Optimization of home care nurses in Canada: A scoping review

Abstract Nurses are among the largest providers of home care services thus optimisation of this workforce can positively influence client outcomes. This scoping review maps existing Canadian literature on factors influencing the optimisation of home care nurses (HCNs). Arskey and O'Malley's five stages for scoping literature reviews were followed. Populations of interest included Registered Nurses, Registered/Licensed Practical Nurses, Registered Nursing Assistants, Advanced Practice Nurses, Nurse Practitioners and Clinical Nurse Specialists. Interventions included any nurse(s), organisational and system interventions focused on optimising home care nursing. Papers were included if published between January 1, 2002 up to May 15, 2015. The review included 127 papers, including 94 studies, 16 descriptive papers, 6 position papers, 4 discussion papers, 3 policy papers, 2 literature reviews and 2 other. Optimisation factors were categorised under seven domains: Continuity of Care/Care; Staffing Mix and Staffing Levels; Professional Development; Quality Practice Environments; Intra‐professional and Inter‐professional and Inter‐sectoral Collaboration; Enhancing Scope of Practice: and, Appropriate Use of Technology. Fragmentation and underfunding of the home care sector and resultant service cuts negatively impact optimisation. Given the fiscal climate, optimising the existing workforce is essential to support effective and efficient care delivery models. Many factors are inter‐related and have synergistic impacts (e.g., recruitment and retention, compensation and benefits, professional development supports, staffing mix and levels, workload management and the use of technology). Quality practice environments facilitate optimal practice by maximixing human resources and supporting workforce stability. Role clarity and leadership supports foster more effective interprofessional team functioning that leverages expertise and enhances patient outcomes. Results inform employers, policy makers and relevant associations regarding barriers and enablers that influence the optimisation of home care nursing in nursing, intra‐ and inter‐professional and inter‐organisational contexts.


| Stage 1: Defining the research question
The research question was defined in collaboration with nursing leaders in home and community care and other sectors on the Home Care Nursing Optimization Workgroup Advisory Sub-Committee (henceforth named the Advisory Committee) of the Ontario Ministry of Health and Long-term Care (including co-authors RV, RG, AW, AL).
The Advisory Committee identified seven domains considered to influence optimisation of home care nursing (Table 1)  What is known about this topic • The Canadian healthcare system is underperforming given financial investments.
• Changing population demographics and system pressures to shift care from acute care to community are driving demand for home care services.
• Nurses are among the largest providers of home care; optimising the nursing workforce can enhance health system performance and positively influence outcomes for clients with increasingly complex needs.

What this paper adds
• Numerous inter-related factors influence optimisation of home care nurses, who are critical members of the healthcare team.
• Results can inform other nations within similar contexts and experiencing home care sector challenges.

| Stage 2: Identifying relevant studies
With Advisory Committee input, the inclusion/exclusion criteria and search strategy were developed and implemented. Advisory Committee engagement increased the relevance of this review for practice and policy. Inclusion/exclusion criteria are detailed below (see Table 2).
Our search strategy included: electronic databases, grey literature and suggestions from Advisory Committee experts. The following databases were searched, adapting search terms according to each database's subject heading terminology and syntax re- Reference lists of included citations, key reports and organisational websites were hand-searched (Supporting material 2).

| Stage 3: Study Selection
Two researchers independently reviewed assigned titles and abstracts for relevance. Articles with no abstract or Domains influencing optimisation Definitions

Continuity of care and consistency of care provider
Continuity of care is "how one patient experiences care over time as coherent and linked" (Reid, McKendry, Haggerty, & Foundation, 2002). Consistency of care provider is an enabler of care continuity and refers to "…the patient's experience of a 'continuous caring relationship' with an identified healthcare professional" (Gulliford, Naithani, & Morgan, 2006) (p. 248)

Staffing mix and staffing levels
Staff mix is the combination of different categories of healthcare personnel employed for the provision of direct client care in the context of a nursing care delivery model (McGillis Hall et al., 2011), while staffing level refers to the number of patients per nurse and the skill mix of the staff (Royal College of Nursing, 2012) 3. Professional development to maximise nurses' continuing competency Professional development activities can support nurses in maintaining and continuously enhancing the knowledge, skills, attitude and judgment required to meet client needs in an evolving healthcare system (adapted from the Canadian Nurses Association [Canadian Nurses Association, 2016])

Quality practice environments
Quality practice environments (QPEs) maximise the health and wellbeing of nurses, quality patient outcomes and organisational and system performance. Features of QPEs include benefits and compensation, job insecurity, management issues, recruitment and retention issues, safety issues, restructuring and managed competition, work-related stress, and satisfaction (Based on RNAO's definition of a healthy work environment and six Healthy Work Environment Best Practice Guidelines (Registered Nurses' Association of Ontario, No Date)]

Intra-& Interprofessional and Inter-sectoral collaboration
Inter-professional collaboration involves a variety of healthcare professionals working together to deliver quality care within and across settings, while intra-professional collaboration involves multiple members of the same profession working collaboratively to deliver quality care within and across settings (College of Nurses of Ontario, 2014) 6. Enhancing scope of practice Enhancing scope of practice involves implementing evidence-based nursing roles that maximise both current scope of practice utilisation, and legislative/regulatory enhancements that expand the scope of nursing practice, to most effectively utilise the evolving knowledge, skills and competencies of the nurse to produce optimal patient/ client outcomes (

| Stage 5: Collating, summarising and reporting the results
Stage 5 involved collating, summarising and reporting results.  TA B L E 3 Types of evidence included in the review (n = 127)

| Factors influencing optimisation based on each domain
Factors (italicised) influencing optimisation of home care and reported outcomes are presented under each domain.

| Domain: Continuity of care and consistency of care provider
Evidence for this domain is widely supported in the reviewed literature, both in the empirical literature (quantitative, qualitative, mixed
Home care funding models also had an important influence on nursing optimisation. Managed competition refers to a process for contracting home care services among for-profit and not-for-profit organisations previously used in home care in Ontario (Abelson et al., 2004). Managed competition negatively impacted staff mixes and staffing levels. To win service contracts, home care agencies: competed for contracts through managed wages and benefits Uncertainty of contract renewals and threats or loss of a contract resulted in workforce destabilisation and a "climate of fear" (Kushner et al., 2008), which negatively impacted safety, care quality care, job performance, access to professional development , and recruitment and retention (Abelson et al., 2004;Shamian, Mildon, et al., 2006). System impacts included increased workforce casualisation (Bediako, 2002) and organisational nursing losses to other agencies or sectors Shamian, Mildon, et al., 2006).
Home care nursing leaders also require opportunities for leadership development to supervise and manage staff who often work in isolation (Andrews et al., 2010;Lankshear, Huckstep, Lefebre, Leiterman, & Simon, 2010). This was needed to build competence in leadership roles. Ongoing nursing leader development through distance-learning helped increase nurses' self-confidence in leadership (Lankshear et al., 2010).
Community nurses want more job permanence, income stability and full-time positions (Doran et al., 2004;Tourangeau et al., 2014); permanent contracts, working full-time and salaried pay are associated with negative turnover intention (Zeytinoglu et al., 2009).
System level funding influences quality practice environments.
Given the shifting focus from acute care to the community and home, it was estimated that by 2020, almost two-thirds (67%) of Canadian nurses will be working in community-based settings com-  Denton et al., 2006;Higuchi et al., 2002;Schofield et al., 2010), which has contributed to barriers to optimising HCNs.

| Domain: Intra-professional and, interprofessional and inter-organisational collaboration
This domain is supported by literature using a variety of methods with intra-professional collaboation addressed primarily in emipical studies (quantitative, qualitative and mixed-methods) and inter-professional and inter-organisational collaboration addressed in both the emipirical and other literature reviewed.

| Domain: Enhancing scope of practice
Two factors influenced nurses' scope of practice-changing role expectations and functions of HCNs, and the organisation of case management functions. This domain is supported by both empirical and position/discussion papers within the reviewed literature.

Changing expectations of the roles and functions of HCNs contrib-
uted to a lack of role clarity and definition (Schofield et al., 2010); for effective community health practice, leadership needed to better understand the roles of RNs and LPNs . Some administrators are unsupportive of nurses and question their work, which is juxtaposed with the need for HCNs to have the freedom to practice to full scope (Schofield et al., 2010) particularly within inter-professional teams (McWilliam et al., 2003). With the growth in home care, nursing roles have changed to include: more care administration functions (Alameddine, Laporte, Baumann, O'Brien-Pallas, Croxford, et al., 2006); redistribution of work (Bediako, 2002); system navigation (Caplan, 2005); collaboration with physician practices (Korabek et al., 2004); delegated tasks from the RN to the LPN (Home Care Sector Study Corporation, 2003a); and expanded roles for RNs in rural and remote regions (VON Canada, 2005). LPN roles could be maximised to include client admission assessments and leadership roles in quality improvement initiatives (Meadows & Prociuk, 2012). Barriers to HCNs working in expanded scopes of practice include a continued focus on the medical model restricting delivery of holistic care and health promotion (Underwood, 2003).

Organisation of case management functions further influences
HCNs' scope of practice. For example, RNs employed by Community Care Access Centres in Ontario took on the role of assessment and consultation, then handed off care to nursing agencies (Alameddine, Laporte, Baumann, O'Brien-Pallas, Croxford, et al., 2006), often with LPNs to deliver care (Meadows & Prociuk, 2012). Others have identified that removing the case manager role from direct care providers has limited HCNs' sense of autonomy and scope of practice (Kushner et al., 2008). screening and assessment tools (Black, Barzilay, & Sheppard, 2010;Forbes & Edge, 2009;Nagle & White, 2013), electronic health records and tele-health (Canadian Healthcare Association, 2009), as well as providing access to information resources (Doran et al., 2010) can help optimise HCN. Commonly reported benefits of ICT use includes improved: care quality (Canadian Healthcare Association, 2009;Caplan, 2005); coordination of care (Canadian Healthcare Association, 2009;Canadian Homecare Association, 2009;Goodwin et al., 2008;Nagle & White, 2013); and, access to and exchange of information between providers (Canadian Healthcare Association, 2009;Canadian Homecare Association, 2009;Canadian Nurses Association, 2013;Denton et al., 2003;Goodwin et al., 2008;Higuchi et al., 2002). Electronic health records enabled information sharing and care continuity between HCPs, and reduced duplication of documentation and risk of errors, (Canadian Healthcare Association, 2009;Canadian Nurses Association, 2013;Caplan, 2005;Doran et al., 2014;Nagle & White, 2013).

| Domain: Appropriate technology
Related to the domain inter-organisational collaboration, shared electronic documentation of patient information was critical to effective collaboration (Doran et al., 2014) Goodwin et al., 2008;Higuchi et al., 2002;Home Care Sector Study Corporation, 2003a;Lehoux et al., 2003). As in our scoping review, the UK and European nations have reported that HCN are experiencing burnout related to the heavy workloads and emotional demands of home care nursing which is exacerbated by a lack of recruitment to home care nursing and an ageing workforce (Morris, 2017;Vander Elst et al., 2016). A Belgian study found that task autonomy, social support and opportunities for learning could buffer workplace stresses (Vander Elst et al., 2016). A recently published Canadian study (Tourangeau, Patterson, Saari, Thomson, & Cranley, 2017) confirmed our findings that HCN retention was related to a number of modifiable factors including:

| D ISCUSS I ON
income stability, meaningfulness of work, continuity of care, positive relationships with supervisors, work-life balance, and satisfaction with salary and benefits. One factor related to retention in this study that was not revealed in our review included nurses' perceptions of the quality of care provided by their organisation (Tourangeau et al., 2017).
Krietzer and colleagues argue that dissatisfaction in the US nursing workforce is related to bureaucratic structures, poor working conditions, and a loss of autonomy which has led to shortages in the workforce (Kreitzer, Monsen, Nandram, & De Blok, 2015). In contrast, an innovative self-directed nursing team model of care-Buurtzorgdeveloped in the Netherlands has shown to increase nursing satisfaction and a sense of autonomy over patient care, particularly for nursing assistants and bachelor's degree prepared nurses (Maurits et al., 2017). These autonomous nurse-led teams have been shown to spend little time on administration by using computerised systems, make local connections, and support continuity in care (Dharamshi, 2014;Sheldon, 2017). Other characteristics of the model include: nursing engagement in developing creative solutions to problems, simplified billing, financial stability, low overhead, web-based communities of practice, and administrative management (Kreitzer et al., 2015). Such innovative models in home care need to be explored more fully in light of growing care demands and fiscal realities as their potential to fully optimise HCN.
Of the 127 including papers, most conducted descriptive studies or program evaluations using qualitative (n = 30), qualitative (n = 17) or mixed methods approaches (n = 23), while three papers involved an experimental study and one applied an uncontrolled quasi-experimental study. This points to the need for rigorous experimental studies to better understand what and how interventions can support optimisation of HCNs while ensuring positive patient outcomes. Given the complexity inherent in the optimisation of HCNs, future pragmatic trials are recommended. The strength of pragmatic trials is that they are implemented in real world conditions allowing for their results to be applied in routine practice settings (Patsopoulos, 2011).
A limitation of this scoping review is that many of the primary sources lacked specifics to identify roles, functions, and educational preparation of the nurses. As such, we were unable to map the literature by sub-populations of nurses. This scoping review did not assess the scientific rigor of research studies, however it followed all recommended steps of a scoping review (Arksey & O'Malley, 2005) and maps over 20 years of home care nursing literature of Canada.

| CON CLUS IONS
The results from this review of Canadian literature highlights that a broad range of complex and interrelating factors influence the optimisation of the HCN workforce. These results can inform policy makers, home care employers, managers and service providers within Canada and beyond on strategies to optimise home care nursing, since other nations report similar challenges in meeting demands for HCN services. It is critical to ensure that the HCN workforce works to full scope, ensuring appropriate staffing and skills mix working in teams, role clarity and leadership support, which are supported by technology and quality practice environments in order to meet the complex needs of patients needing nursing care.