The number of older people with multimorbidity and disabilities is increasing worldwide, and because of their extensive care needs, these individuals are at risk of frequent hospitalisation (World Health Organization (WHO), 2016). From the health and welfare perspective, multimorbidity in older persons encompasses a number of health problems and an overall need of care. In addition to diseases, multimorbidity includes physical and cognitive dysfunction, sleep disorders, pain and sensory difficulties (Statens Offentliga Utredningar, 2010). According to WHO, a disease-oriented approach is no longer appropriate in home care. Home care in Europe will need to be changed to reflect the increasing number of care-dependent older people and noncommunicable diseases. Changes in patient needs and social structure require a different approach from the health and social sectors (WHO, 2018). Genet et al (2011) showed how the development of home care policies differs among European countries but identified four domains that constitute the key aspects of home care systems: policy and regulation, regulation of quality, financing and organisation, and service delivery.
Home visits to the patient as a preventive measure to identify the risk of ill health may be a means of health promotion. Early health promotion interventions increase the ability to maintain health (Hendriksen and Vass, 2005). Nicolaides-Bouman et al (2007) showed that systematic home visits by nurses to follow up a patient's health status on a single occasion or as multiple visits could promote better health and prevent adverse events. Nurses received advice on how to monitor the problems experienced by older patients depending on the health status of each individual and their need for help and support. Both the nurses and patients were found to benefit from this supervision.
Moe et al (2013) stated that it is important to respect older patients' privacy when their home is transformed from a private residence into a place of professional care. Such respect creates a sense of dignity for older patients, as they are viewed and confirmed as human beings. Griffith (2017) reported that home visits during which patients do not receive appropriate assessment, care or treatment can cause them concern. According to Avlund et al (2002), patients can feel worried and insecure about how home care will be performed after they are discharged from hospital and can be concerned about they information they are given, for example, about how medication should be taken. Frydenberg and Brekke (2012) illustrate communication difficulties regarding administration of medication when patients move between different care settings.
Follow-up home visits should include questions about what happened at the hospital and a review of possible post-treatment interventions and further visits, in addition to questions about medication adjustments and the patient's need for help from healthcare professionals. Home care visits provide patients with a sense of security about their needs being satisfied. This practice has been shown to decrease re-hospitalisation rates since patients do not seek emergency care as often as they would without the follow-up visit (Rytter et al, 2010). Home visits to older patients are an important part of nurses' work, as such visits create confidence and trust, in addition to strengthening the relationship between nurses and patients (Kennedy, 2002).
The present study is based on the findings of a Swedish report entitled ‘Follow-up 48–72’ about follow-up supervision by a healthcare centre or home care nurses for older patients returning home after hospitalisation (Vårdsamverkan, 2014). The target group in the report comprised patients with multimorbidity aged 65 years and over who had been hospitalised at least twice in the previous 6 months or were considered to be in need of immediate follow-up (Hansson, 2013) to ensure that their care needs were met. As part of the project, an immediate follow-up home visit to older patients with multimorbidity was introduced in collaboration with the hospital. After receiving patient approval, the nurses made immediate follow-up home visits within 48-72 hours of the patient's discharge from hospital. They then informed the hospital ward about the patient's health status and nursing needs. During the follow-up visit, the nurses assessed whether the patient was doing well at home or if there was a need for more nursing or other help, and they ensured that the medication was correct to enable the patient to remain at home.
The aim of the present study is to describe nurses' experiences of follow-up visits to older patients with multimorbidity immediately after discharge from hospital. The reason for interviewing nurses with experience of caring for older patients with multimorbidity was because this can often be complex for community care nurses.
Methods
Study design
The present study has a qualitative design, in which individual semi-structured interviews were analysed by means of qualitative content analysis (Graneheim and Lundman, 2004). According to Polit and Beck (2008), this research method enables interpretation of people's social reality as well as description of their lived experience. Supplementary questions can be posed during the interview in order to follow-up what the participants expressed, and open-ended questions enable participants to talk openly and describe experiences in their own words. Thus, questions such as ‘what do you mean?’ and ‘can you describe that in more detail’ were posed to obtain information about the nurses' experiences of home visits to older patients with multimorbidity recently discharged from hospital.
All interviews were conducted at the participants' workplace after their working hours when they could talk without interruption. The interviews, each of which lasted approximately 1 hour, were recorded on a dictaphone and identified by a number in accordance with the ethics guidelines for confidentiality of the Northern Nurses' Federation (2003); thereafter, they were transcribed verbatim. The recorded interviews were listened to repeatedly to ensure that they were in line with the transcribed text.
The inclusion criteria were registered nurses employed in community care with experience of (1) caring for older patients with multimorbidity at home and (2) of follow-up home visits immediately after discharge from hospital, such as those in the Follow-up 48-72 project. In fact, most of the participants had been involved in the Follow-up 48-72 project. However, even those who had not participated did have experience of follow-up home visits immediately after discharge from hospital. The exclusion criterion was no experience of follow-up home visits immediately after discharge from hospital.
Fifteen nurses were asked to participate in the study and 10 agreed. The participants, comprising nine women and one man, were recruited from a home care organisation with experience of follow-up home visits to older patients with multimorbidity immediately after discharge from hospital. Of the 10 participants, seven were specialist nurses in intensive care, medicine, surgery, occupational health, oncology, rehabilitation and primary care. They were aged between 33 and 68 years, and their experience of professional home care ranged from 1.5 to 20 years (Table 1).
| Gender | Age (years) | Education/qualifications | Number of years spent working as a nurse | Number of years in home nursing |
|---|---|---|---|---|
| Female | 68 | Registered nurse |
46 | 20 |
| Female | 63 | Registered nurse |
41 | 1.5 |
| Female | 37 | Registered nurse |
14 | 14 |
| Female | 61 | Registered nurse |
41 | 8 |
| Female | 45 | Registered nurse |
7.5 | 5 |
| Female | 42 | Registered nurse |
18 | 13 |
| Female | 35 | Registered nurse |
9 | 9 |
| Female | 49 | Registered nurse | 8 | 1.5 |
| Female | 33 | Registered nurse | 6.5 | 6.5 |
| Male | 39 | Registered nurse | 12 | 4 |
Ethics considerations
The study received ethics approval from University West's review board (Dnr 2015/520B22) and permission to perform it was granted. The Helsinki guidelines were also adhered to. The nurses who participated provided both written and oral information. Those who agreed to participate signed an informed consent form, indicating that they had received information about the study and were aware that participation was voluntary and that they were free to withdraw at any time during the study. The participants were assured of confidentiality and that the material would be used solely for this study.
Data analysis
A qualitative content analysis was performed on the nurses' statements on the basis of the recommendation in Graneheim and Lundman (2004). The transcribed interviews were read several times to gain an overall understanding of the participants' views, and meaning units relevant to the aim of the study were extracted. These units were condensed and coded, and the codes were repeatedly checked to ensure consistency with the original text. The codes were compared and consolidated to form subcategories. The subcategories were then compared, resulting in the formation of categories that corresponded to the aim of the study. During the analysis, the original text was referred to repeatedly in order to verify that the link between the categories and meaning units was maintained. According to Graneheim and Lundman (2004), the analysis should go back and forth between the parts and the whole of the text.
Results
Two categories emerged that described nurses' experiences of immediate follow-up visits to older patients with multimorbidity who had been discharged from hospital: Relieving anxiety at home and Creating trust at home. The first comprised the subcategories Being prepared and Responding to the patient's questions, while the second had the subcategories Having overall responsibility and Following up the patient's health status.
Relieving anxiety at home
There was no prescribed routine for the nurses' follow-up home visits with older patients with multimorbidity who had recently been discharged from hospital. The nurses were only told to obtain information about the patient and their hospital stay, as well as to clarify any uncertainties that arose when the patients returned home.
The quotation below illustrates a nurse's experience of the follow-up home visits immediately after hospital discharge.
‘… we have had this collaboration with the hospital and the 48–72 project so it has become a routine … when the elderly patient returns home from hospital … and you see that something has changed … you will definitely make a home visit’.
Being prepared
Because of the lack of instruction on how to proceed with the follow-up visits, and because the visits were not routinely performed, it was difficult for the nurses to prepare for them. However, they experienced that the follow-up home visits benefitted not only patients but also their relatives and the nurses themselves, as such visits could prevent ill health, relieve the patient's concerns and reduce the risk of deterioration.
Only one nurse reported having her own routine for follow-up visits when patients were discharged from hospital. This involved examination to ensure that the nursing care to date was as good as possible and to assess the need for further nursing interventions. The following quotation illustrates this nurse's experience of such visits.
‘I do not go to all follow-up home visits … but usually I do the daytime ones. I prioritise those visits. But even at night when I make a decision on the phone, I sometimes feel that it is necessary to follow it up and I do so’
Before a follow-up home visit to an unfamiliar patient, it was important that the nurses had some information about the patient's health status and the reason for hospitalisation. This information could be obtained from the patient's journal or an oral report from the hospital.
Responding to the patient's questions
Nurses viewed follow-up home visits immediately after hospital discharge as ensuring safe and high quality care for the patient. They attempted to ensure high quality by resolving any problems related to medication, responding to patients' questions about health and suffering and assessing the need for further nursing in the home.
‘Make a home visit to get a first-hand look at how the patient is doing, check the medication so that everything is correct. It is also a matter of patient safety’.
When patients returned home from hospital, a common problem was that they felt insecure and were unsure about the information they had received. It was difficult for them to know which medications were relevant and although they might have received a prescription for new drugs from the hospital, they had not yet obtained these from the pharmacy. Follow-up home visits immediately after hospital discharge enabled nurses to provide patients with useful information, alleviate any uncertainties about prescriptions received from the hospital and check that patients had the right medication at home.
Creating trust at home
Nurses experienced the creation of trust when they gave patients the feeling of being in safe hands, taken care of, confirmed and relief that someone was checking up on their needs at home. A follow-up home visit immediately after discharge from hospital strengthened patient care as they received support in their own homes. The nurses' experiences also showed the necessity of respect for each patient's integrity. The above experiences can be described as having overall responsibility and following up the patient's health status.
Overall responsibility
The nurses, who had overall responsibility for the care of the patient at home, experienced that the follow-up home visit created trust and generated a feeling of safety among the patients. Even if the patients had received information at the hospital, many lived alone and did not always remember what they had been told, for example, about further care, medications or health status. With a follow-up home visit immediately after discharge, nurses could answer many of the patients' questions, thus reducing their insecurity and anxiety.
‘It can make patients less insecure, knowing that there is someone they can turn to. If they feel safer they may be less likely to return (to the hospital) or feel worried about something’.
When the nurses were unable to answer the patient's questions about their hospital stay or if they needed additional information, they simply contacted the hospital from which the patient had been discharged.
Sometimes the nurses could feel threatened by patients or their relatives who expressed that a follow-up home visit was not required and that the nurses were not welcome. This was often a consequence of the patients living in an abusive situation and being suspicious that the purpose of the visit was to check on their home life. Although the nurses felt insecure in such situations, the matter was sometimes resolved once the purpose of the visit was explained. If the nurses were unable to explain the purpose of the follow-up home visit immediately after discharge to the patients and relatives, they had to leave and return later. For instance, one nurse was threatened with a rifle on the stairs of the patient's home.
‘I've even stood with a rifle pointed at me by a relative, but it ended well, I just said “if you want help, then put away the weapon”.’
However, the follow-up home visit was accomplished in this case without any further problems. There were no consequences for the patient, for example, no report was made to the police that the nurse had been threatened, as there was no further threat and the nurse was no longer afraid.
The nurses experienced that to accomplish the follow-up home visit, it helped to be sensitive and calm in order to understand the patients' situation and illness. Further, even if the nurse assessed that the patients needed no further visits, they were satisfied that a good foundation of trust had been laid.
Follow up of the patient's health status
The nurses experienced that follow-up home visits gave a picture of the patients' physical and mental health status and wellbeing after hospitalisation. They could also see how the patients managed at home and had an opportunity to obtain additional information, for example, regarding nutrition, elimination, pain and social relationships. If something was wrong, the hospital could follow up as necessary. The following quotation reveals the experience of checking on the patient's health status during the follow-up visit.
‘Follow-up home visit for me means that I get my own idea of how the healthcare recipient is feeling, both physically and mentally’.
The nurses also determined whether the patient had other nursing needs and if more home visits were required.
The nurses found that the follow-up home visits could prevent patients' health from deteriorating and avoid unnecessary re-hospitalisation. The nurses patiently listened when patients narrated the events of hospitalisation. As mentioned above, even though the patients had received information at the hospital, they felt insecure when they came home and had questions about what happened during their hospital stay and what would happen next. In terms of ensuring patient safety, the nurses felt assured because they were able to contact the hospital for additional information about the patient's stay.
Discussion
The aim of the present study is to describe nurses' experiences of follow-up home visits to older patients with multimorbidity immediately after discharge from hospital. An interview guide with open-ended questions was used in this study. Graneheim and Lundman (2004) stated that an interview guide is a strength as it ensures that informants are all asked the same questions, which can increase the reliability of the results. The use of an interview guide ensured that the same questions were asked to all participants, thus enabling the authors to focus on the study aim and pose relevant supplementary questions, all of which increased the credibility of the study. According to Graneheim and Lundman (2004), the use of quotations in addition to a detailed description of the sample, data collection, data analysis and ethics considerations provides an opportunity to assess the transferability of the findings. Ethics considerations were taken into account throughout the interpretation of the material, and the authors always kept in mind the aim not to abuse or violate confidentiality. Both authors read and discussed the material together.
The nurses experienced that a follow-up visit immediately after discharge made patients feel safer at home and created a relationship of trust. It was not unusual for patients to feel overwhelmed when they came home from hospital. One reason for this is certainly impaired health, while another may be the information overload received by the patients. Avlund et al (2002) argued that it can be difficult for patients to understand the information received at the hospital, making them unsure about medication and further care when they return home. Not understanding the information received or the subsequent steps in care can give rise to anxiety and cause suffering (Dahlberg et al, 2003; Eriksson, 2018). A follow-up home visit immediately after hospital discharge enables nurses to check that the patients have the correct medication at home and alleviate their uncertainties. Dossette boxes and other devices can be considered in order to be certain that patients take the right medication. This can make the patients feel safer at home and give the nurses an overview of the situation. Frydenberg and Brekke (2012) found that drugs often do not function as expected when patients move between different care settings and that these errors can be harmful. Helping patients to organise their medication when they come home from hospital is a patient safety issue and can create trust.
When patients' nursing needs are met, it enables them to maintain their self-esteem and prevents them from feeling that they are a burden to others (Borglin et al, 2005). However, it is important that nurses act in a professional manner and explain the purpose of the follow-up home visit to the patients and their relatives. It is often forgotten that patients are whole and unique persons consisting of a body and soul as opposed to an object or a diagnosis (Arman et al, 2004; Kasén et al, 2008).
Rytter et al (2010) show that attention in the form of a home visit after discharge from hospital creates feelings of safety for patients and may lead to them not seeking emergency care. Thygesen et al (2015) argue that the rate of readmission to hospital decreases when patients with chronic diseases receive support by means of home visits as part of a community care programme, although their study was not specific to older people.
Strengths and limitations
Although this is a small study in terms of the sample size, it can provide an understanding of the importance of nurses' home visits to older patients immediately after discharge from hospital.
Seven of the 10 participants were specialist nurses and had different specialist education. The fact that the authors did not distinguish between the different specialities in the results might be a limitation. All participants had at least 1.5 years of experience in home care and follow-up home visits immediately after discharge from hospital.
Recommendations for future research
Future research should investigate the patients' experience of the nurses' home visit after discharge from hospital. The nurses in this study expressed that they did not work on the basis of a checklist when following up the patient. Thus, future research should also investigate whether a home care checklist would be helpful and if it ‘improves’ the nurse's assessment, planning and follow-up of patient care interventions, thus reducing patient suffering and promoting health. From a global perspective, it would be interesting to investigate whether any such home care programmes have been implemented and how their efficacy is evaluated.
Conclusions
The present study highlights the need for and benefits of supervision of older patients returning home after a hospital stay. An immediate follow-up home visit after discharge is important to ensure sustained care of older patients with multimorbidity, as their care needs are often complex. Patients who are insecure and anxious when they return home after discharge from hospital suffer unnecessarily. This could perhaps be prevented by follow-up home visits immediately after discharge becoming part of the routine in community care.
The nurses in our study experienced that a home visit immediately after patients had been discharged from hospital facilitated their continued care at home. Older patients are vulnerable, and a home visit that creates trust can reduce their suffering and help them to cope and feel safe when they return home from hospital, thus avoiding unnecessary readmission.