Homecare is facing one of its biggest challenges: the growing imbalance between the increasing demand for care at home and the decreasing supply of home nurses. The demographic and economic evolutions and trends increasingly confront home nurses with caring for patients with frailty, functionalities, and multimorbidities, requiring more intensive and technically complex procedures to be done at home. Policymakers responding to these trends aim to shift the healthcare system towards a multidimensional, chronic disease-oriented system. Homecare has to engage in this process to help shaping and managing a model of homecare that focuses on the individual, chronic, healthcare needs of each patient, client, or informal caregiver; on patient empowerment; and on continuity of care. Furthermore, as the demand for homecare is continuously growing, questions arise concerning the supply of home nurses, which increases more slowly than the overall demand.
Consequently, the role of home nurses as providers of healthcare has been changing and will continue to change. However, are home nurses ready for this changing role and how does home nursing respond to these trends and evolutions in primary care? The retention of healthcare workers (what are important factors to stay in the job/healthcare); task shifting (what about the possibility of function differentiation); and task purification (what is the contribution of each team discipline to patient care) are important cornerstones to answer these questions. The ultimate aim of this dissertation was to support home nursing in this process by exploring the current and future role of home nurses in the perspective of these three cornerstones.
Retention of home nurses
In chapter 2 we used the Belimage Homecare instrument to provide insight in the professional self-image of 758 home nurses. This study highlighted both the positive self-image of home nurses and the existence of a delicate balance between the large degree of autonomy that home nurses have and the need to feel supported in their professional role and responsibility. The practice environment, including time pressure, workload and insufficient support, needs to be addressed in order to keep it from having a negative impact on the professional self-image of home nurses in the long-term.
In chapter 4 the technique of in-depth interviews was used to explore the experiences of twelve home nurses, twelve healthcare assistants and eight home nursing managers with regard to the delegation of nursing activities to healthcare assistants; the supervision of healthcare assistants; and the impact of this integration on the work of home nurses. All the participants reacted positively to the employment of healthcare assistants in the organization: healthcare assistants take care of a less care dependent patient population, allowing the home nurses to spend more time on more complex, technical nursing care. However, the analysis revealed some barriers, such as a knowledge gap and insecurity felt by healthcare assistants leading to unnecessary patient visits by home nurses; unfamiliarity of home nurses with the role of delegating activities and supervising healthcare assistants; and poor face-to-face communication between home nurses and healthcare assistants. These barriers often resulted in a loss of a holistic view on the patient situation.
In chapter 3 the views and experiences of both primary care professionals and hospital healthcare workers were explored with regard to the shift of care from the hospital to the homecare setting. Therefore, in-depth interviews with fifteen home nurses and eight medical specialists, and two focus groups with eight and fifteen general practitioners, respectively, were performed. Three important statements were highlighted. First, it was difficult for the respondents to make a clear distinction between technical and complex interventions. Therefore, more research is needed to provide a clear definition of "technical" and "complex" interventions. Secondly, the earlier discharge of more palliative care patients and more chronically ill patients confronts primary care with more intensive and complex care at home and with a shift from pure technical interventions to more intellectual care. Thirdly, for home nursing to be ready for these changes, some financial and organizational aspects need to be addressed, such as the investment in specialized home nurses; a financing system that covers the daily (24-hour) practice of home nurses; the investment in a more and better integrated and properly financed multi- and interdisciplinary collaboration and communication.
In chapter 5 we explored the international literature to evaluate the instruments used to measure the activity profile of home nurses and to determine which activities home nurses perform in their daily practice. We identified nine studies. They all used different measurement instruments of questionable validity. We found that the activity profile of home nurses was mainly characterized by a combination of pure technical and surveillance activities with psychosocial and administrative activities. However, the level of abstraction in the activities performed by home nurses had a major impact on the interpretation of their activity profile.
Consequently, in the scope of the absence of a gold standard to measure the daily activities of home nurses in primary care, we developed and psychometrically tested the 24-hour recall instrument for home nursing in chapter 6. The validity and the interrater reliability of this instrument were high: the proportions observed agreement were very high; the strength of kappa agreement was substantial to almost perfect; the prevalence index showed great variety; and the bias index was low. The findings in this study supported the validity evidence based on test content and the interrater reliability of the 24-hour recall instrument. This instrument can be used to investigate the current activity profile of both home nurses, and auxiliary nurses or healthcare assistants in home nursing. This would provide important information for managers and policymakers to profile the activities of home nurses and healthcare assistants and to proactively anticipate to the fast evolving needs of home nursing.
In chapter 7 the 24-hour recall instrument for home nursing was used by 2478 home nurses and 277 healthcare assistants. The activity profile of home nurses and healthcare assistants was mainly characterized by self-care facilitation activities. In the combination of data, the activities from the category "self-care facilitation" were mainly performed in combination with other activities related to the categories "Other care", "Administration", and "Psychosocial care" for the home nurses; and "Other care", "Administration", and "Communication" for the healthcare assistants. This study is an important first step in the identification of what it is that home nurses and healthcare assistants do in homecare, using a validated and reliable measurement instrument for home nursing.
The ultimate aim of this dissertation was to help and to support home nurses to cope with the unfolding evolutions and trends by exploring the current and future role of home nurses in the perspective of the retention of home nurses, task shifting and task purification. We can conclude that home nurses have a positive professional self-image. This is an important foundation to cope with the existing imbalance and to retain the nurses in homecare. Furthermore, healthcare assistants were integrated in home nursing to maintain and improve the efficacy of home nursing. The fact that healthcare assistants take care of a group of patients that does not have a specific nursing indication or nursing need, is an important step in the support of this idea. However, further research is necessary to gain evidence for this statement. Finally, the use of a validated and reliable measurement instrument for home nursing (the 24-hour recall instrument for home nursing) highlighted that the activity profile of home nurses is mainly characterized by self-care facilitation activities in combination with more intellectual activities. However, further research is necessary to explore if the integration of healthcare assistants in home nursing shifted more complex (holistic) care situations to the home nurses and more simple hygiene care situations to the healthcare assistants.