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Exploration of the administrative aspects of the delivery of home health care services: a qualitative study

Exploration of the administrative aspects of the delivery of home health care services: a... Background: Because of the variety of services and resources offered in the delivery of home health care, its man- agement is a challenging and difficult task. Objectives: The purpose of this study was to explore the administrative aspects of the delivery of home health care services. Methods: This qualitative study was conducted based on the traditional content analysis approach in 2015 in Iran. The participants were selected using the purposeful sampling method and data were collected through in-depth semi-structured personal interviews and from discussions in a focus group. The collected data were analyzed using the Lundman and Graneheim method. Results: 23 individuals participated in individual interviews, and the collected data were categorized into the two main themes of policymaking and infrastructures, each of which consisted of some subcategories. Conclusion: Health policymakers could utilize the results of this study as baseline information in making decisions about the delivery of home health care services, taking into account the contextual dimensions of home care ser- vices, leading to improvements in home health care services. Keywords: Home health care, Home care agencies, Nursing, Administration, Qualitative study, Iran a reduced need for repeated referrals to the emergency Background departments, the shortening of the waiting time in As life expectancy rises and chronic conditions become treatment centers, vacancy of specialty hospital beds, more common and the population ages, the use of nurs- decreased emergency department crowding, improving ing services at home is an inevitable and undeniable the quality of life and savings in health care expenses [3– phenomenon [1]. Home care includes nursing, medi- 5]. The management of the delivery of home care services cal, rehabilitative, and social services [2]. These services is a challenging and difficult task, because of the variety include a wide range of primary and advanced services of services needed, the variety of resources needed to offered at three levels of prevention by different individu - offer the services, and shortage of human resources [ 6]. als from health care professionals to volunteers, such as The management and provision of home care services friends, family members, and neighbors [2]. This type of in each society depends on the cultural context of the care leads to shorter hospital stays, fewer readmissions, society, the available infrastructures, and the structure fewer and less serious hospital-acquired complications, of the health system of that country [7]. As a developing country in the Middle East, Iran has to deal with vari- *Correspondence: H-hidari@razi.tums.ac.ir ous ethnic and cultural groups, and the phenomenon of Social Determinants of Health Research Center, Lorestan University an aging population, and, as a result, the heavy burden of Medical Science, Khorramabad, Iran of chronic diseases [8]. In this country, various levels of Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 2 of 7 health services are offered to the society by universities of a qualitative study could help in achieving a deep under- medical sciences in each province [9]. standing of this phenomenon. In Iran, nurses will be licensed to establish nursing counseling and nursing services institutes by the Ministry Objectives of Health and Medical Education. In these institutions, This study aimed to explore the administrative aspects of different groups of medical professionals can serve at dif - the delivery of home health care services. ferent levels of primary, secondary and tertiary preven- tion and care alongside each other, based on the needs Methods of the patients and their families. The technical team Design includes general practitioners and specialist doctors, and This qualitative study, which had a content analy - the nursing team, includes nurses at different levels of sis approach, was conducted in 2015 in Iran. It was education (B.Sc., M.Sc., and Ph.D.), operating room and attempted to achieve maximum variability and enroll anesthesiology technicians, medical emergency techni- information-rich participants in order to significantly cians, rehabilitation technicians, and psychologists at facilitate an in-depth study and to advance toward the different levels of education, with valid certificate pro - core objectives. Therefore, nurses, physicians, caregiv - vide specialized services based on their fields in home ers, policymakers, patients and their families that were nursing care centers. Non-technical members of the familiar and had experience with home health care were centers include nurse-aids and practical nurses or nurse selected using the purposeful sampling method. The assistants who have received a valid certificate of basic inclusion criteria were: having adequate experience in the services from non-university centers and have the com- provision of home health care, being communicative and petence to provide basic services to clients [10]. Manag- expressive, and being willing to participate in the study. ing and coordinating the process of providing services to clients via home care centers is the responsibility of qual- Data collection ified nurses. Nurses are not licensed to prescribe medi - Data were collected through in-depth semi-structured cations in the Iranian health system [11]. Additionally, individual interviews and from discussions in a focus terminally ill patients rarely receive their health services group. All the interviews were conducted in a quiet and from home care institutes, and most of them are hospi- private place and were recorded using a digital voice talized during the last days of their lives and pass away recorder. The guiding questions of the interview were in hospitals [5]. Managing the provision of home care as follows: “Can you talk about home health care? What services is difficult and challenging due to the diversity of do you think about home nursing care? How should services offered, the variety of resources required to pro - home health care be directed?” During the interview, vide services, and labor shortage. The diversity of patient exploratory and probing questions were asked from the needs, the qualifications of caregivers, the high workload interviewees to clarify the issues. At the initial stages of caregivers, the diverse demands made on the organiza- of the study and during interviews, the research ques- tion, the long distances that the caregivers have to travel tions were semi-structured, but over time, the ques- to the residences of the patients are among the factors tions became more structured. Sampling and interviews that make the provision of home nursing services chal- continued until saturation was achieved [15]. The dura - lenging [12, 13]. According to some studies, home care tion of each face-to-face interview was between 20 and services in Iran face a number of challenges, including 40  min. In order to obtain richer data and obtain data deficiencies in policymaking, lack of resources, incom - from group discussions, a session of the focus group plete guidelines, the fact that there is inadequate famili- was held. arity with this type of care in the society, and the lack of adequate regulations and directives on how to provide Data analysis home care services [13, 14]. Based on the views of Lundman and Graneheim, data Naturally, proper planning is required for home care, analysis was conducted simultaneously with the inter- and before planning, it is necessary to investigate the tar- views [15], such that immediately after each interview, get phenomenon from different management perspec - the statements were written down by hand and typed tives, so that its various dimensions are well understood, verbatim. Next, the handwritten texts were studied sev- so that the stakeholders can have a deeper understand- eral times and the initial codes were extracted. After ing of the target phenomenon in order to make the right that, related codes were merged based on their similari- decisions. Therefore, given the absence of a study in this ties and differences, categories and themes were formed, regard and the long-term experiences of the authors in and finally the concepts that were hidden in the data were providing home care services, it seemed that conducting extracted. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 3 of 7 Trustworthiness Table 1 The classes and subclasses of the dimensions of home care Based on the views of Lincoln and Guba, in order to ensure the accuracy and reliability of the data, the crite- Main categories Subcategories ria of credibility, confirmability, and trustworthiness were Policymaking Using multi-dimensional management in the used [16]. For this purpose, the researcher had long-term structure of the health system contact with the participants. After the initial analysis, the Nurse as the axis of the home care team codes were discussed with the participants to ensure their Community orientation in health system accuracy, and if the codes were not consistent with the Infrastructure Readiness of the Social context views of the participants, corrections were made, so that Societal understanding of home care the researcher and the participants reached agreements Societal understanding of nurses on the codes. Furthermore, discussions were held among The views of professionals regarding home the members of the research team to reach agreements on care the selected codes and the categories and themes that had The coverage of the services by universal emerged. The participants in the study greatly varied in insurance terms of age, gender, educational attainment levels, work Suitable electronic communications experience, length of their work experience, and the type Adequate knowledge of home care and location of their occupations during their careers. The training of professionals The training of the patients’ families Ethical considerations Inter-professional cooperation This study was examined by the ethics committee of Inter-sectoral cooperation the Tehran University of Medical Sciences and received a written permission with the code of IR.TUMS. REC.1394.175. Written informed consents were obtained “… There are negative views regarding home care, from the participants. and the reason is that the medical system is physi- cian-centrist…. They think their wallets would suf - Results fer….” (Participant number 5). 23 individuals were interviewed in person, including 11 men and 12 women. One of the participants was inter- viewed three times and another participant was inter- Nurses as the axis of home nursing care viewed twice. Overall, 25 individual interviews were The analysis of the data indicated that one of the most performed. The participants in the focus group were 7 important members of the home care team is the nurse. individuals including 5 men and 2 women. In this regard, a specialist physician stated that After data analysis, data were placed in the two main “… the nurse knows more about the patient’s prob- themes of policymaking and infrastructures, each of lems than other members of the health care team, which consisted of some subcategories (Table 1). because he/she spends more time with the patient, and it is the nurse that can act as the guide for the Policymaking health care team….” (Participant 5). The analysis of the data showed that methods of policy - making could affect the offering of health services to the clients. This theme itself consists of the three categories Community orientation in the health system of using multidimensional management in the structure Data analysis showed that, to enrich home nursing care, of the health system, taking account of the role of nurses it is necessary that the health system does not limit health as the axis of the home care team, the necessity of com- services to the hospital. munity orientation in the health system. In this regard, one of the instructors emphasized the importance of the provision of health services at the level Using multidimensional management in the structure of the of the community, and stated that health system “…If the intention of the health system is to break The analysis of the data indicated that the participants this cocoon, sitting at health and treatment centers mentioned that physician-centrism is a barrier to the and expecting to be able to do something is useless, development of home nursing care. In this regard, a nurse …” (Participant 4). practitioner active in the policymaking field stated that Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 4 of 7 Infrastructures lies could play an important role in the success of home In order to reach the goals, some factors play a funda- care programs. mental and basic role, and the activities of the other In this regard, a professional active in the field of home parts of the system depend on the correct functioning care states of these factors. This theme consists of six categories “… doctors prefer patients to remain in the hospital including, readiness in the social context, the coverage because of the financial benefits ….” (Participant 8). of the services by universal insurance, suitable electronic communication infrastructures, adequate knowledge, inter-professional and inter-sectoral cooperation for the Coverage of home care services by universal insurance provision of home nursing care. Data analysis indicated that home care involves high costs and the coverage of home care by universal insur- The readiness of the social context ance is beneficial. In this regard, one of the participants Data analysis suggested that social class, economic and talks about the benefits of home care services being cov - cultural status, beliefs, norms, and the understanding of ered by insurance companies: members of the society regarding home nursing care ser- “… If insurance companies cover a percentage of vices can directly influence the extent to which families the costs, people won’t turn to illegal centers … and take advantage of home care, and the way these services [these services] become regulated…” (Participant 5). are offered, and can facilitate or hinder the progress of home nursing care programs. “…the coverage of home care services by universal insurance has been emphasized by the WHO…” (The Social perception of  home care Data analysis showed Focus Group). that society’s understanding and interpretation of home nursing care could affect the modes of utilization of home care. In this regard, a physician in charge of an institute Suitable electronic communications offering home nursing care stated that Data analysis suggested that if good communication sys- tems are available, home care providers (nurses, caregiv- “… ultimately you may culturally reach conclude ers, etc.) can easily keep in touch with the other members that if you receive such a service at home, it is less of the care team, and provide the services needed by the costly for you, less troublesome, and more conveni- patient quickly. ent, and your dignity and respect is preserved…” (Participant 9). Adequate knowledge of home care Data analysis showed that a factor that can affect the Society’s perception of  the nurses The participants in provision of home nursing care is academic training in this study believed that, for the provision of home care universities and the training of families when they need to flourish, it is necessary that members of society have a home nursing care. positive view towards the nurse, and consider him/her as an educated, qualified, reliable person who is effective in The training of  professionals Data analysis emphasized the patient’s recovery process. In this regard, one of the community-oriented training of the nurses, which can be participants stated that included in the educational curriculums. In this relation, a specialist physician says that home care nurses should “…. People think that nurses can only perform injec- be better versed and more skillful in the services they pro- tions and infusions… Unless we represent the nurse vide than hospital nurses and states as a professional… a medical professional, who is as skillful as a G.P… home care will not be successful …” “… All training programs for nurses should be (Participant 2). changed.… Since the equipment and the setting are no longer clinical, and the nurse must provide a totally different type of service to society …” (Partici - The viewpoints of  practitioners towards  home care The pant 2). participants in this study believed that the interpretation of specialists regarding the benefits of home care, the extent to which they trust the process of the provision of Training the patient’s family The participants believed home nursing care services, and their cooperation in rec- that, before starting the home nursing care services, it ommending home nursing care to patients and their fami- is necessary that the patients and their families receive Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 5 of 7 general training from the center providing home care ser- “… They can classify it. … An elderly patient who has vices, so that family members will be able to participate Alzheimer’s must pay more than a patient who is in the care of the patient and as a result, the costs can be alert and not an invalid. … Based on this, they can reduced. give us a range, for example from three hundred to four hundred and fifty dollars…” (Participant 6). Inter‑occupational cooperation A nurse offering home care services said, Data analysis showed that home care involves team- work, and it is necessary that different health profession - “… Minimum and maximum rates should be set…” als cooperate to provide services to the patient. A nurse (Participant 7). stated A nurse active in policymaking said, “… No one can be an expert in all fields.… For exam - “…Some individuals work on a part-time basis and ple, a patient might develop bedsores.… I may not are not full-time employees. … They are in fact have adequate information and knowledge about contractors …. A large part of the tariffs belongs to bed sores, then I should consult my colleagues.…” them. …” (Participant 16). (Participant 7). The process of the provision of home nursing care services Inter‑sectoral cooperation Data analysis showed that, in the provision of home nurs- Data analysis showed that it is essential that various ing care, it is essential that the admission process, the organizations should contribute to health care efforts. provision of care services, and the evaluation of the pro- One of the participants said: vided services should be done based on specific and pre - “… Municipalities should cover home care services. determined plans and programs. Health services belong to municipalities…” (Partici- “… After taking the history of the patient and con- pant 2). sidering all the obtained information, a specific pro - tocol is prepared for the patient….” (Participant 14). The management of the provision of home nursing care Data analysis suggested that setting and making use of Discussion proper criteria for the recruitment of personnel, the In this study, data analysis revealed that policymaking management of financial resources, and the care process and infrastructures could be two vital factors in the man- are factors that can contribute to the success of home agement of the delivery of home health care services. nursing care. In the policymaking dimension, community orienta- tion of the health system is among the factors that can Factors related to  human resources Data analysis indi- affect home care [17]. Therefore, it is necessary that poli - cated that it is necessary that home care institutes take cymakers propel the health system towards community- great care in the recruitment and hiring of the needed centered services. Another factor in the policymaking work force, so that they can hire qualified and experienced dimension that can help with the advancement and pro- individuals that can provide appropriate and satisfactory motion of home care programs is the use of multi-dimen- services to the patients. In this regard, the manager of a sional management in the administration of the health home care center says system, such that the health system takes advantage of “… Our nurses should be able to perform catheteri- the capacities of competent experts at various manage- zation, gavage, nasogastric intubation, ECG, injec- ment levels. In this regard, the World Health Organi- tions, and venipuncture.…” (Participant 9). zation has mentioned that physician-centrism in the management of health systems is a grave challenge [18]. According to the WHO, if the health systems want to Financial resources Data analysis showed that financial be able to adequately respond to the health needs of the turnover is a vital component of every organization, such society, they must be aware of the role that nurses and that proper and regular auditing can help the progress midwives play in these systems [18]. of the organization, and leads to the satisfaction of the A key member of the home care team is the nurse [19]. employees and customers. In this regard, a nurse active in Therefore, it is necessary that the needed arrangements policymaking said about the importance of tariff regula - be made for the recruitment and employment of the tions: needed work force. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 6 of 7 Authors’ contributions One of the factors that can play an important role in Study design: HH, HS, ANN, Data collection: HH, Data analysis: HH, HS, ANN, the provision of home care services is the coverage of Study supervision: ANN, AH, Manuscript writing: HH, HS, Critical revisions for home care services by universal health insurance. WHO important intellectual content: ANN, AH. Translation into the English language: MA. All authors read and approved the final manuscript. has emphasized the by universal insurance coverage and the reduction of the payments that people make to Author details receive health services, which is a movement that is rep- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. School of Medicine, resented by the expression Universal Health Coverage Lorestan University of Medical Sciences, Khorramabad, Iran. Social Deter- (UHC), according to WHO [20]. In this regard, lack of minants of Health Research Center, Lorestan University of Medical Science, insurance coverage and traditional management causes Khorramabad, Iran. Department of Community Health Nursing, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorrama- people to receive these services from unlicensed insti- bad, Iran. Department of Home-based Palliative Care, ALA cancer prevention tutes and caregivers [21]. and control of charity center (MACSA), Tehran, Iran. Educating and training health, nursing, and medicine Acknowledgements graduates in providing services outside treatment centers The authors would like to profusely thank all individuals who supported and is a vital dimension [22]. Therefore, educational institutes helped them in conducting this study. should include courses on home care for various groups Competing interests of health graduates, especially nurses, to prepare them The authors declare that they have no competing interests. for working in communities. One infrastructure that is necessary for the provision Availability of data and materials The audio and text files of the individual interviews and focus group discus- of home care services is inter-sectoral and inter-occupa- sions are available on request. tional cooperation. The provision of home care services involves teamwork [23], on the other hand, coopera- Ethics approval and consent to participate This study was considered by the ethics committee of the Tehran University of tion and coordination between hospitals and home care Medical Sciences and received a written permission with the code of IR.TUMS. teams are undeniably crucial, and can help reduce re- REC.1394.175. Written informed consents were obtained from the participants. admissions and improve service quality. Funding Another important infrastructure is the existence of This manuscript was extracted from a PhD dissertation that was supported executive and administrative protocols for the provision and funded by the Tehran University of Medical Sciences, Iran, with the Grant of home care services, which can help with the organi- Number 9121199005. zation of home care services, the recruitment of human resources, the estimation of the fees and the costs, and Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- the design of the care process [24]. These protocols can lished maps and institutional affiliations. help with the assessment of the needs of the clients and their economic and financial status [25]. Therefore, Received: 2 December 2017 Accepted: 16 January 2018 given its own economic, social, and cultural condition and its health system, each country should compile standard instructions for the provision of home care services. References 1. World Health Statistics. Noncommunicable diseases: World Health Limitations Organization; 2014, https://www.who.int/…/ncds-country-profiles-eng. pdf. Accessed 10 Feb 2015. This was a qualitative study conducted on a limited pop - 2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care ulation and generalizations from this study may not be administration in the United States and Canada. N Engl J Med. easily feasible. 2003;349(8):768–75. 3. Xiao R, Miller JA, Zafirau WJ, Gorodeski EZ, Young JB. Impact of home health care on healthcare resource utilization following hospital Conclusion discharge: a Cohort Study. Am J Med. 2017. https://doi.org/10.1016/j. It is necessary to transform the delivery of home health amjmed.2017.11.010. 4. 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The for the management of the delivery of home health care future of home health care: a strategic framework for optimizing value. services. Home Health Care Manag Pract. 2016;28(4):262–78. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 7 of 7 8. Roudi F, Azadi P, Mesgaran M. Iran’s population dynamics and demo- 16. Kornbluh M. Combatting challenges to establishing trustworthiness in graphic window of opportunity. 2017. https://iranian-studies.stanford. qualitative research. Qual Res Psychol. 2015;12(4):397–414. edu/sites/default/files/publications/irans_population_dynamics_and_ 17. World Health Organization; 2014, http://www.oecd-ilibrary.OOHS- demographic_window_of_opportunity_1.pdf. Accessed 15 Dec 2017. OiU.org/social-issues-migration-health/data/oecd-health-statistics_ 9. Asaei S. Iran’s excellent primary health care system. United Nation Inter- health-data-en.30/07/14.ao. Accessed on 10 Feb 2015. national Children Emergency Fund (UNICEF): https://www.unicef.org/ 18. 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Exploration of the administrative aspects of the delivery of home health care services: a qualitative study

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Abstract

Background: Because of the variety of services and resources offered in the delivery of home health care, its man- agement is a challenging and difficult task. Objectives: The purpose of this study was to explore the administrative aspects of the delivery of home health care services. Methods: This qualitative study was conducted based on the traditional content analysis approach in 2015 in Iran. The participants were selected using the purposeful sampling method and data were collected through in-depth semi-structured personal interviews and from discussions in a focus group. The collected data were analyzed using the Lundman and Graneheim method. Results: 23 individuals participated in individual interviews, and the collected data were categorized into the two main themes of policymaking and infrastructures, each of which consisted of some subcategories. Conclusion: Health policymakers could utilize the results of this study as baseline information in making decisions about the delivery of home health care services, taking into account the contextual dimensions of home care ser- vices, leading to improvements in home health care services. Keywords: Home health care, Home care agencies, Nursing, Administration, Qualitative study, Iran a reduced need for repeated referrals to the emergency Background departments, the shortening of the waiting time in As life expectancy rises and chronic conditions become treatment centers, vacancy of specialty hospital beds, more common and the population ages, the use of nurs- decreased emergency department crowding, improving ing services at home is an inevitable and undeniable the quality of life and savings in health care expenses [3– phenomenon [1]. Home care includes nursing, medi- 5]. The management of the delivery of home care services cal, rehabilitative, and social services [2]. These services is a challenging and difficult task, because of the variety include a wide range of primary and advanced services of services needed, the variety of resources needed to offered at three levels of prevention by different individu - offer the services, and shortage of human resources [ 6]. als from health care professionals to volunteers, such as The management and provision of home care services friends, family members, and neighbors [2]. This type of in each society depends on the cultural context of the care leads to shorter hospital stays, fewer readmissions, society, the available infrastructures, and the structure fewer and less serious hospital-acquired complications, of the health system of that country [7]. As a developing country in the Middle East, Iran has to deal with vari- *Correspondence: H-hidari@razi.tums.ac.ir ous ethnic and cultural groups, and the phenomenon of Social Determinants of Health Research Center, Lorestan University an aging population, and, as a result, the heavy burden of Medical Science, Khorramabad, Iran of chronic diseases [8]. In this country, various levels of Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 2 of 7 health services are offered to the society by universities of a qualitative study could help in achieving a deep under- medical sciences in each province [9]. standing of this phenomenon. In Iran, nurses will be licensed to establish nursing counseling and nursing services institutes by the Ministry Objectives of Health and Medical Education. In these institutions, This study aimed to explore the administrative aspects of different groups of medical professionals can serve at dif - the delivery of home health care services. ferent levels of primary, secondary and tertiary preven- tion and care alongside each other, based on the needs Methods of the patients and their families. The technical team Design includes general practitioners and specialist doctors, and This qualitative study, which had a content analy - the nursing team, includes nurses at different levels of sis approach, was conducted in 2015 in Iran. It was education (B.Sc., M.Sc., and Ph.D.), operating room and attempted to achieve maximum variability and enroll anesthesiology technicians, medical emergency techni- information-rich participants in order to significantly cians, rehabilitation technicians, and psychologists at facilitate an in-depth study and to advance toward the different levels of education, with valid certificate pro - core objectives. Therefore, nurses, physicians, caregiv - vide specialized services based on their fields in home ers, policymakers, patients and their families that were nursing care centers. Non-technical members of the familiar and had experience with home health care were centers include nurse-aids and practical nurses or nurse selected using the purposeful sampling method. The assistants who have received a valid certificate of basic inclusion criteria were: having adequate experience in the services from non-university centers and have the com- provision of home health care, being communicative and petence to provide basic services to clients [10]. Manag- expressive, and being willing to participate in the study. ing and coordinating the process of providing services to clients via home care centers is the responsibility of qual- Data collection ified nurses. Nurses are not licensed to prescribe medi - Data were collected through in-depth semi-structured cations in the Iranian health system [11]. Additionally, individual interviews and from discussions in a focus terminally ill patients rarely receive their health services group. All the interviews were conducted in a quiet and from home care institutes, and most of them are hospi- private place and were recorded using a digital voice talized during the last days of their lives and pass away recorder. The guiding questions of the interview were in hospitals [5]. Managing the provision of home care as follows: “Can you talk about home health care? What services is difficult and challenging due to the diversity of do you think about home nursing care? How should services offered, the variety of resources required to pro - home health care be directed?” During the interview, vide services, and labor shortage. The diversity of patient exploratory and probing questions were asked from the needs, the qualifications of caregivers, the high workload interviewees to clarify the issues. At the initial stages of caregivers, the diverse demands made on the organiza- of the study and during interviews, the research ques- tion, the long distances that the caregivers have to travel tions were semi-structured, but over time, the ques- to the residences of the patients are among the factors tions became more structured. Sampling and interviews that make the provision of home nursing services chal- continued until saturation was achieved [15]. The dura - lenging [12, 13]. According to some studies, home care tion of each face-to-face interview was between 20 and services in Iran face a number of challenges, including 40  min. In order to obtain richer data and obtain data deficiencies in policymaking, lack of resources, incom - from group discussions, a session of the focus group plete guidelines, the fact that there is inadequate famili- was held. arity with this type of care in the society, and the lack of adequate regulations and directives on how to provide Data analysis home care services [13, 14]. Based on the views of Lundman and Graneheim, data Naturally, proper planning is required for home care, analysis was conducted simultaneously with the inter- and before planning, it is necessary to investigate the tar- views [15], such that immediately after each interview, get phenomenon from different management perspec - the statements were written down by hand and typed tives, so that its various dimensions are well understood, verbatim. Next, the handwritten texts were studied sev- so that the stakeholders can have a deeper understand- eral times and the initial codes were extracted. After ing of the target phenomenon in order to make the right that, related codes were merged based on their similari- decisions. Therefore, given the absence of a study in this ties and differences, categories and themes were formed, regard and the long-term experiences of the authors in and finally the concepts that were hidden in the data were providing home care services, it seemed that conducting extracted. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 3 of 7 Trustworthiness Table 1 The classes and subclasses of the dimensions of home care Based on the views of Lincoln and Guba, in order to ensure the accuracy and reliability of the data, the crite- Main categories Subcategories ria of credibility, confirmability, and trustworthiness were Policymaking Using multi-dimensional management in the used [16]. For this purpose, the researcher had long-term structure of the health system contact with the participants. After the initial analysis, the Nurse as the axis of the home care team codes were discussed with the participants to ensure their Community orientation in health system accuracy, and if the codes were not consistent with the Infrastructure Readiness of the Social context views of the participants, corrections were made, so that Societal understanding of home care the researcher and the participants reached agreements Societal understanding of nurses on the codes. Furthermore, discussions were held among The views of professionals regarding home the members of the research team to reach agreements on care the selected codes and the categories and themes that had The coverage of the services by universal emerged. The participants in the study greatly varied in insurance terms of age, gender, educational attainment levels, work Suitable electronic communications experience, length of their work experience, and the type Adequate knowledge of home care and location of their occupations during their careers. The training of professionals The training of the patients’ families Ethical considerations Inter-professional cooperation This study was examined by the ethics committee of Inter-sectoral cooperation the Tehran University of Medical Sciences and received a written permission with the code of IR.TUMS. REC.1394.175. Written informed consents were obtained “… There are negative views regarding home care, from the participants. and the reason is that the medical system is physi- cian-centrist…. They think their wallets would suf - Results fer….” (Participant number 5). 23 individuals were interviewed in person, including 11 men and 12 women. One of the participants was inter- viewed three times and another participant was inter- Nurses as the axis of home nursing care viewed twice. Overall, 25 individual interviews were The analysis of the data indicated that one of the most performed. The participants in the focus group were 7 important members of the home care team is the nurse. individuals including 5 men and 2 women. In this regard, a specialist physician stated that After data analysis, data were placed in the two main “… the nurse knows more about the patient’s prob- themes of policymaking and infrastructures, each of lems than other members of the health care team, which consisted of some subcategories (Table 1). because he/she spends more time with the patient, and it is the nurse that can act as the guide for the Policymaking health care team….” (Participant 5). The analysis of the data showed that methods of policy - making could affect the offering of health services to the clients. This theme itself consists of the three categories Community orientation in the health system of using multidimensional management in the structure Data analysis showed that, to enrich home nursing care, of the health system, taking account of the role of nurses it is necessary that the health system does not limit health as the axis of the home care team, the necessity of com- services to the hospital. munity orientation in the health system. In this regard, one of the instructors emphasized the importance of the provision of health services at the level Using multidimensional management in the structure of the of the community, and stated that health system “…If the intention of the health system is to break The analysis of the data indicated that the participants this cocoon, sitting at health and treatment centers mentioned that physician-centrism is a barrier to the and expecting to be able to do something is useless, development of home nursing care. In this regard, a nurse …” (Participant 4). practitioner active in the policymaking field stated that Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 4 of 7 Infrastructures lies could play an important role in the success of home In order to reach the goals, some factors play a funda- care programs. mental and basic role, and the activities of the other In this regard, a professional active in the field of home parts of the system depend on the correct functioning care states of these factors. This theme consists of six categories “… doctors prefer patients to remain in the hospital including, readiness in the social context, the coverage because of the financial benefits ….” (Participant 8). of the services by universal insurance, suitable electronic communication infrastructures, adequate knowledge, inter-professional and inter-sectoral cooperation for the Coverage of home care services by universal insurance provision of home nursing care. Data analysis indicated that home care involves high costs and the coverage of home care by universal insur- The readiness of the social context ance is beneficial. In this regard, one of the participants Data analysis suggested that social class, economic and talks about the benefits of home care services being cov - cultural status, beliefs, norms, and the understanding of ered by insurance companies: members of the society regarding home nursing care ser- “… If insurance companies cover a percentage of vices can directly influence the extent to which families the costs, people won’t turn to illegal centers … and take advantage of home care, and the way these services [these services] become regulated…” (Participant 5). are offered, and can facilitate or hinder the progress of home nursing care programs. “…the coverage of home care services by universal insurance has been emphasized by the WHO…” (The Social perception of  home care Data analysis showed Focus Group). that society’s understanding and interpretation of home nursing care could affect the modes of utilization of home care. In this regard, a physician in charge of an institute Suitable electronic communications offering home nursing care stated that Data analysis suggested that if good communication sys- tems are available, home care providers (nurses, caregiv- “… ultimately you may culturally reach conclude ers, etc.) can easily keep in touch with the other members that if you receive such a service at home, it is less of the care team, and provide the services needed by the costly for you, less troublesome, and more conveni- patient quickly. ent, and your dignity and respect is preserved…” (Participant 9). Adequate knowledge of home care Data analysis showed that a factor that can affect the Society’s perception of  the nurses The participants in provision of home nursing care is academic training in this study believed that, for the provision of home care universities and the training of families when they need to flourish, it is necessary that members of society have a home nursing care. positive view towards the nurse, and consider him/her as an educated, qualified, reliable person who is effective in The training of  professionals Data analysis emphasized the patient’s recovery process. In this regard, one of the community-oriented training of the nurses, which can be participants stated that included in the educational curriculums. In this relation, a specialist physician says that home care nurses should “…. People think that nurses can only perform injec- be better versed and more skillful in the services they pro- tions and infusions… Unless we represent the nurse vide than hospital nurses and states as a professional… a medical professional, who is as skillful as a G.P… home care will not be successful …” “… All training programs for nurses should be (Participant 2). changed.… Since the equipment and the setting are no longer clinical, and the nurse must provide a totally different type of service to society …” (Partici - The viewpoints of  practitioners towards  home care The pant 2). participants in this study believed that the interpretation of specialists regarding the benefits of home care, the extent to which they trust the process of the provision of Training the patient’s family The participants believed home nursing care services, and their cooperation in rec- that, before starting the home nursing care services, it ommending home nursing care to patients and their fami- is necessary that the patients and their families receive Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 5 of 7 general training from the center providing home care ser- “… They can classify it. … An elderly patient who has vices, so that family members will be able to participate Alzheimer’s must pay more than a patient who is in the care of the patient and as a result, the costs can be alert and not an invalid. … Based on this, they can reduced. give us a range, for example from three hundred to four hundred and fifty dollars…” (Participant 6). Inter‑occupational cooperation A nurse offering home care services said, Data analysis showed that home care involves team- work, and it is necessary that different health profession - “… Minimum and maximum rates should be set…” als cooperate to provide services to the patient. A nurse (Participant 7). stated A nurse active in policymaking said, “… No one can be an expert in all fields.… For exam - “…Some individuals work on a part-time basis and ple, a patient might develop bedsores.… I may not are not full-time employees. … They are in fact have adequate information and knowledge about contractors …. A large part of the tariffs belongs to bed sores, then I should consult my colleagues.…” them. …” (Participant 16). (Participant 7). The process of the provision of home nursing care services Inter‑sectoral cooperation Data analysis showed that, in the provision of home nurs- Data analysis showed that it is essential that various ing care, it is essential that the admission process, the organizations should contribute to health care efforts. provision of care services, and the evaluation of the pro- One of the participants said: vided services should be done based on specific and pre - “… Municipalities should cover home care services. determined plans and programs. Health services belong to municipalities…” (Partici- “… After taking the history of the patient and con- pant 2). sidering all the obtained information, a specific pro - tocol is prepared for the patient….” (Participant 14). The management of the provision of home nursing care Data analysis suggested that setting and making use of Discussion proper criteria for the recruitment of personnel, the In this study, data analysis revealed that policymaking management of financial resources, and the care process and infrastructures could be two vital factors in the man- are factors that can contribute to the success of home agement of the delivery of home health care services. nursing care. In the policymaking dimension, community orienta- tion of the health system is among the factors that can Factors related to  human resources Data analysis indi- affect home care [17]. Therefore, it is necessary that poli - cated that it is necessary that home care institutes take cymakers propel the health system towards community- great care in the recruitment and hiring of the needed centered services. Another factor in the policymaking work force, so that they can hire qualified and experienced dimension that can help with the advancement and pro- individuals that can provide appropriate and satisfactory motion of home care programs is the use of multi-dimen- services to the patients. In this regard, the manager of a sional management in the administration of the health home care center says system, such that the health system takes advantage of “… Our nurses should be able to perform catheteri- the capacities of competent experts at various manage- zation, gavage, nasogastric intubation, ECG, injec- ment levels. In this regard, the World Health Organi- tions, and venipuncture.…” (Participant 9). zation has mentioned that physician-centrism in the management of health systems is a grave challenge [18]. According to the WHO, if the health systems want to Financial resources Data analysis showed that financial be able to adequately respond to the health needs of the turnover is a vital component of every organization, such society, they must be aware of the role that nurses and that proper and regular auditing can help the progress midwives play in these systems [18]. of the organization, and leads to the satisfaction of the A key member of the home care team is the nurse [19]. employees and customers. In this regard, a nurse active in Therefore, it is necessary that the needed arrangements policymaking said about the importance of tariff regula - be made for the recruitment and employment of the tions: needed work force. Shahsavari et al. Asia Pac Fam Med (2018) 17:1 Page 6 of 7 Authors’ contributions One of the factors that can play an important role in Study design: HH, HS, ANN, Data collection: HH, Data analysis: HH, HS, ANN, the provision of home care services is the coverage of Study supervision: ANN, AH, Manuscript writing: HH, HS, Critical revisions for home care services by universal health insurance. WHO important intellectual content: ANN, AH. Translation into the English language: MA. All authors read and approved the final manuscript. has emphasized the by universal insurance coverage and the reduction of the payments that people make to Author details receive health services, which is a movement that is rep- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. School of Medicine, resented by the expression Universal Health Coverage Lorestan University of Medical Sciences, Khorramabad, Iran. Social Deter- (UHC), according to WHO [20]. In this regard, lack of minants of Health Research Center, Lorestan University of Medical Science, insurance coverage and traditional management causes Khorramabad, Iran. Department of Community Health Nursing, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorrama- people to receive these services from unlicensed insti- bad, Iran. Department of Home-based Palliative Care, ALA cancer prevention tutes and caregivers [21]. and control of charity center (MACSA), Tehran, Iran. Educating and training health, nursing, and medicine Acknowledgements graduates in providing services outside treatment centers The authors would like to profusely thank all individuals who supported and is a vital dimension [22]. Therefore, educational institutes helped them in conducting this study. should include courses on home care for various groups Competing interests of health graduates, especially nurses, to prepare them The authors declare that they have no competing interests. for working in communities. One infrastructure that is necessary for the provision Availability of data and materials The audio and text files of the individual interviews and focus group discus- of home care services is inter-sectoral and inter-occupa- sions are available on request. tional cooperation. The provision of home care services involves teamwork [23], on the other hand, coopera- Ethics approval and consent to participate This study was considered by the ethics committee of the Tehran University of tion and coordination between hospitals and home care Medical Sciences and received a written permission with the code of IR.TUMS. teams are undeniably crucial, and can help reduce re- REC.1394.175. Written informed consents were obtained from the participants. admissions and improve service quality. Funding Another important infrastructure is the existence of This manuscript was extracted from a PhD dissertation that was supported executive and administrative protocols for the provision and funded by the Tehran University of Medical Sciences, Iran, with the Grant of home care services, which can help with the organi- Number 9121199005. zation of home care services, the recruitment of human resources, the estimation of the fees and the costs, and Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- the design of the care process [24]. These protocols can lished maps and institutional affiliations. help with the assessment of the needs of the clients and their economic and financial status [25]. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Dec 1, 2018

References