Barriers to efficient management of in‐home care: A qualitative content analysis

Abstract Aim Inefficient management is one of the major barriers to development of in‐home care in the society. Accordingly, the present study aims to identify the barriers to efficient management of home care nursing using a qualitative approach. Design The present study is a qualitative‐descriptive work of research. Method Data were collected using semi‐structured, in‐depth, individual interviews with 19 nurses from November 2020 to May 2021. The collected data were analysed using Graneheim and Lundman's method. Results The findings of the study were categorized into four main themes, namely lack of effective standards, ineffective interactions, inappropriate cultural/social context and professional issues, and 15 subthemes. Conclusion In‐home care nurses in Iran experience various problems in their practice. Creating an appropriate cultural/social context in Iranian societies, providing the necessary infrastructure, including insurance, providing comprehensive, clear guidelines for in‐home care, encouraging teamwork and organizing workshops to promote effective interactions between the personnel and patients can improve the quality of in‐home care nursing.


| INTRODUC TI ON
The ever-increasing prevalence of long-term diseases, disabilities and conditions caused by old age in recent decades has posed many countries with a variety of healthcare challenges (Sethi & Rani, 2017).
Providing long-term care to patients in clinical environments like hospitals and clinics not only imposes considerable costs on the healthcare system, but exposes patients and their families to various forms of emotional and psychological tension (Halevi Hochwald et al., 2020). As an innovative strategy, in-home care has raised interest as a way to prevent or minimize the problems associated with prolonged hospitalization (Johannessen et al., 2020;Lindblad et al., 2018). In-home care is an essential service which is provided in patients' homes with the cooperation of patients and their families and has many benefits for patients, as well as the healthcare system (Wiig et al., 2018). In this way, Floridi et al. (2021) also state that socioeconomic condition is effect in the use of home care, so that people with unfavourable economic conditions cannot afford to use

| Background
Among the most significant benefits of in-home care are the following: providing timely, comprehensive care to patients, disease management, completing hospital services, reducing medical costs, decreasing the need for in-hospital care, increasing the participation of patients and their families and raising patient satisfaction (Estabrooks et al., 2011;Kattouw & Wiig, 2019;Ree et al., 2019;Xiao et al.,2017). Accepted by many in today's world, in-home care has paved the ground for expansion of healthcare services throughout the society (Estabrooks et al., 2015). Yet, studies show that there are certain obstacles to effective in-home care, including caregivers' poor competence, lack of a suitable infrastructure, cultural issues, insufficient inter-professional coordination and cooperation, caregivers' dissatisfaction, lack of acceptance in the society and inefficient management (Konetzka, 2020;Song et al., 2020;Wiig et al., 2018).
One of the main barriers to development of in-home care on a social level is inefficient management. It is clear that poor management and organization results in the dissatisfaction of caregivers, patients and patients' families, as well as the society's reluctance to accept this type of care.
All of the above studies state although home care has numerous advantages, but there are still cultural, social and economic barriers to its implementation in many parts of the world. These barriers in Iranian society and culture due to religious and ethnic attitudes can be different from other places. Accordingly, there is a need for more research. In this way, qualitative research can play a significant role in exploring, describing and obtaining an in-depth understanding of the management problems and challenges in the implementation of in-home care in Iran. An understanding of the different aspects of in-home care nurses and the current management issues in this area can help with a proper evaluation of the quality of this type of care. Considering the multi-dimensional nature of the management challenges in in-home care, qualitative content analysis is a proper method for investigating the subject. The present study was conducted to identify the barriers to efficient management of in-home care.

| Design
The present study used a descriptive qualitative design which is an effective method to obtain insight into a research question and establish the subjects' perception of who, what, place of events or experiences treatment (Doyle, et al., 2020). As the barriers to efficient in-home care management in Iran are unknown, the researchers used the above-mentioned approach. The reporting of the study was based on the consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al., 2007).

| Sampling and recruitment processes
In this study, selected by purposeful sampling, 19 in-home care nurses, who worked as caregivers at home, participated in the study.
The study lasted from November 2020 to May 2021. The inclusion criteria were having at least 1 year's experience of in-home care, being Iranian, speaking and understanding the Persian language, and the ability to provide appropriate and sufficient information on the subject. The authors try to select participation with maximum variation. Therefore, nurses were selected from a wide range of age, sex, marriage and educational level. In this study, 19 nurses worked in 3 home care services. Participants' information is provided in Table 1.

| Data collection
Twenty-three nurses were invited to participate in the study, but 4 nurses refused due to busy schedule, intensive shifts and spending time with their families. Therefore, data were collected through 19 semi-structured individual interviews with 19 nurses. The participants were video called for interviews on WhatsApp at times which were convenient for them. The second author, who is an assistant professor of nursing and has led numerous qualitative studies, conducted and analysed all the interviews. Each interview started with a few general questions: "Can you describe your typical day of inhome care?", "Based on your experiences, what challenges and barriers adversely affect the quality of services provided during in-home care?", "What strategies do you suggest for improving the quality of in-home care services?" and "How have the existing barriers affected your performance as a caregiver?" Next, based on the participants' answers, follow-up questions would be asked to increase the clarity of the information, for example "Can you explain further?", "What do you mean by that?" and "Can you give an example?" The interviews were oriented around the main objective of the study. Each interview lasted from 38 to 52 min. Immediately after each interview, the first author would listen to the recorded interview several times and transcribe it. Immediate analysis of the data collected from each interview allowed the researchers to plan the next interview in view of the data they had obtained already from the previous interviews.

| Data analysis
The collected data were analysed according to qualitative conventional content analysis. Thus, based on the explicit and implicit content of the meaning units, key points in the transcripts were extracted as open codes. The open codes were classified based on their similarities and differences and the process of abstraction continued until a theme emerged (Graneheim & Lundman, 2004). Accordingly immediately after each interview, the first author (PS) transcribed the recorded content. At the reading stage, the transcripts were carefully read line by line and the significant paragraphs were marked to stand out. The words, sentences or paragraphs that carried significance about the challenges to efficient management of home care were also selected as meaning units. Each meaning unit was assigned a code. At the next stage, the second author (FM) reviewed the transcripts and verified the unit meanings and codes. The codes that were found to be similar and homogenous were then merged to form categories. To confirm the reliability of the codes, the researchers reviewed the categories and compared them with the primary data. Eventually, in several joint meetings, after contemplating and comparing the categories, the research team extracted the obtained themes. MAXQDA software 10.0 R250412 was used to help data analysis and classification (Table 2, Example of data analysis process).

| Rigour
To test the trustworthiness of the data, the researchers applied Lincoln and Guba's criteria (Cypress, 2017). Accordingly, to ensure credibility, the researchers used prolonged engagement with data, member checking and peer debriefing. For member checking, 5 members of the nursing staff were asked to evaluate a copy of the encoded interviews. For peer-checking, 7 experts were asked to examine the process of data analysis and verify the codes and categories. The dependability of the findings was enhanced by describing the methods of coding the concepts and themes and providing textual and audio data. Moreover, three members of the research team examined the findings separately and subsequently discussed them to resolve any disagreements towards ensuring dependability.
To ensure the confirmability of the data, the researchers presented the participants with the encoded data and asked them to confirm the accuracy of the extracted categories and subcategories. By providing detailed information about the respondents' characteristics, manner of conducting the interviews, and the methods of data collection and data analysis, along with documented examples of the participants' quotes, the researchers increased the transferability of the study results. The study subjects were selected in view of the objectives of the study and in an unbiased manner. As soon as they were collected, the data were analysed to help the researchers be aware of the development of the research.

| Ethical considerations
All participants gave written informed consent to participate in the study. The present study was conducted in accordance with the prin-

| RE SULTS
In this study, 19 nurses (12 male and 7 Female) participated with the clinical nursing experience of 2-18 years. The 4 main themes and 15 subthemes extracted from the data are shown in Table 3.
In this study, the forward-backward method was used to translate quotations. The quotations were first translated into English by a bilingual person (fluent in Persian and English) and then translated again from English to Persian by another bilingual person.
Researchers and some participants reviewed the text translated from English to Persian to make sure the meaning is the same.

| Lack of effective and comprehensive standards
One of the extracted main themes was lack of effective and comprehensive standards which consists of the subthemes of lack of effective protocols for in-home care and lack of organizational protocols (lack of protocols for evaluation of the performance of caregivers and lack of protocols for evaluation of the performance of organizations which offer in-home care services).
3.1.1 | Lack of effective protocols for in-home care

| Lack of organizational protocols
Lack of organizational protocols, the other subtheme of lack of effective and comprehensive standards, consists of two subcategories: lack of protocols for evaluation of the performance of caregivers and lack of protocols for evaluation of the performance of organizations which offer in-home care services.

| Shortage of organizations which provide in-home care
Commenting on the number of home care organizations, one of the participants stated that: "In our country, the role of home care institutes has not been established clearly yet and the number of the existing institutes is not nearly enough to meet the needs of patients and the society" (P13).

| Concentration of in-home care organizations in big cities
According to one of the participants: "Most of the available home care institutes and agencies are located in big cities and the people in small towns can't benefit from their services. It is necessary that the government and the policymakers in the healthcare system take steps to develop such centres in small towns too so the ideal of social justice in equi-

| Lack of equipment and efficient personnel
Based on the participants' experiences, lack of equipment and experienced personnel is a major barrier to efficient management of in-home care, with adverse effects on the quality of care. One of the participants stated that: "At some home care centers, there is a lack of essential equipment. Some of their equipment is old and in need of repair. I've often had to use a suction machine to extract secretions from my patients' airways, but the machine is old and doesn't work right. And when I tell our manager, he says, "New equipment will cost an arm and a leg and we can't afford it, so just use the one you have" (P2).
According to another participant: "Home care organizations just don't care about the quality of care. To keep their expenses low, they hire inexperienced personnel. I've even seen them employ nursing students in some cases. In my opinion, this is blatant disregard for the patients' rights and puts their safety at risk" (P18).

| High costs of in-home care
The high costs of in-home care pose another barrier to efficient management of in-home care from the participants' point of view.
According to another participant: "The cost of home care is really high. Unfortunately, insurance companies don't cover home care expenses and the patients themselves should pay the costs, which puts extra burden on the patients' families. Very often, I've seen patients who needed several weeks of home care, but because they couldn't afford it, they decided to cancel their services after a week or two" (P11).

| Professional issues
Another theme in significant barriers to efficient management of inhome care was found to be "professional issues" which consists of the following subcategories: caregivers' physical and psychological safety, occupational burnout and occupational stress.

| Caregivers' physical and psychological safety
The participants' experiences showed that another major barrier to efficient management of in-home care was putting the caregivers'

| Occupational burnout
Based on the participants' experiences, the nurses who provide

| Occupational stress
The participants' experiences showed that the nurses who provide in-home care services are subject to considerable occupational stress and anxiety. As one of the participants stated: "Caring for patients, especially those who are seriously ill, in their homes is so stressful. If the smallest thing happens to a patient, we really don't know who will defend our rights. Giving home care is taking a big risk and you should be prepared for the consequences" (P16).

| DISCUSS ION
The present qualitative study was conducted to identify the barriers to efficient management of in-home care. The experiences of the inhome care nurses who were interviewed in the present study show that the barriers to efficient management of in-home care are comprised of lack of effective and comprehensive standards, ineffective interactions, inappropriate cultural/social context and professional issues. One of the major obstacles is lack of effective and comprehensive protocols, which consists of lack of effective protocols for in-home care, lack of organizational protocols, lack of protocols for evaluation of the performance of caregivers and lack of protocols for evaluation of the performance of home care organizations.
In the study of Heydari et al. (2016), one of the major challenges in in-home care is lack of executive protocols for caregivers who are involved in in-home care. The participants of the study stated that there was no formal training for examining and prioritizing patients, nor were there any clear instructions about payment of salaries, estimation of cost or qualification of caregivers in the home care system. The participants believed that protocols could help resolve conflicts between caregivers and home care agencies and improve the quality of nursing services, which ultimately increases patient satisfaction (Heydari et al., 2016).
Similarly, in their study, Fatemi et al. (2019) report that there is a lack of clearly stated standards and list of duties of caregivers in in-home care. Poor professional integrity, inadequate interaction between nurses and home care agencies, and lack of feedback from supervisors are reported to be other issues for in-home care nurses.
Lack of state guidelines is another challenge in nurses' providing quality care (Fatemi et al., 2019). American Nurses Association (ANA) has laid down standards for home care nurses and their professional practice. Designed to assess home care, these standards address examination, diagnosis, identification of consequences, planning, implementation, evaluation, ethics, education, evidencebased practice, quality of performance, communication, leadership, participation, assessment of professional performance, resource management and environmental hygiene. All home care centres are required to comply with these standards (Gorski, 2016).
In the United States and Australia, home care centres possess precise monitoring protocols and easy-to-use communication platforms. In many other countries, however, there is not a specific organization which is responsible for an accurate and thorough evaluation of the performance of home care companies (Palesy et al., 2018). In developed countries today, home care services are provided through smart, web-based networks which entail various forms of comprehensive evaluation, monitoring and coordination in order to ensure information security, facilitate the registration of and access to patients' medical history and reduce the cost of in-hardly answer their questions (Sundler et al., 2016). The results of another study show that successful palliative home care depends on intimate communication and cooperation between patients, patients' families, home care nurses and general practitioners (Arbaoui et al., 2012). It appears that in-home caregivers can benefit from training in verbal and non-verbal communication to understand their patients' entire needs. Person-centred communication and carerelated dialogs can improve the quality of in-home care services (Li et al., 2016).
Another major barrier to efficient management of in-home care was found to be lack of an appropriate cultural-social context for providing in-home care. This theme consists of the subcategories of an ambivalent attitude to in-home care, shortage of in-home care organizations, concentration of in-home care organizations in big cities, the government's failure to support patients who require in-home care and the organizations which provide in-home care services, lack of equipment and efficient personnel, and the high costs of in-home care. According to Heydari et al. (2016), one of the major challenges in home care nursing is the society's distrust of non-medical caregivers. In addition, the society's negative perception and distrust of doctors and healthcare providers' lack of security are significant barriers to in-home care. In-home care nurses enter the personal territory of patients and their families, but do not have a pre-determined care plan (Heydari et al., 2016). The results of the study of Heggestad et al. (2020) show that concern about failing to maintain patients' privacy, disrespecting patients' dignity and not showing respect for patients' autonomy are important ethical challenges in in-home care. Thus, in-home care providers should observe the principles of professional ethics throughout their practice and respect their patients' dignity while caring for them in order to encourage trust in home caregivers (Heggestad et al., 2020).
Financial difficulties pose another challenge to in home care nursing. The revenues of home care organizations often fall short of their running costs, and there is intense competition between these organizations. Social issues, lack of security and low social status are other problems which adversely affect nurses' motivation to work in home care organizations (Danielsen et al., 2018).
In-home care nurses also refer to lack of human resources and equipment as obstacles in their profession (Association, 2013).
According to a study, lack of insurance coverage restricts patients' access to in-home care services (Suurmond, 2016 (Fatemi et al., 2019). According to the study of Yang (2017), home caregivers' work environment is highly stressful as home caregivers are often subject to verbal aggression and other anxietyinducing behaviours on the part of their patients' families, with potentially adverse effects on their performance (Yang, 2017). Yasin et al. (2020) report that home caregivers are more prone to occupational burnout than doctors and medical assistants because the former are in the frontline of caring for patients and, therefore, experience more emotional tension and burnout. Also, organizational stressors, including delayed salary payment, lead to home caregivers' emotional exhaustion and occupational burnout (Yasin et al., 2020). Other stress-inducing factors for in-home care nurses are failure to be present at patients' residences at a prearranged date and time and fear of damaging patients' property (Cooper et al., 2016). Other studies report poor work management, lack of peer support, shortage of equipment needed for providing in-home care, low professional competence, unexpected events and inconvenient working hours to be causes of stress for home caregivers (Atashi & Nejatian, 2020). The study of Yoshimatsu and Nakatani (2020) shows that teamwork and cooperation between caregivers play a significant part in reducing home caregivers' depression and stress (Yoshimatsu & Nakatani, 2020). In addition to supervision on the performance of home care organizations, support for the personnel and provision of the necessary equipment, the organizational culture should encourage all home caregivers to cooperate with each other. These conditions can increase inhome caregivers' psychical and psychological security and reduce the risk of stress, emotional exhaustion and occupational burnout for them.

| IMPLI C ATI ON S FOR N UR S ING
Nursing managers can use the results of this study to identify and eliminate the factors affecting the optimal implementation of home nursing care and improve the quality and effectiveness of home nursing services.

| CON CLUS IONS
The in-home care nurses who were interviewed in the present study had experienced a variety of obstacles in their career, which indicates the gap between the quality of in-home care in Iran and the international home healthcare standards. Creating an appropriate cultural and social context in Iranian societies, providing a suitable infrastructure, including insurance coverage, clear, comprehensive guidelines for in-home care, promoting teamwork and organizing workshops to encourage effective communication between caregivers and patients can help improve the quality of in-home care in Iran.

CO N FLI C T S O F I NTE R E S T
The authors declare that they have no competing interests. Bijani, Data analysis. All authors read and approved the final manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.