S1.8 Towards understanding the complexity of home care nursing

Chair: Ragnhild Hellesø

Background: In most parts of the developed world, the view of what constitutes good health and social services for older persons has changed. The evolution of healthcare delivery in terms of where service can take place calls for new and deeper insights into how long-term care can best be provided in patients’ own homes. Nurses have a pivotal role in caring for patients in their homes as well as assisting them with their daily planning.  However, the literature has shown that much effort has been placed on describing nursing practices in hospital settings, but less focus has been on nursing care provided in municipalities. Integration of services, both between different occupational groups and service levels, such as primary and secondary services, is considered to be of central importance. It calls for efficient inter-disciplinary team-work, open communication, enhanced co-ordination of services and continuity of care especially for patients with complex health issues. A holistic approach based on seamless services is advocated. However, it is not evident what constitutes seamless care or how professional care in private homes should be provided in order to ensure safety and maintain quality of care. Despite these expectations from the policy level, which has called for community-based services, very few studies have addressed and explored the nature of home care nursing practice. In this symposium, we will provide an in-depth insight and theoretical formulations based on our research conducted in three Nordic countries.  These studies provide new ideas that should be considered when designing health care services to meet the complex needs of the older population.  In this symposium, we will use three cases to exemplify the complexity of home care nursing. Each of the studies is focused on a particular practice, and the challenges that are encountered across nations and new possibilities within elderly care will be presented. Furthermore, in the discussion, we will highlight some overall perspectives that are learnt from the three cases. Our emphasis is on the theoretical, methodological and empirical challenges in developing knowledge when studies are conducted outside the traditional health care sector; i.e. in the patients’ home.

S1.8.1 Home care nursing as information practice

Ragnhild Hellesø

University of Oslo

Background: The slogan “Getting the right and accurate information at the right place for the right patient”, which is derived from the well-known slogan “caring for the right patient at the right place” is particularly apt for information management in health care. Several studies have revealed the challenges in accessing timely and accurate information about patients when needed. The introduction of information technology has not met the demand of efficient information flow within general health care so far, and the problem is particularly notable in the home care nursing sector. Few studies have addressed home care nurses’ information need at the point-of-care.  The aim of this study was to explore home care nurses’ informatics practices. Methods: We conducted a multi-method study with 97 observations in patients home and 27 semi-structured interviews with nurses in three Norwegian municipalities. Findings: Home care nurses’ information practice has two dimensions; one is patient-related and the other organizational-related. The patient-related dimension refers to the need of up-to-date information about patients’ conditions on a continuous basis. The other, organizational dimension refers to the dynamic collaboration that oscillates between working with one particular person, limited in time and space, and collaborating with multiple providers, which requires long-term interdisciplinary and inter-organizational collaboration and coordination. Conclusion: Information management in home care is complex and involves many actors and levels of information.

S1.8.2 Home care nursing as relational practice

Kristin Björnsdóttir

University of Iceland

Background: Although home care nursing services are considered  to be of central importance in enabling  older people to remain at home, research in this area is scarce. This study is aimed at enhancing the understanding of the nature of helpful home care nursing practice. Drawing on theories of practice as enacted and complex, nurses work with different agents and knowledge to proceed in their daily work was explored. Methods: The method is ethnographic, using field-work, interviews and text analysis. I worked with five home care nurses who were team leaders, observing them during their visits to the homes of 15 elderly persons and conducted repeated interviewing with the nurses. The elderly persons were interviewed in their homes. The findings were analysed using systematic text condensation. Results: The work of home care nurses was characterized by creating and maintaining a net of services and informal assistance for each patient. As part of the net, home care was enacted through relational, but often invisible care practices, involving different actors—patient, family and health and social care workers—to help the elderly persons live comfortably at home. The work was collective in a sense that it was shared by different actors through a common understanding that had been developed and preserved in conversations in the teams. Conclusion: Home care nursing practice is largely relational, a net of services is created for each patient to provide them with the assistance needed to remain at home. Home care nursing is a collective effort from the patients, their relatives, and health and social care workers. They are all connected in a net and the boundaries of responsibility and expertise between them are fluid. These findings remind us of the importance of understanding the practice and the implications of practice when authority decide what needs to be done.

S1.8.3 Home care nursing as collaborative practice

Mette Geil Kollerup, Tine Curtis, Birgitte S. Laursen

        Aalborg University, Denmark

Background: Medication management in patients’ homes after hospital discharge is a complex and context-specific practice with many actors and processes involved. Discrepancies are found in up to 94% of medication lists at hospital discharge and medication mismanagement causes the majority of reported adverse events in municipal health care. The aim of this study was to explore visiting nurses’ post-hospital medication management and thereby enable development of interventions in order to improve patient safety.  Methods: Visiting nurses’ post-hospital medication management was explored by participant observations at twelve initial visits in patients’ homes after hospital discharge. Data consisted of field notes and were supplemented by information from medication lists and journal notes as well as photos from the homes. Results: The visiting nurses mediated their provided nursing care according to available information of the patient’s conditions and to rules and regulations. The visiting nurses established order in medications in the homes and in medication lists. Conclusion: In order to enhance patient safety in post-hospital medication management the visiting nurses collaborate with hospitals, general practitioners, different home health care professionals, the patient and their relatives. By mediating and establishing order, the visiting nurses balance professional responsibility and ethical values in a fragmented and task oriented health care setting.