‘I try to make a net around each patient’: home care nursing as relational practice

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Excerpt

In recent years, home care services have been restructured to aid older people and the chronically ill to maintain residence in their own home and, when possible, prevent admittance to acute care or nursing homes 1. An array of services has been developed to facilitate extended residence in the home such as day care, respite services and technology‐based support. At the same time, home care services are increasingly shaped by organisational methods that are aimed at saving costs and assuring quality. These methods primarily draw on rationalism, defining the work to be done in a narrow, task‐based way, undermining the holistic nature of practice that previous organisational methods allowed for. These new methods are characterised by strengthening trends towards division, codification and standardisation by emphasising time measures and performance‐related payments, strict work schedules and caps on services 2, limiting time allotted to each person being cared for and leading to narrowing of the scope of practice 4.
In many of the Nordic countries, where home care services have been universally and publicly provided over a long period of time, scholars have raised concerns that the use of these new organisational methods will undermine practitioners’ ability to provide services that accommodate individual needs 3. Studies from the Nordic countries have found a high motivation to provide meaningful assistance to patients and their relatives among home care staff, while their work environment is increasingly experienced as financially constrained 6. In UK, studies have revealed how a pay‐for‐performance contract introduced to General Practitioners (GP) challenged the practice of holistic care which had previously prevailed 8. This payment structure has been found to dictate a task‐based approach 9 which discourages practice nurses from engaging in activities that are not part of the payment structure but that are nevertheless seen as important to patients’ well‐being 10. The danger, following the implementation of organisational changes that aim at rationalisation and retrenchment, is that the practices involved in providing home care services will become eroded or at least changed in fundamental ways 11.
In this article, I draw on findings from a study of home care nursing practice to make the often hidden work of everyday home care nursing practice visible. In doing so, we may come to understand what aspects of this increasingly important area of health‐care should be preserved and enhanced. The study was conducted in Iceland, and at the time of the data collection, home care services had only been minimally influenced by the organisational methods referred to above, making it an excellent site to study this practice.
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