity.²⁶ Previous studies on this topic show that encounters in home care mean that the home care nurse must be responsive to and respect the patient's autonomy, while at the same time being regulated by laws and regulations. It might lead to ethical demands sometimes being unattainable and it could lead to feelings of insufficiency and ambivalence in how to best care for the patient.²⁷

A review of existing research in this field shows that most studies have elaborated on aspects of the encounter such as communication,^28–30 presence,^31,32 dignity,^33,34 relationship,^35–37 attitudes,^38,39 and the role of the home care nurse.^40–45 However, increasing the knowledge of the encounter as a whole is vital to facilitating the development of home care and ensuring patients’ well-being at home. Thus, the aim of this study was to describe home care nurses’ experiences of encounters with patients in their homes.

Methods and design

To gain a deeper knowledge of the encounter, a qualitative descriptive design with an inductive approach was used. Through individual semi-structured interviews, the participants could describe and share their subjective view of the encounter, in a deeper, more nuanced manner.⁴⁶ The interviews were subjected to qualitative content analysis, as described by Graneheim and Lundman.⁴⁷ To guide the reporting of the study the method was compliant with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.⁴⁸

Recruitment and sample

The participants were recruited from a home care team consisting of 18 female home care nurses in a mixed urban and rural municipality close to a city in northern Sweden, which serves about 500 patients each year. With purposive sampling, participants were recruited with the inclusion criteria of being a home care nurse with experience of encountering patients in their homes. In the present study, ‘home’ refers to a patient's home, such as an apartment or a house that does not belong to any institution. The information regarding the study was given verbally as well as in writing to all the home care nurses. This information included an invitation to participate in the study and a consent form. Using a return envelope addressed to the first author, 11 RNs (median age = 52.5 years; age range = 26–66 years) gave their consent to participate. Then, the first author contacted all the respondents to make individual interview appointments.

In addition to all the participants being RNs (n = 11), seven of the participants had a master's degree in nursing. Their nursing experience was in the range of 1–40 years (median = 17.9 years) and their experience of working in home care ranged from 5 months to 10 years (median = 4.4 years).

Data collection

Individual interviews with open-ended questions⁴⁹ were conducted by the first author between March and May 2020 by telephone due to COVID-19 restrictions. All interviews were conducted during working hours in an undisturbed environment. Data were collected by using a pilot-tested semi-structured interview guide. The participants were asked the same prepared questions with follow-up questions that depended on the respondent's answers. This structure is well suited for data collection because it is flexible but still allows for comparison between participants’ different views on the same issues.⁴⁹ The main question asked was: ‘Please describe how you encounter patients in your everyday work’. To clarify and encourage further descriptions, the following follow-up questions used: ‘Could you tell me more about that?’; ‘How do you mean?’; and ‘When that happened what did you do?’ The interviews lasted 70–90 min (median = 81 min), and they were digitally recorded and transcribed verbatim by the first author. The first author had no previous connection to the participants.

Data analysis

To describe what was clearly stated in the text about the participants’ experiences of the encounters in home care, the data were analyzed using manifest qualitative content analysis with an inductive approach.⁴⁷ First, the data were read several times to comprehend the content and identify the meaning units relevant for the aim of the study. Second, the meaning units were condensed, while preserving their essence. Third, the condensed meaning units were encoded, abstracted, compared for similarities and differences, and then sorted into subcategories and categories (see Table 1). To enhance trustworthiness,⁴⁷ the codes, subcategories, and categories were reflected with all the authors throughout the analysis, in order to achieve consensus of the findings.

Table 1.

Examples of the analysis process.

Meaning unit	Condensed meaning unit	Code	Subcategory	Category
In their home, I enter as the patient's guest. Therefore, I feel that I become more sensitive. I become more cautious and have no preconceived notions about the patient I encounter	I enter as a guest and become more sensitive and cautious and have no preconceived notions about the patient I encounter	Being a guest	To meet various people, situations, and needs	Adapting to diversity
I want to come to an agreement with the person who is ill and their next of kin as well, making sure we have an understanding. Since I take the time, I can usually explain why I make different assessments, and we will always work out an agreement of some kind	I want to come to an agreement with the person and next of kin, making sure we have an understanding. I take the time to explain why I make different assessments	Find an understanding	To find a common ground	Creating collaboration

Ethical considerations

The participants consented to participate after receiving verbal and written information about the aim of the study. In accordance with the guidelines of the Swedish Research Council,⁵⁰ the participants were assured of confidentiality and no one outside the research group had access to the data. Ethical considerations followed the Declaration of Helsinki throughout the study,⁵¹ and ethical approval was obtained from the Swedish Ethical Review Authority (No. 2019-06333).

Results

The results have been presented in two categories and four subcategories (see Table 2), and the content is presented with quotations from the interviews.

Table 2.

Overview of categories and subcategories.

Categories	Subcategories
Adapting to diversity	To meet different people, situations, and needs
	To see the individual
Creating collaboration	To get to know the other To find a common ground

Adapting to diversity

This category describes home care nurses’ experiences of multifaceted everyday encounters with patients in their homes and their need to perceive how different patients need different nursing measures. This category includes the subcategories: ‘To meet different people, situations, and needs’ and ‘To see the individual’.

To meet different people, situations, and needs

The home care nurses described their everyday encounters with patients as not only ordinary but also multifaceted and unique. They needed to sense how patients wanted to be treated or interacted with, given that they came to their patients’ homes. At home, there was the integrity of the patients that the home care nurses needed to respect and adapt to:

‘In their home, I enter as the patient's guest. Therefore, I feel that I become more sensitive. I become more cautious and have no preconceived notions about the patient I encounter.’ (P9)

The home care nurses often did not get to know the patients’ situations until the moment they entered their homes. The home care nurses described adding the whole atmosphere at home to their assessment of the care needed by the patients, often reflecting on the patients’ home situations. For example, the home care nurses described some encounters where the patients had good social connections, felt happy living at home, and managed quite well. Others lived in poor conditions or endured unwanted solitude:

‘Patients want to be independent in their homes, although sometimes it may be better to live in a special accommodation than at home and be alone.’ (P6)

Due to the varying experiences of everyday encounters, the home care nurses performed measures depending on the situation and the context. For example, they described encounters such as meetings with patients who were dying in one home with those who remained lonely in another home. Furthermore, some patients could be mentally ill or abusive. They could be suspicious, unfriendly, or scared, or have communication problems. Some were sad, angry, or in agony, or they had illnesses of various durations. The home care nurses said they were emotionally affected in various ways, depending on whom they encountered. By calmly waiting, listening, and respecting each patient's wishes, the home care nurses could better respond to the patient's needs.

To care for the individual

To care for the individual, the home care nurses had to be flexible and be able to adapt to whatever happened in the encounter. This was sometimes a challenge as they usually worked alone and had to make several vital assessments. Regardless of whether the encounter was temporary or long-lasting, the home care nurses described the positive aspects of treating every encounter as a new occasion to assess the patient's current needs. Hence, even though they showed hesitation at first, the home care nurses were able to get closer to the patient as time progressed:

‘I do not always know the patient. I enter the patient's home and wonder what kind of person I will encounter. I notice that quickly though, whether it is an easy-going person who wants to talk a lot or a person of few words. I have to start right from there and see what happens.’ (P7)

One home care nurse described that by working with people over the years, she had learned that keeping a good tone and showing respect to the patients would facilitate a positive encounter. However, the home care nurses sometimes faced challenges in caring for the individual due to unfriendly patients or their next of kin, lack of access to the patient's medical records or having scant verbal information before the encounter. This made the situation a bit stressful, and understanding the patient's needs in relation to their symptoms was difficult.

In addition to a lack of knowledge or technically challenging conditions, time constraints could hinder home care nurses from providing patients with the necessary care. The home care nurses stated that even though they had a fixed schedule for each assignment, some encounters could take an unpredictable turn of events, causing their schedules to deviate somewhat. When time was limited, the home care nurses felt stressed about having to move on to the next patient waiting for them.

The home care nurses described how different encounters often led to different measures being implemented. For example, according to the patient's wishes or due to time constraints, the home care nurses sometimes had to be objective about the primary purpose of the encounter, for example, only to treat a wound. While during others, however, they would perform non-nursing duties, such as home service chores. Caring for the individual created a desire to reflect and learn from those they met and the measures they had performed. However, that time for reflection and learning was considered to be sparse, which was described as being a shame.

Creating collaboration

This category describes home care nurses’ experiences of the relationship as an initiation of caring and the importance of working together on a common basis. The category includes the subcategories ‘To get to know the other’ and ‘To find a common ground’.

To get to know the other

The home care nurses described the encounters in the patients’ homes as being honest and personal, where the patients could be themselves in a safe and secure environment. The home care nurses would try to initiate a conversation with the patients on something of interest, to facilitate the opportunity of getting to know them. How the relationship developed depended on the personal chemistry or the original purpose of the encounter. According to the home care nurses, some relationships shifted with time. Long-lasting encounters where the home care nurse had an opportunity to get to know the other would strengthen the relationship:

‘I have followed him for several years, and he is someone I have taken to heart just because I know him, as well as his history.’ (P5)

To get to know the other, the home care nurses described the importance of mutual trust, especially if something unexpected were to happen. They also described the need to ease the emergence of trust. For example, by making themselves available for the patients, encountering them openly, and taking their time to stay, because gaining trust might take some time:

‘I cannot demand answers. It might take a few encounters, a few visits before they begin to open up to me.’ (P4)

When the encounters were short and temporary because of time constraints associated with shorter procedures, such as follow-ups or caring for minor wounds, the encounters were at risk of becoming task-orientated, with the nurses performing the measures by adhering strictly to the plan rather than relating to the patient. In addition, in some encounters, the patients made it clear to the home care nurses that they did not want to interact more than was necessary and that the home care nurses could perform their measures and then leave them alone. Although the home care nurses described some encounters as more task-oriented, they still strived to interact with everyone respectfully.

To find a common ground

The home care nurses described that when caring for patients in their homes, collaborating and finding a common ground with the patient and any next of kin was important. They said that they always strived to do the best for the patient by trying to come to an agreement on the measures to be taken, through respectful and honest dialogue:

‘I want to come to an agreement with the person who is ill and their next of kin as well, making sure we have an understanding. Since I take the time, I can usually explain why I make different assessments and we will always work out an agreement of some kind.’ (P10)

If the patient did not agree with the need for measures, the home care nurses said this was mostly because the patient felt insecure, lacked the knowledge and will, or did not trust the home care nurses. The home care nurses described how they used their creativity to find different solutions to encourage the patient to receive treatment. If this was unsuccessful, they provided the care at home, based on the conditions stipulated by the patient.

When they did not find a common ground, the home care nurses described doing their best to try to provide the care needed. However, sometimes, they had no choice but to leave the patient without performing the measures. Even though the home care nurses were well aware that they could not force themselves into a patient's home, in some situations, they simply could not leave a patient without performing services, such as administering vital medications, and they had to work more efficiently:

‘He does not want me to be in his home to dispense his medications. He often lies in his bed, and he shouts at me to get out. I need to hurry because I really have to dispense those medications!’ (P11)

Discussion

The results highlighted that given the diverse encounters they have, the home care nurses stated that they have to respect and adapt to the patients’ integrity and the culture within each home, which can be quite challenging since their homes are non-traditional care environments where an extra level of critical thinking and adaptability is required. The home care nurses must take into consideration that home, as defined by Martinsen,²⁶ is a place to dwell and to which one is attached and feels a sense of belonging towards.

Since all the encounters were different and sometimes unpredictable, demands were made on the home care nurses’ sensitivity, flexibility, creativity, and efficiency. Treating every encounter as new was a way to assess and adapt to a patient's current needs and quite often their needs shifted and were not expressed or easy to perceive. The home care nurses described that various encounters, situations, and wishes from the patients, led to the practice of different types of care. Some care was task-oriented, while others were more holistic. By being inventive and flexible and relying on their knowledge and previous experiences, the nurses were able to relate well to these varied encounters. This type of finding is also stated by Cowan et al.,⁵² who said that nursing in home care requires complex combinations of knowledge, skills, and performance. Such competence is developed not only through education, experience, and maturity²² but also in cooperation with colleagues since teamwork is essential for acquiring valuable theoretical and practical knowledge.⁵³ However, since nurses who work in home care often perform patient care alone, with time limits, there might be increased risks of making mistakes.⁵⁴ This raised concern among the home care nurses in the present study, as they are directly and solely responsible for patients’ care and health promotion measures.

The home care nurses were aware of the diversity of opportunities and restrictions for caring when encountering patients in their homes, and as stated by Fjørtoft et al.,⁵⁵ today's home care nurses are defined by their ability to assess their patient's needs and tailor the treatment accordingly. However, home care nurses might encounter some factors within each home that might impact their work and their patient's health, such as poor patient hygiene.⁵⁶ Such problems, together with the problem of reluctant patients and the unpredictable nature of the job, are described in the present study as challenging working conditions. The home care nurse is obligated to satisfy the patient's need for safety, continuity, and security.¹⁴ However, time constraints upon the home care nurses can affect the nursing process in home care because having small time margins can lead to stress in the home care nurses. This not only risks the patients’ need for safety, continuity, and security but also affects personal continuity because the home nurse feels a responsibility to help the patient. Performing person-centered care means moving the focus from the illness to the person who is ill and it requires a holistic approach.⁵⁷ Giving patients their time facilitates conversation between the home care nurse and the patient because it allows presence, which is something a high tempo and stress can ruin. Previous research in this field shows that in home care, the time requirement is unique for each patient.⁵⁸ Therefore, home care nurses should not rush the encounter.

In the present study, creating collaborations was facilitated by getting to know the other and by finding common grounds. The home care nurses had different ways of establishing an initial relationship, but how it subsequently developed differed. Previous studies highlighted that meaningful relationships are enhanced when home nurses encourage patients to talk about their lives. It is then that the nurses can listen to and try to understand the patients’ experiences, so that they can then suggest measures to improve their health.^30,59 However, even though it is fundamental to feel connected to establish a close relationship,⁶⁰ the home care nurses in the present study did not always experience this, especially with reluctant patients or in short and temporary encounters. Then there is a risk of nurses becoming task-oriented, which can make the encounter feel rather mechanical. As stated by Jacobs,⁶¹ the patient's lifestyle at home and personal relationships are not always compliant with the procedures and requirements of care. Therefore, it may lead to eroded autonomy where patients become objects of care. That is, passive, not able to identify with their actions, and with no say in the construction of their care and daily lives.

Martinsen²⁶ stated that in an encounter, there is a mutual dependence that becomes concrete in the absence of health. The relationship between a nurse and a patient is altruistic with balanced reciprocity, characterized by a need for help, where the nurse unselfishly provides care and nursing. Caring for others is manifested in human relationships through compassion, trust, hope, and open speech.⁶² The results of the present study show different ways of relating to the patients and making them trust the home care nurses. To gain this trust, Martinsen²⁶ emphasizes the importance of always seeing the other with the heart's eye.

The results of the present study further show that collaborating with the patient strengthens their autonomy and participation in care through reciprocity and shared decision-making. According to Corbett and Williams,⁶⁰ this will create opportunities for listening and understanding what is particularly important to the patient and facilitate positive health outcomes.

Reflection and professional guidance are possible ways of supporting decision-making among the home care nurses who are faced with ethical dilemmas and moral distress,⁶³ and it might counteract the problem of the needs and wishes of the patients being neglected when performing planned practical measures.

Caring for a patient includes performing measures that sometimes cure, often help, and always strive to improve the patient's health and well-being.⁷ The result of the present study indicates that to reach the goal of providing support towards a functional and meaningful life without being intrusive, home care nurses must balance the fulfillment of the demands of their professional standard with the patient's needs and wishes.

The professional knowledge and experience will provide a flexible horizon of understanding in encounters with the patients,⁶⁴ which is fundamental given the individuality and integrity of the older person and the distinctive feature of the home care context.⁶⁵

Methodological considerations

A qualitative content analysis provides a systematic and rigorous way of analyzing interview text, ensuring an organized summary of the key results.⁴⁷ To achieve trustworthiness, a purposive sample was used to recruit the participants, enlisting people who could provide informative knowledge regarding experiences of encounters with patients in home care. Some procedural limitations could be that the sample size was small, with the data being collected from one home care group in one municipality only. However, the interviews provided us with rich data, describing the participants’ similar and dissimilar experiences. Since trustworthiness in a qualitative study is not achieved due to sample size, but rather the richness of individual interviews,⁶⁶ 11 participants were judged to be enough.

Using the telephone to collect data in clinical nursing research has both advantages and challenges.⁶⁷ In this case, there was clear communication from each participant, as they were consistently involved and provided rich information. The interview questions were designed in collaboration with all the authors in such a manner that the participants were able to speak freely and truthfully without any hesitation. One pilot interview was conducted to test the interview questions. The testing did not lead to any changes, and the pilot interview was included in the analysis. Although the same author conducted the interviews, transcribed the text and carried out the initial analysis, there was a joint discussion between all authors throughout the steps of the analysis process. Consensus on the results was reached, which enhanced trustworthiness. In striving for credibility, the quotations were selected from the interview text and highlighted to better illustrate the results. Brinkmann and Kvale⁴⁹ have stated that reflexivity includes the researcher's background, experience, education, and the way the researcher engages with the data. All authors are RNs with experience of encounters with patients in different contexts and the diverse experiences simplified the possibility of looking at the data from a broad perspective.

With reference to transferability, the present study had a qualitative design, aimed towards describing the home care nurses’ experiences. As such, the results may not be generalizable.⁴⁹ However, similar results were found in all interviews, with just a few variations depending on the nurses’ experience. Furthermore, the way home care organizations are structured and the way home care nurses work may differ worldwide. Despite this, our results are relevant and might be transferred to other contexts as well to increase the understanding of the nurse-patient encounter.

Conclusion and implications

Nursing in homes is suggested as the care environment of the future, which means there is a need for a way of working that improves the health and well-being of the elderly, increases patient safety, and becomes sustainable. The study found that the nature of the problem expressed by the patient in the encounter with the home care nurses could be understood and addressed when home care nurses got to know the patient's whole life situation instead of merely isolated parts of it. This will require home care nurses to adapt to diversity and to collaborate with their patients. Home care nurses should take advantage of and strengthen the quality of the precious time in the encounter with the elderly and, in doing so, create a sense of security in people who can age in their homes and be involved in their care and in their lives. Implementing the findings could entail the nurses to live up to the ethical demand and support the Sustainable Development Goal 3 of the 2030 Agenda, i.e. to ensure healthy lives and promote well-being for all, at all ages.⁶⁸ Since most previous studies in this field have elaborated on aspects of the encounter, this is a contribution to the research that complements the gap in knowledge and strengthens existing research regarding the encounter in home care.

Footnotes

Acknowledgments

The authors want to thank all the home care nurses for their contribution to this study.

Author contributions

ALG was responsible for the data collection, the initial data analysis, and the writing of the article. OH, AKA, and MHR acted as supervisors and participated in drafting the manuscript, the analysis, and the completion of the article. All the authors have read and approved the final manuscript.

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.

ORCID iD

Anna Larsson Gerdin

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