Original research•

Contributing factors involved in the safety of elderly people with chronic illness in home healthcare: a qualitative study

Abstract

Introduction Patients receiving home care are often elderly people with chronic illnesses that increasingly experience patient safety barriers due to special care needs.

Objective The present study was conducted to determine the factors involved in the safety of elderly patients with chronic illnesses receiving home care.

Methods A qualitative study with a conventional content analysis method was conducted in home care agencies of Tehran, Iran from August 2020 to July 2022. For data generation, semistructured interviews were conducted with 11 nurses, 2 nurse assistants, 1 home care inspector (an expert working at the deputy of treatment) and 3 family caregivers. Moreover, four observational sessions were also held. Data analysis was done using the five-step Graneheim and Lundman method.

Results According to the results, the facilitators of the safety of the elderly patients with chronic illnesses included the family’s participation, nurse’s competence, efficiency of the home care agency management and patient’s participation in patient safety. The barriers to patient safety included problems created by the family, nurse’s incompetence, inefficiency of the home care agency, patient’s prevention of patient safety, home care setting limitations and health system limitations.

Conclusion The majority of the factors involved in the safety of elderly patients with chronic diseases receiving home care had dual roles and could serve as a double-edged sword to guarantee or hinder patient safety. Identification of the facilitators and barriers can assist nurses and the healthcare system in planning and implementing patient safety improvement programmes for elderly patients with chronic illnesses.

What is already known on this topic?

  • The available studies have paid less attention to a comprehensive evaluation of factors involved in patient safety in home health care. Understanding the people’s experiences of factors involved in patient safety in the context of home health care can provide valuable data to identify the risks and overcomeing them in nursing care.

What this study adds?

  • The present study was conducted to extract the patient safety facilitators and barriers in home health care. Modification and reduction of the barriers can be achieved through assessing these factors and preventing them in the home environment.

How this study might affect research, practice or policy?

  • Through identifying these factors, the home care agencies managers and policymakers can determine patient safety barriers, address them properly, and take corrective steps to improve their performance.

Introduction

Today, people have a higher chance of living beyond 60 years of age across the world due to increased life expectancy and reduced mortality. The old age is a threat to a person’s health and independence. Elderly people experience many chronic problems, which imposes heavy financial burdens on the families and healthcare systems.1 For this reason, the policies have shifted towards home care for the elderly people with chronic illnesses in most countries.2 The rate of receiving home care services in European countries increased from 17% in 1980 to 22% in 2004.2 On the other hand, this rate is estimated to increase to 32% by 2030.3 Home care services has been a great help to elderly patients with chronic illnesses receiving long-term care through cost reduction.3 Today, due to an increase in the elderly people and chronic conditions, the utilisation rate of these services has increased markedly4 so that one in every five families requiring assistance due to long-term problems receive home care in European countries.5 Iran is not an exception, and the number of home care agencies has grown noticeably in recent years.4 These centres offer home healthcare after confirmation of the treating physician and agreement of the family5 under the supervision of medical universities.2

Due to economic reasons, there is an increasing interest in home healthcare among elderly people and patients with chronic conditions.6 The complexity of the situation and lengthy nature of care are associated with many safety risks for these patients.7 On the other hand, home healthcare may lead to different safety challenges since the home environment is organised for living, not providing healthcare.7 No accurate statistics are available on the error rate in home care.6 It has been reported that the rate of early readmission after initiation of home healthcare is high, and four out of seven patients receiving home care are readmitted.8 Furthermore, the elderly people and chronic patients are at risk of falls, medication error, infection, nutritional problems, environmental hazards and financial and emotional problems.6 Patient safety challenges at home are influenced by a broad spectrum of factors,9 which vary across cultures and from one home to another.10 Some studies found that members involved in home healthcare such as the patients, family caregivers and home healthcare nurses have a significant role in patient safety.11 Providing continuous care to the patients usually exposes family caregivers to serious problems including physical, mental and social problems,12 fatigue resulting from prolonged care13 and financial problems.13 The family caregivers’ exposure to these problems leads to multiple patient safety challenges. Some studies found that the family caregivers’ interaction with nurses and their participation in the care process could affect the patient safety.14 The nurses, as the principal home caregiver, should be able to use their abilities to provide safe and high-quality home healthcare.15 However, their exposure to numerous problems in the home environment, which is not designed for care, causes several patient safety problems.16 It seems that the patients can be involved and participate in their own safety,15 especially elderly patients with chronic illnesses that require more complex care.17 In addition to human factors, entering a new environment that is not designed for care may be associated with numerous challenges and risks for the patients.18 Therefore, it can be stated that the patient safety process depends on several factors.19 The majority of the studies have addressed the factors threatening patient safety in the hospital and very few studies have evaluated these factors in home healthcare.6 Many studies have emphasised the need for further research in this regard.6

The available studies have paid less attention to a comprehensive evaluation of factors involved in patient safety in home healthcare, especially human and environmental factors. On the other hand, the factors involved in patient safety are affected by cultural and social factors in the Iranian society due to the close relationship of the family members and the important role of the family in this culture.20 Home care nurses have a close relationship with the family members and patients; therefore, it seems that factors involved in safety may be affected by the social structure and family traditions.17 Understanding the people’s experiences of factors involved in patient safety in the context of home healthcare can provide valuable data to identify the risks and overcoming them in nursing care. Based on this, the research question ‘According to the experiences of the members involved in home care, what factors are involved in the safety of elderly people with chronic diseases?’ was formed in the mind of researchers. Therefore, the present study was conducted to determine the factors involved in the safety of elderly people with chronic illnesses in the context of home healthcare using a qualitative approach with a conventional content analysis method. In this method, to explain the phenomenon without imposing predetermined categories or previous theoretical views, information is obtained directly from the study participants.

Methods

Study design

The present study was conducted using a qualitative approach with a conventional content analysis method (secondary analysis of the data of a large grounded theory study) according to the method proposed by Graneheim and Lundman21 from August 2020 to July 2022 to improve the existing knowledge about the safety of elderly patients with chronic conditions in home healthcare since this concept was not addressed previously.6 In this approach, categories are extracted from the data.21 The study was conducted in three home care agencies affiliated with Tehran University of Medical Sciences,Tehran, Iran. The Consolidated Criteria for Qualitative Research (COREQ) checklist was used in this study (online supplemental file 1).22

Sampling

Fifteen interviews were conducted with nine home care nurses, two home care nurse assistants, one home care inspector (an expert working at the deputy of treatment) and three family caregivers (table 1). Moreover, four observational sessions were also held at the homes of the patients receiving home care during which four nurses, four elderly patients with chronic diseases and four family caregivers were observed (table 2). The inclusion criteria in this study included: members involved in home care for elderly patients with chronic diseases, willingness to participate in the study and ability to communicate. Also, the exclusion criteria in this study included: unwillingness to participate in this study at any stage of the research and non-elderly patients with acute conditions.

Table 1
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Demographic characteristics of participants (interviews)
Table 2
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Demographic characteristics of participants (observations)

The participants were selected using purposive sampling with maximum variation from nurses with at least 1 year of experience as a home nurse care. In addition to selecting participants with maximum variation, the research also used theoretical sampling whenever needed. It was tried to include participants that were experienced in home healthcare and were interested in joining the study. To achieve maximum variation, subjects with differences in terms of age, sex, marital status, education level and home care experience were interviewed. After applying the inclusion criteria and identifying the research objective, the proper time and place for the interviews were determined.

Data collection

In-depth, semistructured (face-to-face) interviews and observation were used to evaluate patient safety in real settings.23 For this purpose, fifteen in-depth, semistructured interviews (60–90 min) were conducted by the researcher (first author) and four observation sessions (8–11 years) were held at the homes of elderly patients with chronic illnesses. The interviews started with a general open-ended question, and the following questions were asked based on the participants’ answers to achieve the study objective. Some of the questions used in the interviews were as follows: ‘According to your experience, what things facilitate or threaten the safety of patients at home?’. All interviews were ended with the question ‘Are there any items that I did not ask and you wish to add?’ (online supplemental file 2). The location for face-to-face interviews was selected at the discretion of the participants (home care agency or patient’s home). To improve the accuracy of the interviews and resolve ambiguities, participants 1, 2, 3, 4, 6 and 7 were interviews twice. The researcher let the participants express the opinions freely and did not force or induce her opinion during the interviews. All interviews were recorded with permission and then transcribed verbatim. The comment command of the Microsoft Word software was used for data management. No new data were obtained from participant 12 onward, and it seemed that all concepts were adequately addressed. Then, three more interviews were conducted to ensure data saturation was achieved, and the data were categorised. The observation method (observer as participant) was also used in the present study (table 2) to evaluate patient care in a real setting.16 Four observation sessions were held to observe important occurrences including the care method and the interactions of people involved in the care process, the researcher’s interpretation of the observations was recorded at an appropriate time.24 To encourage the participants’ interaction, the method of ‘observer as participant’ was used and the researcher took part in some of the care activities (training the patient and family members, vital signs monitoring and assistance in patient’s position change.24 During the observations, the questions that occurred to the researcher were asked as open-ended questions and notes were taken at an appropriate time.25

Data analysis

Data analysis was done simultaneously with data collection with a conventional content analysis approach using the five steps proposed by Graneheim and Lundman including transcribing the interviews verbatim, reading through the scripts several times to obtain a general understanding, determining and coding the meaning units, categorising the primary codes into larger categories and determining the subjects of the categories.21 The interview and observations were transcribed immediately. The transcripts were read through several times to ensure the researcher’s immersion in the data. The words, sentences and paragraphs related to the study objective were considered as meaning units. The meaning units were coded using the participants’ words or appropriate labels extracted from the data. The codes were constantly evaluated, analysed and compared with each other regarding their similarities and differences, and codes with conceptual similarities were grouped into categories. The categories were also compared with each other and grouped into main categories based on their conceptual similarity.

Trustworthiness

The criteria proposed by Guba and Lincoln (1985), including credibility, transferability, dependability and confirmability are used to assess the rigour of qualitative studies. In order to achieve credibility, the following were done: spending a long time on data collection, using observations and interviews for data collection (triangulation), conducting complementary interviews, using member checking (controlling the extracted categories by participants). To confirm the dependability and confirmability of the findings: storing the audio files and transcripts of the interviews, field notes, reminders, codes, categories and stories in a safe and confidential place, supervision over all stages by an advisor and a supervisor, auditing by two external reviewers (qualitative research experts) were done. To ensure transferability: observation, thick description of the study and its stages were done. And to improve authenticity and reflexivity, the researcher tried to disregard their assumptions regarding the factors involved in the safety of elderly patients with chronic illness in home healthcare and minimise bias through self-awareness about the assumptions.26

Ethical considerations

This study received ethical clearance from Iran University of Medical Sciences (IR.IUMS.FMD.REC1399.430). The participants partook in the study voluntarily after receiving verbal information about the study objectives. Informed consent was obtained from all participants before the interviews and observations. The participants were informed of the recording of interviews and confidentiality of the data and were assured that they could leave the study at any time during the study.

Results

The findings included 2 main categories, 10 subcategories and 24 primary categories (table 3). The main categories were: (1) Patient safety facilitators: ‘family’s participation’, ‘nurse’s competence’, ‘efficiency of home care agency’ and ‘patient’s participation in patient safety’ and (2) Patient safety barriers: ‘problems created by the family’, ‘nurse’s incompetence’, ‘inefficiency of the home care agency’, ‘patient’s prevention of patient safety’, ‘home care setting limitations’ and ‘health system limitations’.

Table 3
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Main categories, subcategories, primary categories and some statements of participants

Patient safety facilitators in home healthcare

Family’s participation

The family is one of the most important components of home care. The participants believed that the family’s participation was a very important factor in patient safety. The participants stated that safe cooperation of the families like vigilance and supervision over care, cooperation and provision of the necessary care equipment could improve patient safety. Moreover, the constructive interaction of the family with the nurse and patient can facilitate patient safety in home care.

Nurse’s competence

The participants believed that the nurses were a main component of patient care and safety management. According to the results, nurses, as one of the parties involved in healthcare, can facilitate patient safety. Nurses can facilitate patient safety through their responsibility, flexibility and work conscience, which are inherent competencies. Moreover, the knowledge and art, skills, experience, vigilance and belief in human values are among acquired competencies of the nurses whose improvement can facilitate patient safety according to participants.

Efficiency of home care agency

The participants believed that the management of the home care agency, as the main institution responsible for coordination and provision of human force and equipment, had a determining role in patient safety. Home care agencies can facilitate patient safety through establishing an efficient supportive-guidance system, formulating regulations and procedures, and coordination of related services.

Patient’s participation in patient safety

The participants stated that among people involved in patient care, the patients themselves have an important role in patient safety. The elderly people and chronic patients can maintain their safety through cooperation with the healthcare team, especially nurses. In other words, the patients themselves have a fundamental role in their safety as a person involved in healthcare.

Patient safety barriers in home healthcare

Problems created by family

The participants stated that some families hindered patient safety through inappropriate interferences, inefficient interactions and not providing care equipment and necessities. The families’ interference in patient safety included care interferences (insisting on implementing a certain type of care) or folksy interferences (insisting on administering a traditional treatment). However, the findings indicated that the problems created by families were not deliberate and were rooted in their unfamiliarity with the care process.

Nurse’s incompetence

The participants believed that some nurses jeopardised the patient safety with their unprofessional conduct like concealing, being self-centred, lack of commitment to patient safety and ignorance. Moreover, some nurses put patient safety at risk due to lack of knowledge and skills (lack of experience, lack of knowledge about home care).

Inefficiency of home care agency

The participants stated that home care agency could weaken the patient safety due to lack of support and guidance from managers (lack of coordination and supervision, lack of an integrated team and failure to provide training and equipment) and lack of rules and protocols (forcing long shifts on nurses, violating the rules, paying little attention to evaluating the nurses’ education degrees). According to the participants, home care agencies play an important role as an intermediary body between the family, patient and nurse, and the patient safety could be jeopardised if this role is not implemented correctly.

Patient’s prevention of patient safety

The elderly people and chronic patients may endanger their own safety if they undertake hazardous actions like ignoring the nurse’s orders or uncooperativeness due to complexities resulting from chronic conditions or old age such as cognitive deficit.

Home care setting limitations

According to the results, the home environment is not suitable for care and is not designed and organised to serve this purpose in Iran. Therefore, when this environment is used for care, multiple limitations occur such as the nurse’s limitations including the nurse being single-handed, being forced to administer a drug without authorisation, errors in drug provision, fatigue resulting from long shifts and receiving doctor’s authorisation after administering a drug. Other home limitations included access limitations such as time and location restrictions, limitations in access to specialists, paraclinical limitations like laboratory, radiology facilities and other services, insufficient access to proper equipment and difficulties communicating with the doctor. Moreover, situation control limitations like the unexpectedness of the patient’s condition, a risky and unpredictable environment and unexpected interruptions in the function of equipment were other home care setting limitations that served as barriers to patient safety in home healthcare. According to the participants, these factors threatened the patient safety constantly in home healthcare.

Health system limitations

According to the participants, factors threatening patient safety were not limited to the family and home environment, and some of them were related to the healthcare system. When the study was being conducted, most countries, including Iran, faced COVID-19 pandemic and its complications, which had serious effects on the patient safety. For example, the restrictions related to the pandemic like increased costs, shortages, and the high probability of COVID-19 infection in elderly patients with chronic diseases were among the patient safety barriers. Moreover, drug and treatment limitations like a high inflation rate, drug shortages and limited insurance coverage were other barriers. Since the healthcare system should have supervision over home healthcare, this responsibility has been assigned to the deputy of treatment of medical universities, that had a poor performance in this regard according to the results. The absence of a process for evaluating the nurses’ academic degree in the higher levels, supervision without follow-up and following up on a case only based on the families’ complaints were other barriers to patient safety according to the participants.

Discussion

One of the strengths of the present study was a comprehensive evaluation of the determinants of patient safety in home care. The results showed that the role of the members involved in care (the nurses, family caregivers, patients, and home care agencies) could either improve or threaten patient safety like a double-edged sword. The role of active participation of the family as a team working in close cooperation with the nurse is of great importance.27 Team-based participatory care involving the nurse and family caregiver has been discussed in many studies.27 This care is based on the cooperation and participation of the members involved in care, including family caregivers.28 A constructive cooperation and relationship between the caregivers, nurses and patients in the present study indicated the importance of collaboration and teamwork in patient safety. Some studies have considered the interconnected relationship among the nurse, family and patients as the sides of a triangle.29 The results of the present study showed that some families threatened the patient safety through interfering in care due to being inexperienced in care or believing in traditional medicine. In Iran, some families believe in the effectiveness of traditional or Islamic medicine and try to accelerate the recovery process through implementing the principles of complementary medicine, and therefore practice folk medicine. The results of the present study showed the practice of folk medicine (without consulting with a doctor) by the family and their insisting on complementary medicine. According to the participants, the reason for this interference is that the family believes that they own the house, which affects the care process in home healthcare. This finding was exclusively reported in the present study and no similar study has reported this finding. Moreover, the results showed that due to the chronicity of the disease, some family caregivers became exhausted and refused to participate in the care of their patient or to provide the necessities of care. Moreover, it should be noted that the family caregivers do not receive an official support from the health system for home care, which further adds to the burden of care. Some studies emphasised lack of sympathy and cooperation in some family caregivers.30 When chronic care is intended, the role of family caregivers becomes more important due to the length of care and complexity of the barrier factors;31 therefore, training the nurses and their support for the family32 may have an important role in reducing the barriers and improving the facilitators of patient safety.

Considering the complexity of home care and the risks associated with it, the competence of healthcare providers to offer high-quality and safe care guarantees patient safety. Competence is a multidimensional concept. The results of the present study showed that the inherent and acquired competence of the home care nurses was an important factor in patient safety and lack of these competencies threated the patient safety. Moreover, according to the available evidence, home care nurses, especially those who provide care to elderly patients with chronic conditions that have health complexities, should have competency, which is achieved through continuous education and training,33 experience34 and observance of moralities.34 A lack in all or some of these competencies can compromise patient safety.35 Finally, it can be stated that assessing the competency level of the home care nurses36 is an important factor in patient safety to ensure the delivery of high-quality care.

The results showed that home healthcare centres are responsible for establishing and managing an effective relationship between all parties involved in care to maintain and promote patient safety. In fact, it can be argued that these centres engage all parties in care like the links of a chain; on the other hand, an inefficient management can break the links of the chain. According to the evidence, management,37 coordination,38 follow-up,39 supervision,40 training,41 recruiting and assembling an efficient team42 and formulating the rules and procedures43 to maintain and improve patient safety are among the main principles of home healthcare centres. Considering the above, these centres should try to drive their organisational culture towards patient safety.44

The role of the patient both as a healthcare recipient and a member involved in patient safety is of great importance. The present study found that the patients’ participation in care and their cooperation with the home healthcare team had a determining role in their own safety. According to the evidence, chronic and elderly people45 patients are more exposed to health threats due to complexities of care. Therefore, the safety conditions of home healthcare for these patients should be assessed more carefully once they enter the home or even before it.46

The results showed that the home environment was not designed for care, which served as a factor for escalation of unexpected and dangerous incidents. According to the present and other studies,47 adequate equipment and specialists48 may not be present at home at the same time. The nurses are single-handed and cannot use their friends’ assistance for consultation. The results showed that elderly patients with chronic diseases mostly had complex health-related problems and required more equipment and repeated paraclinical procedures. According to the present study and other studies,49 all pieces of equipment are not readily available at all times. Limited access to paraclinical services like immediate access to laboratory or radiology services was another barrier to patient safety in the present study. Considering the above, it can be argued that the home environment suffers from serious limitations for delivering optimal care, especially for elderly patients with chronic diseases, which should be addressed properly according to the patient’s condition before comprising the patient safety.50 51

Healthcare system limitations were other barriers to patient safety in home healthcare. During the COVID-19 and with respect to economic challenges, many countries, including Iran, experienced high inflation rates, increased costs and shortages in some equipment. The elderly people with chronic diseases sometimes needed equipment like oxygen concentrators or respiratory devices at home, which created many problems for these patients due to the COVID-19 pandemic. These devices were either unavailable or the insurance companies refused to reimburse the high costs. Insurance coverage limitations aggravated the situation during the COVID-19 pandemic according to the present and other studies.49 Previous studies reported that the COVID-19 pandemic and its consequences imposed economic limitations on the healthcare systems.52 However, meticulous supervision over home care agencies should be carried out strictly under any circumstances.52 The results of the present study showed that the inspectors only inspected home care agencies and did not have a direct supervision over their home care, which created many problems for patient safety. In conclusion, it is necessary to redefine the evaluation indicators of home care agencies52 based on the needs and modify the safety barriers.

Limitations

This study had several limitations. For example, some nurses, patients and family members were not willing to cooperate; however, the researcher tried to persuade them through explaining the objectives of the study. As another limitation, the study was conducted during the COVID-19 pandemic and the researcher tried to observe social distancing during interviews and observations. Moreover, the participants wore facial masks during the interviews, which prevented the researcher from observing their facial expressions.

Conclusion

The present study was conducted to extract the patient safety facilitators and barriers in home healthcare. The findings showed that some factors like the family cargivers, patients and home care agencies could facilitate or compromise patient safety like the two plates of a scale. The heavier the facilitator plate, the better the patient safety, and the heavier the barrier plate, the more the threats to patient safety. In fact, facilitators and barriers coexist at all times. It is obvious that it is impossible to eliminate all barriers, and only measures can be taken to modify them. Modification and reduction of the barriers can be achieved through assessing these factors and preventing them in the home environment. Through identifying these factors, the home care agencies managers and policymakers can determine patient safety barriers, address them properly and take corrective steps to improve their performance. According to the results of the present study, it is suggested that patient safety in home healthcare should be integrated into the nursing curriculum in bachelor’s and Master’s levels as well as their continuous education. Also, by identifying barriers and facilitators in safe care at home, home care nurses can provide appropriate solutions to create safe care for the patient at home.

Ethical approval and consent to participate

The present study was approved by Iran University of Medical Sciences, Tehran, Iran with the ethics code number (IR. IUMS. FMD.REC1399.430). All experimental protocols were approved by the ethics committee/Institutional Review Board of Iran University of Medical Sciences. All methods were performed in accordance with the guidelines and regulations of relevant qualitative studies. All participants were aware of the aim and design of the study. Written informed consent was obtained from all participants prior to the interview or observation. Participants' permission was obtained before recording conversations. They were also assured that their information would be kept confidential and they could withdraw from the study at any time. Due to conducting the study during the COVID-19 pandemic, the researcher tried to observe all the points related to social distancing during the study.

Patient and public involvement statement

Based on the purpose of the study, the participants (home care nurses, home care nurse assistants, home care inspector and family caregivers) participated in this study in the form of face-to-face interviews. The participants shared their experiences in the field of patient safety in home care with the researcher. Also, the participants, including elderly patients with chronic diseases, participated in the observation by the researcher. The participants gave permission to the researcher to observe the patient care process at home. Participants and patients had no role in the design, presentation and preparation of this study.

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