Balancing between extremes—Work in hospital‐at‐home

Abstract Aim To describe HAH staff's perceptions about HAH care, including work structures, processes and outcomes. Design Cross‐sectional descriptive study of three HAH units in Finland. Methods Three focus group interviews of interprofessional staff members (N = 24) were analysed through thematic content analysis (COREQ). In addition, an audit visit was conducted at Guy's and St Thomas' @home service, the United Kingdom. Results The Finnish HAH staff perceived they were balancing between different extremes: the patient's and his/her near‐one's opinions and wishes, well‐being and integrity, the promotion of person‐centred care and own work safety, a deeper meaning for work and the need for further support. Both in Finland and the UK, patients were perceived to be satisfied with care and HAH was perceived to save hospital bed places.

| 399 VAARTIO-RAJALIN eT AL. aid offered by social care, primary and rehabilitative nursing care, as well as respite care provided to informal caregivers (Genet et al., 2011). Home health care encompasses a range of activities, from preventive health work to palliative care, all with the goal of enhancing patients' functional health status and quality of life (Brazil et al., 2012). Nowadays, home health care is even offered cumulatively and as part of primary health care: to pertinent working age individuals, individuals with mental health problems, families with ill children and terminal phase patients (Ministry of Social Affairs & Health, 2017).
Furthermore, the emergence of the trend towards hospital avoidance has led to the development of care being provided through hospital-at-home (hospital-in-the-home, patient-centred medical home) services, with the acronym HAH hereafter used to refer to such care services.
Hospital-at-home is a service alternative usually discussed in relation to hospital avoidance or early patient discharge from hospital care, because one objective underlying the increase in HAH is the reduction in healthcare costs (Toofany, 2008). HAH can be offered as form of primary, specialized or private care or as a combination of these. In one scoping review (Vaartio-Rajalin & Fagerström, 2019, N = 35), researchers found that before a planned hospital stay or in conjunction with hospital discharge, a physician or a rapid response team should conduct a holistic assessment of a patient's physical and psychological health, acute and chronic symptoms, symptom distress, functional status, disease stage, comorbidities and motivation. This assessment could be performed at the hospital, during a proactive or acute, unscheduled home visit or by telephone call. At a minimum, subsequent to a patient giving his/her informed consent to receive HAH, the preparedness of the patient's near-ones to shoulder some responsibility for the patient's care should be explored. In an interview study of HAH patients and their near-ones (N = 45), researchers found that patients' near-ones may be elderly, have some health problems themselves or experience altered social roles stemming from HAH  being too burdening (Farina, 2001). The broadness and depth of this assessment should, of course, correspond to the reason underlying a patient's need for HAH, including anticipated length of care.
To ensure that patients' needs are met, a comprehensive professional competence framework that incorporates the coordination of multiple systems and intra-and interprofessional collaboration is needed (Larsen, Broberger, & Petersson, 2017). Following an initial pre-admission assessment, for HAH staff HAH care includes planning, coordinating, implementing and evaluating advanced care, that is the monitoring of medicine compliance and patients' clinical condition (Ministry of Social Affairs & Health, 2017), taking blood samples and other measurements, giving different infusions and transfusions, intravenous injections or respiratory treatments (Bäcklund et al., 2013). Furthermore, HAH care includes informing, educating, coaching and supporting patients as well as their near-ones in home care activities and in adapting to role and relationship transitions.
HAH is realized in interprofessional teams (comprised of a physician/ geriatrician and a nurse; possibly even social workers, pharmacists, nutrition therapists or physiotherapists) together with patient's near-ones. In regard to the nursing being provided, HAH activities are realized by either registered nurses (RNs), district nurses (DNs) or advanced practitioner nurses (APNs) .
There are some profession-specific competency requirements for HAH staff. In a scoping review, researchers found that the competence framework for rapid response team members was comprised of 2-30 years clinical experience in a specialty, the undertaking of a physical assessment, the completion of a clinical reasoning course at degree or Master's level, the completion of non-medical prescribing studies, having a clinical supervisor and engaging in self-reflection through the use of a competency workbook . Other researchers have seen that the competence framework for those engaged in rapid response team work but not nursing per se included employment in senior roles in acute hospital settings, specialization or experience in acute care, oncology or gerontology, having or working towards a Master's level degree in advanced practice and/or having completed modules in advanced physical assessment skills and having completed a non-medical prescribers course (Öhlen, Forsberg, & Broberg, 2013). Also presupposed were, for example psychosocial (Pusa, Hägglund, Nilsson, & Sundin, 2015), communicative, cooperative (Bäcklund et al., 2013), technology, evidence-based and documentation competencies (Öhlen et al., 2013) and leadership competencies (Lagerstedt, 2012).
There are no specific competency requirements in Finland for staff working in HAH other than the requirement to hold a Bachelor of Health Care, Nursing degree (210 ECTS), which results in qualification as an RN. Still, the National Supervisory Authority for Welfare and Health and the Regional State Administrative Agencies monitor all healthcare services and healthcare organization employers are required to check that all employees have relevant qualifications and the professional competencies needed for the tasks they will perform, especially in relation to medication and device security.
The National Institute for Health and Welfare can also set additional competence requirements for employees in relation to a given work place. In an interview study of HAH patients and their near-ones , researchers saw that the participants (N = 45) perceived the important characteristics of HAH nurses to include not only professional clinical competence but also servicemindedness and flexibility, as well as respect for the patient's situation, home and right to participate in decision-making.
Advanced practitioner nurses are often responsible for clinical history taking, drawing up care plans and coordinating care teams (Fagerström, 2010). In the home care context, APNs are known to shoulder great responsibility for the advanced health and nursing care being received and researchers have demonstrated that APNled care results in equivalent or better outcomes than physician-led services in regard to the reduction in symptom burden, self-management and behavioural outcomes, disease-specific indicators, patient's satisfaction and perception of quality of life and health service use (Chan et al., 2018;Pouliot, Weiss, Pratt, & DiSorbo, 2017;. The ICN Nurse Practitioner/ Advanced Practice Nursing Network (https ://inter natio nal.aanp. org/Pract ice/APNRoles) defines an APN as, "a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country where s/he is credentialed to practise." Compared with specialist nurses, APNs generally have a 2-year Masters level degree and more advanced skills in advanced nursing and medical care and, usually, the extended authority to prescribe medication. APNs are also to some extent involved in research assistant duties such as enrolling study subjects, abstracting medical records, collating study materials or disseminating completed study results, which are important when developing and evaluating evidence-based care structures and processes.
While clinical symptoms primarily guide the decision-making process connected to HAH planning, implementation and evaluation, the "whole patient," seen as a psychosocial and existential person, must be taken into consideration during care at home. The patient's near-ones should also be engaged in HAH care-related processes (Ewing et al., 2015), because a patient's near-ones can experience different role and relationship transitions stemming from HAH . Such patient and near-one engagement is one dimension of person-centred care, which has been defined as: education and shared knowledge in terms of timely and complete information on patient prognosis, progress and disease process; appropriate involvement of family and friends in decision-making and information giving; the sense of inter-provider collaboration and team management; sensitivity to non medical and spiritual dimensions of care; and respect for patient needs and preferences in care. (Shaller, 2007) Person-centred care has also been defined as respect for the personal narratives that reflect a person's sense of self, lived experiences and relationships and the recognition of this respect through the safeguarding of a partnership in shared decision-making and in meaningful activities in a personalized environment (Ekman et al., 2011;Kitwood, 1997;McCormack & McCance, 2006). In a scoping review with an HAH context (Vaartio-Rajalin & Fagerström, 2019), researchers found that patient-centredness was perceived as respect for a patient's autonomy, self-determination capacity and social relationships and made concrete through a continuous, trustful relationship established during the planning and evaluation of care by nurses together with the patient and his/her near-ones. Patientcentredness was thus based on the patient's needs while still being financially viable, with care taking place in the patient's home (seen as the patient's "own") environment. In that review, APNs, DNs and/ or RNs were considered an instrumental factor in the facilitation of patient-centredness (Jeangsawang, Malathum, Panpakdee, Brooten, & Nityasuddhi, 2012;Ljungbeck & Sjögren-Forss, 2017;Pusa et al., 2015). In other research on HAH outcomes, patients and their nearones were seen to have experienced safety, satisfaction, reduced clinical symptoms and better physical, mental and social functionality due to enhanced choice and support from the team providing home care . The aim of this study was to describe how interprofessional HAH staff perceive HAH care, including work structures, processes and outcomes. The research questions concerned HAH staff's perceptions of HAH, including work structures, processes and outcomes: • How are the patient and his/her near-ones taken into consideration both before and during the HAH care process?
• What all does HAH care involve and how does the patient's home affect the HAH care process?
• Which professional competencies are relevant and what does interprofessionality mean in the HAH context?
• What is the effect of HAH care?

| ANALYS IS
The data were tape-recorded and analysed through inductive thematic content analysis (Elo et al., 2014) with a focus on manifest content. As units of analysis, both sentences and parts of the text that represented the idea underlying the whole were applied (Table 2).

| RE SULTS
Altogether three interprofessional teams (N = 24, 20 nurses and four physicians, age 26-58, mean 44) with care work experience ranging from 3-30 years (mean 20.8) and HAH work experience ranging from 2.5 months-18 years (mean 6.6) were interviewed. Of the participants, two nurses were enrolled in an APN educational programme, two physicians had no specialization and two were specialized in internal medicine.
In Focus group A, there were four nurses and one physician, age 27-48 years (mean 40), care work experience 5-20 years (mean 11) and HAH work experience 3.5-7 years (mean 4.8). In Focus group B, there were five nurses and one physician, age 37-58 years (mean 50), care work experience 15-30 years (mean 28 years) and HAH work experience 2-3.5 years (mean 2.9). In Focus group C, there TA B L E 2 Examples of content analysis

Codes Subcategories Category Theme
The patient is asked how he/she manages at home The patient is asked how he/she perceives he/she currently manages at home The patient is asked how he/ she perceives he/she currently manages at home The patient is asked whether he/she has previously used home care services We ask about his/ her near-ones and whether they can assist him/her at home The patient is asked about near-ones and previously used service forms when HAH care is considered When HAH care is considered, the patient and near-ones participate in the decision-making Pre-admission to HAH: Balancing between the patient's and his/ her near-ones' opinions and wishes The patient is asked where he/she wants to receive care The patient expresses his/her desire to be cared for at home The patient states, "I want to go home." The patient is asked where he/ she wants care to take place The patients' near-ones are asked whether they accept HAH care prior to the start of care The near-ones are also asked for their opinions The patient's near-ones are asked whether they accept HAH care TA B L E 3 Subcategories, categories and themes

Subcategories Categories Themes
The patient is asked how he/she perceives he/she currently manages at home The patient is asked about near-ones and previously used service forms when HAH care is considered The patient is asked where he/she wants care to take place The patient's near-ones are asked whether they accept HAH care When HAH care is considered, the patient and near-ones participate in the decision-making Pre-admission to HAH: Balancing between the patient's and his/her nearones' opinions and wishes The nurse makes observations during the first home visit The patient and his/her near-ones are given a chance to reveal narratives The patient's extended family is taken into consideration as being important for the patient The care is flexibly planned in accordance with the patient's situation, needs and preferences The patient is involved in the evaluation and development of care near-ones were found to have mixed feelings and were perceived to feel thankful, feel content and feel relief that care was organized in the home, but could also feel burdened and experience an intrusion into their private space: We have very thankful patients and near ones, it is the main thing which helps one to go on…Their respect is more tangible in the home than in the hospital. They prefer that we are the same nurses all the time, not a new nurse every shift and every day… they feel safe.

(Focus group A)
In all the care evaluation questionnaires we have collected for 11 years, the patients always mention first that they perceive HAH care to be safe… I had always thought that ICU would be safe, but that HAH care…It could have to do with the home context as such, the safe place. They feel safe even though there is no nurse present [around the clock]… One patient told me that on the ward he had to wait for a nurse for over one hour, but at HAH we always answer the telephone and arrive at [a] home within 20 minutes, if necessary.
(Focus group C) The patients recover much sooner, don't get any bacteria like in the hospital… They rehabilitate themselves merely by doing ADL activities at home, they eat better, sleep better…They enjoy their normal life despite the health problem! They have a lot more social contacts, friends and relatives visit them at home rather than in the hospital…Some of them go to work, visit the theater or cinema, take a trip somewhere… (Focus group C) The patient's near-ones feel relief when their lovedones are at home and they know they can ask us, call us… But sometimes the near-ones don't want the patient to receive care at home, because they are so tired of their official caretaker role and prioritize a short period of free time, when the patient is taken to the ward for care.
(Focus group C) The patient's near-ones can also become quite tired of having us in their homes for a long period of time, it is understandable… It disturbs their private life and private sphere… (Focus group B) In regard to outcomes on the staff level, the participants perceived they were balancing between a deeper meaning for one's work and the need for further support. The HAH staff were found to perceive that a deeper meaning underlies HAH care and were seen to perceive a deeper patient-nurse relationship, simultaneously experience independence and genuine collaboration in HAH care compared with hospital care, feel motivated to work, acknowledge the effectiveness of their work and feel a desire for professional development. At the same time, they could perceive a need for support and they were seen to feel challenged and frustrated: This work at HAH is different from ward care because here you have to give something of yourself… it also helps the trust relationship to develop when you tell the patient a little bit about yourself… to be a human being to another human being.

(Focus group A)
This is at the same time independent work and col-laboration…You always have some back-up…the physician is always available, you don't need to wait until the next day or next shift.
(Focus group C) HAH does not automatically lead to economic bene-  Finland and the possible challenges associated with the work conditions in the Finnish setting. In the UK, matrons with a CNS or MNSC education played a central role in care planning and plan revisions (c.f. Fagerström, 2010;Öhlen et al., 2013). Yet in Finland only two participants were seen to possess an advanced education (in the form of ongoing APN education) and they performed the same tasks as the other Finnish HAH nurses, despite APNs being seen as central to the facilitation of patient-centredness (Jeangsawang et al., 2012;Ljungbeck & Sjögren-Forss, 2017;Pusa et al., 2015).

| D ISCUSS I ON
Nevertheless, it would seem that person-centredness is more explicit in the Finnish rather than the UK setting in regard to HAH structures and processes. In Finland, both the HAH patient and his/ her near-ones are taken into consideration before and during HAH care and the pre-admission phase was seen as balancing between the patient's and his/her near-ones' opinions and wishes, while the HAH care process included focusing on both the patient and his/ her near-ones during care (c.f. Ewing et al., 2015;Farina, 2001;Landers et al., 2016;. This is in line with the definition of person-centredness as the appropriate involvement of family and friends in decision-making and information giving (c.f. Shaller, 2007) and respect for relationships and the recognition of this respect through the safeguarding of a partnership in shared decision-making (c.f. Ekman et al., 2011;Kitwood, 1997;McCormack & McCance, 2006).
In Finland, the patient's home was perceived as balancing between the promotion of person-centred care and own work safety, while in the UK work safety was paramount and better safety structures were in place, including working in pairs, own drivers and the use of safety devices, all for the purpose of ensuring time for the realization of person-centred care. Both in Finland and the UK, verbal informed consent was sought from patients during the admission phase, but in Finland patients' near-ones were also asked whether they accept HAH care and were ready to bear some responsibility as co-clients (c.f. . Also, while in both settings patients were asked to provide feedback about HAH care, in the UK all HAH patients were given a health outcome form at the beginning and end of the care period and illness-specific questionnaires (if available). This would be highly recommended also in Finland, because it would facilitate the gathering of evidence-based data and thereby decision-making in relation to the effectivity of and use of relevant resources in HAH.
Despite the slightly different patient groups, HAH in the UK setting appeared to have a stronger focus on tangible curative interventions and coordination than what was seen in the Finnish setting, which was "Coordinating and developing safe patient care through tangible and intangible measures." This difference between the settings may be due to the continuous MDMs seen in the UK, where because each patient situation is discussed there is subsequently no need for additional, separate reports, documents or advocacy activities. It would be important to explore how such kinds of structures and processes affect HAH staff outcomes. As seen here, the HAH staff in Finland perceived they were continuously balancing between the patient's well-being and his/her near-one's integrity and balancing between a deeper meaning for one's work and the need for further support.

| CON CLUS ION
Based on the data sets seen here, it appears that HAH care in the UK is well structured and allows for processes and outcomes to be more easily identified than in HAH care in Finland. In Finland, where the HAH system is newer and still somewhat non-systematic due to its vague structures and processes, a lot of balancing was seen between different extremes. Nonetheless, as only three units in Finland and one unit in the UK were included in this study, these results cannot be directly generalized.

CO N FLI C T O F I NTE R E S T
No conflicts of interest to state.