Abstract
Introduction
Along with global aging, the demand for home care is increasing worldwide, including China. Home care enables patients to receive preventive care, medical care, rehabilitation care, and other health care services at home. High-quality home care can decrease acute care utilization and clinical adverse events; which, in turn, could reduce the financial and psychological burden for patients and family members as well as the society (McKenzie et al., 2013; Mollaoğlu et al., 2013; Yan, 2018). In the United States, approximately 4.9 million Americans received home care in 2014 (Centers for Disease Control and Prevention, 2017). In Canada, an estimated 6.4% of households (881,800) received formal home care services in 2017 (Gilmour, 2018), and the demand is continually growing (Johnson et al., 2018; Molu et al., 2016). In Japan, there is also a tremendous need for home care, which presents a serious challenge for Japan. (Ohta et al., 2018).
Similarly, there is an imperative need to develop home care in China largely due to the rapidly aging population and the increasing prevalence of chronic diseases. In 2015, there were 144 million Chinese adults older than 60 years. It is predicted that Chinese older adults (>65 years) will account for 24% of the global older adults by 2030 (Du et al., 2018). The self-reported need for home care services for the elderly increased from 6.6% to 15% from 2000 to 2015 (Wu, 2018). Research showed that 42% of Chinese community-dwelling older adults have at least one chronic disease, of which 76% require home care (Jiang, 2017; Yang et al., 2016). Other researchers reported that approximately 56% of inpatients in China expected to receive home care after discharge (Dai et al., 2013).
While the need for home care is increasing rapidly in China and other countries, there are shared concerns regarding the quality of care. Sears et al. (2017) reported that the rate of adverse events in Canadian home care settings ranged between 10.1% and 13.2%. When reporting a similar adverse event rate (13%) among home care patients in Ontario, Canada, Doran et al. (2013) also indicated that nursing-related adverse events accounted for 40% of those events. Until recently, China highlighted the importance of home care and significantly increased efforts to its development. China is in the early stage of developing its home care and thus there is a lack of standardized home care process and quality monitoring system or research (Tang et al., 2016). Compared with institutional care, home care providers often provide services alone at a patient’s home without supervision. The shortage of advanced medical equipment further makes the provision of quality home care a challenge. Given these concerns of care quality, this qualitative study aimed to understand existing quality issues in home care in China and explore potential strategies for improving home quality by interviewing various stakeholders of home care. Our research questions were as follows:
Method
Setting
Participants were recruited from four home health agencies located in regions at various levels of economic development in Shanghai, China, all of whom provide home care to patients in their affiliated communities.
Participants
A purposive sampling method was used to recruit participants, including home care providers and patients and/or their caregivers. The inclusion criteria were (a) home care managers who had an experience of managing home care for 5 or more years, (b) nurses who had over 2 years of experience providing home care, and (c) patients who had received home care from any of the four home health agencies and/or their caregivers. All participants provided written or verbal informed consent before data collection. We stopped recruiting participants when theoretical saturation was reached, and 27 participants were interviewed. Participants were mainly female home care nurses in their 40s. The description of the participants’ demographics is shown in Table 1.
Interview Outline.
Data Collection
The Ethical Review Committee of the Second Military Medical University approved this qualitative study. Data were collected via semistructured in-depth interviews. An interview outline was first developed and was refined by pilot interviews. The interview outline is shown in Table 2. All interviews were conducted in a private, quiet, and undisturbed setting to ensure confidentiality. Each interview was audio recorded after obtaining consent from the interviewee. During the interview, the interviewer not only used open-ended questions but also encouraged the interviewees to actively express their ideas. The interviewers also requested timely feedback and confirmation to avoid misunderstandings. Nonverbal behaviors of the interviewees and characteristics of the surrounding environment were observed and recorded too. The transcripts of the interviews were de-identified. To ensure rigor, participants’ nonverbal information was also observed and logs for each interview were written; what’s more, triangular information was collected from home care nurses, managers, and patients/caregivers.
Demographic Characteristics of the Sample (N = 27).
Data Analysis
Audio recordings of interviews were transcribed into text word-by-word with nonverbal information notations within 24 hours. Colaizzi’s seven-step analysis method was used to guide data analysis: the research team first read all texts carefully and repeatedly, analyzed important and meaningful statements (Morrow et al., 2015). They extracted themes by induction, coding, and classification, and finally returned results of the analysis to interviewees for verification. In total, 10 themes about home care quality were identified. We further categorized these themes into three categories, which was guided by the structure-process-outcome (SPO) model (Donabedian, 1969, 2005; Voyce et al., 2015). This theory has been widely used for evaluating health care quality. In the SPO model, the researchers indicate that the quality of health care can be reflected in each of the three domains. The structure quality domain usually includes personnel, equipment, rules and regulations, and environment, which are the basic components of health care quality and quality evaluation (Campbell et al., 2000). The process quality refers to which extent the medical staffs’ performance is consistent with requirements and care protocols. Process quality helps prevent unsatisfied results so that health care work can be more proactive, which makes the evaluation and control of process quality especially important (Donabedian, 2005). The outcomes usually refer to the changes in a patient’s physiological, psychological, and health-related knowledge, behaviors, and social health status that can be affected by structure and process factors (Moore et al., 2015). During data analysis, two researchers analyzed the data with a memorandum. Conflicts in data coding were resolved through discussions between two researchers or verification from interviewees. A senior researcher is also available for guidance during analysis, and analysis notes were recorded to ensure the credibility of results.
Results
Problems in the Quality of Home Care in China
Themes Related to Unsatisfactory Structure Quality
There were four themes under the category of “unsatisfactory structure quality”: unqualified home care environment, limited medical resources and equipment, shortage of home care staff, and lack of rules, and regulations for home care practice.
Theme 1: Unqualified home environment for home care
In general, home care managers and nurses described the home care environment as unqualified in terms of sanitation, air quality, lighting, cleanness of operation desk, and so on. The environment was usually messy, dark, damp, and poorly ventilated. The poor environment was challenging for performing optimal nursing practice; thus, there was a concern that the quality and safety of home care was substantially compromised due to the poor home care environment.
Once I went to a patient’s home to irrigate his bladder. I sensed a strong pungent smell when I was entering the room. His bed was stuffed with different things which made it difficult for me to complete the care. (Manager 1) The rooms of many patients were really small, and dark, and stuff piled up everywhere in their apartments. (Nurse 1) A lot of the times the patient’s room is smelly and dark with stuff piling up in each corner. (Nurse 6) When performing transfusion therapy to a patient, I barely cleaned out a small space on the crowded table to complete the procedure. There is no way to ensure asepsis. (Nurse 7)
Theme 2: Limited medical resources and equipment
Medical resources and equipment, such as a vehicle for home visits, medical instruments, equipment, and supplies, are all necessary for quality home care. Home care managers and nurses mentioned that there was often a lack of such resources and equipment when providing home care.
All the medical instruments, equipment, and supplies were prepared at home health agency offices and then nurses carried them to the patient’s home. In the past, our nurses used regular bags as containers for carrying medical supplies. Now we are using a convenient medical box, which is better, but it still has disadvantages. Though the unused ones are well-packed, there is still the risk of contamination due to the limited room within the box. (Manager 1) It is hard to find a proper transfusion shelf when I perform a transfusion at a patient’s home. Usually, patients make a transfusion shelf by themselves with a piece of wood and a clothing hanger. (Nurse 6) We ride our own bike when we visit patients. There is no transportation service provided for us. So, you can image how difficult a home care visit could be, especially when the weather is bad, like on a rainy day. (Nurse 4)
Theme 3: The shortage of home care staff
Adequate human resource is a critical prerequisite to ensure the quality of home care (Amiri & Solankallio-Vahteri, 2019). Home care managers, nurses, patients, and family members all expressed that there was a significant shortage of home care staff, which limited the development of home care.
In the regions that we provide home care services, there are 180,000 residents, but there are just seven home care offices and seven home care nurses. (Home care) Personnel shortage leads to the lack of standardization of home care. Many home care services can’t be provided (due to personnel shortage). (Manager 5) It’s really laborious that all the care activities such as phlebotomizing, intramuscular injection, and dressing are done by me alone. What I worry about the most is unexpected accidents because I cannot fix everything by myself; I feel that I need more support. (Nurse 7) We need home care. However, many home health agencies in our area complain that there are not enough nurses and they wouldn’t send them to our homes timely, which is also reported on TV. (Family Member 1)
Theme 4: The lack of rules and regulations of home care practice
Rules, regulations, and standards are critical as they provide explicit, specific instructions on what and how to do and what not to do as home care managers and nurses (Xu, 2018). To date, however, there is no mandated quality control system for home care in China as reported by home care managers and nurses.
There is no consistent quality standard not only for home care but also for community care. Our home care is also very inconsistent. We are eager to have a series of national standards and regulations. (Manager 3) Since there are no standard procedures or evaluation criteria for home care in China, I am always wondering how to execute my management responsibilities. (Manager 6) It is better to have clear rules and regulations. We need standards and tailored training so that we can be more confident in providing (high-quality) home care. (Nurse 6) Sometimes the home care nurses don’t provide service consistently between visits. I hope that the home care nurses can provide standardized and quality home care, just like in the hospital. Of course, there should be rules and standards first. (Family Member 1)
Themes Related to Unsatisfactory Process Quality
There were four themes related to process quality: lack of training for home care staff, nonstandardized health assessment before operation, nonstandardized home care practice, and nonstandardized health education.
Theme 1: The lack of training of home care staff
Preservice training and continuing education can help nurses improve their knowledge and skills for providing care, including home care (Stone & Bryant, 2019). This is important to ensure home care quality. However, according to the home care nurses and managers, there were limited training opportunities for home care staff. To date, Chinese nurses learn how to provide home care at work. Home care nurses are expected to provide various types of care, such as rehabilitation services but relevant training is missing.
We hope to receive home care training. Now, we learn (how to provide) home care through practice or observation. There is no standardized training on home care. I did not receive any training for home care before I started working as a home care nurse, which makes it hard to provide standardized quality home care. (Nurse 2) There is a huge need for rehabilitation care due to aging and prevalent chronic diseases in China. To date in China, as long as nurses are registered nurses, they can provide rehabilitation care (and are expected to do so). However, since they have not received formal rehabilitation care training, it is hard to ensure the consistency and effectiveness of rehabilitation care. (Manager 1)
Theme 2: Nonstandardized health assessment before practice
Assessment is the most important and fundamental part of nursing practice (Lang et al., 2008). However, according to our home care patients and managers, most nurses failed to perform systematic patient assessments during home care, which results in increased adverse events.
The home care nurse usually immediately starts to administer medicine through injection after arriving. Occasionally, the nurse would ask about my feelings and reaction. (Patient 1) With the lack of nursing staff, home care nurses usually provide simple health education and health assessment when completing care activities. Thus, the health assessment was not systematic nor regular. (Manager 3)
Theme 3: Nonstandardized home care practice
This study found that during the process of home care, there were problems such as lack of awareness of sterility, inconsistency in inspection, inadequate disinfection and sterilization, improper invasive operation, and inappropriate disposal of medical waste. Rehabilitation nursing is an urgent need in China with patients including the disabled, postacute and postoperative, chronic patients, and the elderly. However, unqualified rehabilitation nursing is still a challenge to high-quality home care.
When the nurse administered the drugs, she didn’t wear a mask or a pair of medical gloves. The drug bottle was opened with her bare hands. (Patients 3) I used a steel pot to cook and thus disinfect these medical scissors and tweezers at home. The nurses usually did not recycle the used gauze and cotton swabs; they just told me to send them to the nearby hospital. (Patients 2) The nurse checks medical orders, drugs, supplies, etcetera, all by herself. There is no way to perform a double-check. (Manager 4) When I tried to evaluate the quality of rehabilitation services, I found the nurse just pinched the patient’s finger, which was definitely not standardized practice. Additionally, there is no standardized process; so, I don’t know how to monitor the quality of rehabilitation service sometimes. (Manager 6)
Theme 4: Nonstandardized patient health education
Providing appropriate health education can improve home care patients’ self-management and thus improve their outcomes. However, it is hard to provide high-quality health education to patients and their family caregivers for many reasons, including a shortage of home nurses and patients’ distrust of home nurses. Poor patient education leads to unsatisfactory patients’ self-management of diseases and poor outcomes of home care.
With a lack of staff, our nurses usually just finish basic nursing care activities. Even though a major responsibility of home care nurses is patient education, they usually fail to accomplish this. (Manager 5) The home nurse does not have time to tell us precise information about a diabetes diet. We obtain this knowledge from the resident nurses, TV or newspapers. (Patient 3)
Themes Related to the Imperfect Outcome Evaluation System
According to participants’ descriptions, the evaluation system of outcomes of home care is not well-established, which influences home care quality management and improvement. The participants also expressed desires that home care outcome indicators should include not only comprehensive patient-related outcomes but also home care outcomes of home care providers, such as job satisfaction.
Theme 1: Lack of comprehensive outcome evaluation for home patients
Our participants believed that the current outcome quality evaluation system needs improvement. In particular, the effectiveness of health education seems to be ignored in the current evaluation system.
My father fell off the bed twice in a month at home. We didn’t have enough knowledge about how to prevent this kind of accident. When evaluating the quality of home care, the effects of health education should be added. Nurses should teach us how to ensure safety at home. Knowledge is the precursor of action. (Family member 3) In fact, I feel that our country’s outcome evaluation indicators for the quality of home care have not been fully established. Outcome indicators, in terms of patients, should include the incidence of adverse events such as patient falls, pressure ulcers, hospital readmissions, and catheter slippage. Of course, it is best to also include indicators evaluating the knowledge mastered by home care patients and their families after health education by home care providers. The levels of health knowledge can affect patients’ health outcomes. However, there is no valid outcome indicator system to guide nurses in home care practices. (Manager 8)
Theme 2: Ignorance of the satisfaction rate of home care staff
According to home care managers and nurses, job satisfaction of home care nurses was low in China. Our study found that the low job satisfaction of home care nurses was due to many reasons, such as the shortage of home care nurses and the intense workload, unclear job responsibilities, lack of professional training, and low salary. Poor job satisfaction impacts the quality of home care; however, the importance of job satisfaction of home care nurses has not been well recognized in China.
There are 11 affiliated residential committees (of our home health agency) but there’s only one home care nurse. I (have to) visit eight or nine families a day, no matter whether it is windy or rainy. Some patients live on the 6th floor or 7th floor without an elevator, I have to climb all the stairs. I am very exhausted (by the end of the day). Thus, job satisfaction is certainly not high, which will affect the quality of home care. (Nurse 6) There is very limited training so the nurses’ confidence in providing quality home care is low, which results in low job satisfaction with the position among home care nurses, which affects the quality of care. (Manager 5)
Strategies to Improve the Quality of Home Care in China
Our participants also offered many suggestions on how to improve the safety and quality of home care in China, including issuing standards for home care practice and evaluation, refining structure quality, improving the process quality, and improving the outcome quality evaluation system. Quotations of strategies to improve the quality of home care in China are shown in Table 3.
Quotations of Strategies to Improve the Quality of Home Care in China.
Theme 1: Issuing standards for home care practice and evaluation
In the interview, both nurses and managers hoped to have and implement national-level standards to improve the quality of home care. The standards would define how to provide home care and how to evaluate the quality of home care, which would make the job responsibilities and goals of nurses and management clearer.
Theme 2: Refining structure quality
Most of our participants stressed the importance of structure quality of home care. Participants emphasized the need to provide necessary equipment and tools for home care and increasing the number of home care staff.
Theme 3: Refining the process quality
Our participants suggested the improvement of the process quality of home care with different approaches such as acting according to practice protocols that include assessment, diagnosis, planning, implementation, evaluation, health education circle and increasing nurses’ adherence to the protocols when providing home care.
Theme 4: Establishing an outcome quality evaluation system
According to the participants, the quality of home care should consider outcomes from both the service providers and patients.
Discussion
In the context of increasing needs for home care and lack of knowledge of the status quo of home care in China, this study qualitatively examined the challenges associated with home care and explored the suggestions from various stakeholders for quality improvement.
Challenges Are Common in Areas Related to Structure, Process, and Outcomes of Home Care
Our study revealed many structure-related issues in home care in Shanghai, China. First, the shortage of home care professionals is the concern from home care providers and patients and their families. The number of nurses per 1,000 population can rise resident life expectancy (Amiri & Solankallio-Vahteri, 2019), while the shortage of home care staff leads to an intensive home care burden, which can result in poor quality and outcomes. Considering home care to some extent as a form of public welfare in China, the government should put more effort into developing educational programs to train home care providers. In addition, increasing the salary and benefits of home care providers so that it is comparable to that of health care providers in other care settings can also help mitigate the negative impact of the home care workforce shortage. Lack of rules and regulations related to home care and lack of continuing training make it hard for home care nurses and other staff to perform optimal care practices, and it will increase risk during home care (Xu, 2018). It also causes problems for the home care managers to perform their supervision duties. The government and professional associations should issue standards and norms for home care. Limited medical resources and equipment is also a problem that needs to be resolved. The electric bicycle may be a feasible and cost-effective vehicle for home care nurses in China because the Chinese residents live in higher density than those in Western countries. The policy makers can make the necessary equipment covered by insurance at least partially if not all. In summary, we suggest that the health department scientifically distribute human resources and equipment among community health agencies, thereby improving the quality of home nursing care.
In terms of process quality, we found that many home care nurses do not have a strong awareness of sterility. They also may not always implement nursing practices according to the protocols. Contributing factors to these issues include the lack of rules and regulations and supervision. Standardized nursing techniques are a major component of nursing including home care, it can help improve patients’ health outcomes (Liu et al., 2019). And nonstandardized practices may directly affect the quality of home care. Thus, it is necessary to establish standards and practice protocols. There is a need to provide professional rehabilitation training and increase the awareness of self-supervision for home care nurses. Last, our study also reinforces the importance of including process quality when developing a home care quality indicator system.
We also found that outcome evaluations in home care are limited to a few common clinical events such as the incidence of pressure ulcers, falls, and patient satisfaction with home care. Other important indicators such as infection, physical function, hospitalization, and rehospitalization are missing. Besides, the outcome assessment in home care should also consider outcomes of nurses and other providers, such as job satisfaction and turnover. This is because providers’ outcomes can directly affect the quality of home care and patient outcome. This result is also consistent with the results of other researchers that emphasized the importance of both caregiver outcomes and family outcomes (Huang et al., 2012; Shyu et al., 1999). It needs to be noted that recommendations for practice/policy need further work since conditions are less than ideal; further study may pay more attention to how policy might be developed and how partners might be brought together for a task force.
Expectations for the Quality of Home Care Varied Across Stakeholders in China
Though not very surprising, it is interesting that specific differences exist in the perspectives of quality of home care between stakeholders. Home care managers focused on nursing care quality and patient satisfaction. Our findings show that most managers would pay attention to the outcome quality, especially the incidence of adverse events and nursing errors. The possible explanation is that in China, the department of home care quality control focuses on adverse events and their prevention. Consequently, home care managers also highly stress controlling adverse events and nursing errors (Sun et al., 2012). Home care nurses generally pay more attention to structure and process quality. They voice their preferences for basic standards and norms for home care practice, convenient transportation, transferrable equipment, and a clean home care environment. Home care nurses are eager to receive recognition and support from patients, professional organizations, and society at large. They believe that improving the structure and process quality is important. Also, home care patients and caregivers are primarily concerned with the improvement of patients’ functional status, quality of life, and adverse event prevention. They would like to receive more health education especially on rehabilitation and disease-related knowledge from home care nurses.
It is interesting to note that our participants paid more attention to structure quality and process quality, in contrast with findings from studies conducted in Western countries. Most common indicators used to evaluate the quality of home care in Europe and the United States are mainly based on the minimum data set of home care quality indicators, Outcome Assessment information set, or Resident Assessment Instrument for Home Care, and these data sets mainly focus on outcome quality (Foebel et al., 2015; Morris et al., 2013). Home care agency in China is at the early stage of development and home care facilities are still under construction (Huang et al., 2018; Ma et al., 2016; Zhang et al., 2010), thus improving organization structure quality and the care process have been the priority for policy makers and home care providers. The results of this study provide indications for home care management and policy enactment in China.
Study Limitations
This study has some limitations. Though this is a qualitative study and generalizability is not its priority; it should be noted that this study was conducted in four communities with different levels of economic development in Shanghai. Future studies on this topic need to be conducted in other geographical locations in China. Despite our efforts to ensure confidentiality and anonymity, there is still the possibility that participants did not fully disclose their views and experiences of the quality of home care due to such concerns.
Conclusions
In this study, themes of concerns on the quality of home care in China were identified via interviewing different stakeholders of home care. Potential strategies were also summarized and discussed based on suggestions of interviewees. Our findings lay the foundation for developing a tailored home care quality evaluation system for quality improvement. Meanwhile, our study also indicates a need of quantitative studies to evaluate the quality of home care in China.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Jiangsu Provincial Education Department (Grant number 2016SJD840012) and Xuzhou Science and Technology Department in China (Grant number KC16SW170).
