Structural Barriers to High-Quality Home Healthcare Nursing: What Home Health Nurses Want Medicare Policy Makers and Agency Administrators to Know

Abstract

Previous research indicates home health nurses (HHNs) worry that current home health care trends are threatening their ability to provide high-quality nursing care. High-quality nursing requires patient-centered and culture-sensitive care. These 2 attributes are indicators of high-quality nursing care. In this qualitative study, 20 HHNs were interviewed to discover their insights into 2 research questions: What barriers affect HHNs’ ability to provide patient-centered, culture-sensitive, high-quality nursing care and how do these barriers affect HHNs and patients? Participants were professional HHNs who provided skilled intermittent care to diverse patient populations in their homes. Participants believed that a lack of time, high productivity requirements, pay-per-visit compensation, documentation burden, EMR systems, and the “industrialization” of HHNs’ practice create structural barriers to high-quality home health nursing. Medicare was perceived as contributing to the barriers with burdensome documentation requirements and regulations that impeded holistic patient-centered care. Nurse participants indicated that the effects of these barriers were nurse stress, burnout, moral distress, and intent to leave; lower patient outcomes and satisfaction; and healthcare disparities. Additional research about the structural barriers were reviewed and found to support the nurses’ perceptions of barriers to high-quality nursing care. In a value-based purchasing system, agencies need to support high-quality nursing care by tackling the barriers to its practice. To address the barriers comprehensively, agencies can institute policies that mirror the American Nurses Credentialing Center’s Pathway to Excellence^®. Medicare policy makers should examine how present policies adversely affect high-quality nursing care.

Introduction

As stewards of Medicare’s benefits, Medicare policy makers constantly search for ways to lower home healthcare costs. As Medicare implements new initiatives and payment systems to decrease costs, Medicare-certified home healthcare agencies experience payment-tightening pressures. Agency administrators, then, seek to decrease their costs with initiatives to increase efficiencies. Yet, little is known about how these agency initiatives impact the quality of care home health nurses (HHNs) provide to their patients or their effects on patient outcomes and nurse satisfaction with their jobs.

In a recent grounded theory study about how HHNs’ develop their skills for patient-centered care (PCC) and culture-sensitive care (CSC), one of the key findings was nurses felt cost-cutting trends in the home healthcare industry were adversely affecting their ability to provide patient-centered and culture-sensitive (PC/CS) care. ¹ Since patient-centeredness and culture-sensitivity are indicators of high-quality nursing care, ² nurses in this study felt that these trends were negatively affecting their ability to provide high-quality nursing care, which in turn affected patient outcomes and satisfaction. The nurse participants perceived these trends as structural barriers within their work environment, which interfered with their ability to deliver high-quality care and with their experience of job satisfaction.

The purpose of this study was to identify the structural challenges and barriers HHNs encounter when trying to provide high-quality nursing care. Knowing the obstacles HHNs face is the first step to addressing and overcoming them with innovative quality improvement strategies. Thus, the research questions for this study were: What obstacles affect HHNs’ ability to provide high-quality nursing care, and how do these barriers affect HHNs and patients? In this study, data from nurses was analyzed to understand their concerns with agency and Medicare policies that create challenges and barriers to high-quality nursing practice.

Methods

This study grew out of the larger, previously-cited grounded theory study about how HHNs develop their PCC and CSC knowledge and skills. ¹ For this current study, the focus is on one question included in the grounded theory study’s interview guide: “What challenges or barriers affect your ability to provide patient-centered and culturally competent care?” Although the answers to this question were briefly summarized in the original grounded theory study, the data obtained from this question were particularly deep and rich, extending beyond PCC and CSC to high-quality nursing practice. Thus, the data are worthy of independent analysis and discussion, which we provide with this study.

A qualitative interpretive design, and Corbin and Strauss’ ³ recommendations for trustworthiness, guided this study. The methods used to secure IRB approval, recruit participants, collect and manage data, and assure confidentiality and privacy of the data have been discussed in detail in the original grounded theory study, ¹ so are not repeated here. Eligible participants were 1) HHNs who were actively involved in providing skilled intermittent care to diverse patient populations or 2) HHNs who supervised or taught nurses who did. Nurses were recruited through home healthcare agency contacts, professional organization contacts and websites, an online discussion group, and snowballing. Each nurse participated in an in-depth interview, which was recorded and transcribed. Each transcript was analyzed for quotes indicating challenges or barriers to “good” nursing or PC/CS care. Nurses’ emotional and practice responses to these obstacles, and HHNs’ perceptions of how they affected patient care were also highlighted. A list of these quotes was constructed and the quotes were then categorized by type of barrier. In reporting the findings, some of the quotes were shortened or edited to render them more grammatically correct and easier to read. Also, to clarify the participants’ quotes, context was sometimes added.

Findings

Sample Demographics

The 20 HHNs who participated in the study were primarily White women (1 Black, 1 man). They practiced in 11 different states throughout the United States, mostly at Medicare-certified home healthcare agencies. Participants’ average age was 52.5 years, with a range of 28 to 68 years. They averaged 13 years of home health experience, with a range of 1 to 45 years. Educational preparation included ADN (4), BSN (11), and MSN, MPH or MS (5) degrees. Most worked as case-managing clinicians; some had supervisory or educational roles on a part- or full-time basis.

Barriers to Excellent Nursing Care

All nurses in the study perceived significant barriers inhibiting their ability to practice excellent nursing care, although they differed in their responses to these barriers. Although a few HHNs (4) responded with resilience and creativity, most felt overwhelmed and dissatisfied with the care they were providing. ¹ They felt they were hampered in their efforts to provide excellent nursing care by agency policies and processes that inadvertently made it difficult to practice according to nursing’s standards and values for high quality care.^{2,4 -6}

Lack of time

Almost all study participants believed that they did not have enough time to provide quality nursing care for their patients. Time pressures were related to productivity requirements and the documentation burden. For example, P7 said, “Time is one of the biggest barriers to good nursing care because if I had more time with the patients, they could make more progress. You’re limited in the amount of time that you can spend just because you have lots of other patients to see.” P17 reported, “I think in home care today, everybody is overworked and overwhelmed. One cannot work like that and give proper care. And I’m not just speaking about our agency, but I see it when I’m on the online home nurses’ discussion page. I hear continuously, ‘Too many patients, not enough time.’” P16 described the “too many patients, too little time” phenomenon in terms of Maslow’s hierarchy of needs, saying nurses only had time in a patient-packed day, to do the minimum needed to meet Medicare’s documentation’s needs.

Several nurses described how a lack of time impeded their ability to practice PC/CS care. For instance, P17 said, “I think working in this culturally diverse area increases nurses’ awareness of culture. Now, sensitivity is a whole other thing. Sensitivity means that you have the time to talk with the patient, such as asking the patient about their problems adhering to the Care Plan instead of quickly performing necessary visit procedures. And time to ask a couple questions that show you care about them as a person.” She then expressed how frustrated she was that she didn’t have time to be more sensitive to patient’s cultural needs. She went on to say,

“I really do believe most nurses really, truly, honestly want to be the best clinical nurse they can be. They want that, but when it dove-tails with being overextended, that’s when nurses are more task-oriented. ‘I’ve got to get these procedures done. I’ve got to get out of here because I’ve got other people waiting.’ I think that home care, from what I can see all over the country, does nursing a disservice by not allowing for more time to be with that patient. If only we had fewer patients to see in an eight hour period.”

P18 observed, “I think that, at least in the home health industry, nurses have become so overloaded with the quantity of patients they have to see in a day, they just go in and do the basics and then get out. So, I don’t feel like we can provide patient centered care.” As participants described the “lack-of-time” issue, their frustration was palpable. “The biggest barrier right now is time” (P19).

Other research studies provide support for these nurses’ perceptions. Providing care in stressfully time-pressured environments is associated with decreased patient safety, health outcomes, quality of clinical decision-making, and nurse engagement with patients^{7 -9} and with increased nurse stress and burnout, bias-driven care, healthcare disparities, and nurse intent to leave their current positions.^{10 -12}

Productivity requirements

Nurses blamed the lack of time primarily on productivity requirements and pay-per-visit compensation. Participants tended to believe that high productivity requirements were inconsistent with high-quality nursing care. P5 reported, “The focus is on productivity. The focus is on ‘get as many patients seen as possible.’ It pushes nurses to go faster and that makes it harder to give patient-centered care, because you’re rush rush rush rush rush. You’re like, I’ve got to get into this one, then I’ve got to go see this one. Boom boom boom boom boom.” A metaphor for how at least some nurses experienced productivity requirements is patients (like widgets) are quickly coming down the conveyor belt, so the nurses feel they only have time to do only the most critical tasks. P5 also said, “It is hard to provide patient-centered care because the agencies want nurses to do task-oriented care. So I think we’re very task-oriented. And we just have time to do the tasks. We’re not assessing the person like we should.” Being task-centered, instead of patient-centered, is beneath the standards for professional nursing practice. ²

Other researchers have also found that high nurse productivity (high patient/nurse ratios) have a negative impact on patient outcomes and increase nurse burnout both in hospitals and home care.^{13 -17} In a recent report, Doak and Crownover ¹⁸ found that nurse productivity levels of 6 or greater visits per 8-hour day were associated with average or below average Medicare quality scores, while agencies with 5.5 or less visits were associated with the highest Medicare quality scores.

Pay-per-visit

Five participants commented that pay-per-visit incentivizes non-PCC. P14 felt that it encouraged nurses to be more about the money than the patients. “They just want the money. They think ‘I can get 50 dollars a visit and I can make 50 visits a week, and I can make six figures a year!’ And they are just in and out, five, ten, fifteen minutes. That’s the time they put in and they think they’ve done their jobs.” Several nurses commented on how pay-per-visit puts some nurses into ethical dilemmas about their need to make an adequate income and their desire to provide PCC. P10 said, “The thing is time is money. The more time I spend with one patient, the less likely I can see another one.” P16 said, “Because you want to make enough money, you’re going to focus on the absolute needs and maybe not take that time to really explore things with the patient or the family.” She felt nurses felt guilty about compromising patient care by trying to make a certain income each day with more visits than quality care required. For some, this led to moral distress (anxiety that occurs when forced to do something against one’s values). P19 described in detail the pay-per-visit ethical dilemma many nurses face.

“I know one thing that irks a lot of our nurses, especially those that try to provide person-centered care, is that we get paid by the visit, not by the hour. So it’s very difficult to reconcile how much time you can give up to PCC. Because we could give time to addressing the patient’s concerns and individualized needs but if you’re only getting paid $40 a visit, and you’ve already driven 35 minutes to get to the patient’s home, you’re just trying to reconcile making sure that you keep yourself accountable for your own wages, and then also giving as much time as you can to the patient. Which is a tough balance.”

P16 added, “I think that’s the challenge. I think nurses should not be paid by the product, which is a patient. I think it’s just so absolutely wrong. I know it’s a major model out there, but I think that we really need to look at that, and I’m surprised that we don’t, given the focus on outcomes. As we move into the value-based purchasing, that task-orientation and quick visits is not going to make it.”

Nursing standards indicate that pay-per-visit compensation systems can put nurses in the midst of an ethical dilemma every day. ¹⁹ The American Nurses Association’s Code of Ethics for Nurses ⁶ warns nurses that their primary goal must always be the optimal health and well-being of their patients. It expressly warns nurses about compensation systems that reward nurses for quantity of care, putting them in a conflict of interest situation.

Documentation burden

Participants tended to perceive time spent documenting robbed them of time helping patients. P6 commented, “I think that nurses don’t have the time to help with the patients as much as they would like because they’re too busy doing all the paperwork.” P 20 said, “Charting is a barrier to good patient care. It’s incredibly burdensome because of Medicare requirements and the time that it takes to chart overwhelms the time that you have with the patient.” P 6 added, “We don’t have time to be patient-centered. We have to make sure that all this stuff is written down because Medicare’s not going to pay us if it’s not written. And that takes away from the time we have with a patient.”

Still, the participants recognized the importance of documentation, but they were resentful that so much of their documentation seemed repetitious and irrelevant to the patients’ needs. They complained that instead of documentation being about communicating with team members about the patient’s priorities, needs and preferences, the focus had to be about what Medicare wanted to see. For instance, P9 said, “So rather than charting by exclusion, I’m charting everything, every time.”

The documentation burden overwhelms many nurses, leaving some with a feeling of frustration and failure. It causes a loss of life-work balance and intent to leave. P8 reported, “Every nurse on my team is documenting at 9 or 10 o’clock at night” and P4 said “Every day, the paperwork and how rigid they are about it, makes me think, at least once, that it is time to retire.” P9 commented on how nurses could only give so much time to each patient each day, and that too much of that time had to be given to documentation, causing new HHNs to leave home health nursing. She said, “I think we’re going to have trouble keeping nurses in home care if we continuously pile on charting demands. That’s a sad thing. It’s a shame that we’re burdening home care nurses with this data collection system that in some ways is good, but in other ways makes nurses leave. Nurses just do not like to invest so much time in paperwork.”

Electronic Medical Record (EMR)

Another documentation issue inhibiting high-quality nursing care was agencies’ EMR systems. Participants came from 18 different home healthcare agencies, but all felt their agencies’ EMR systems, at least in some ways, hindered high quality nursing assessments and care planning. P5 commented on the rigidity of her agency’s EMR that made it time-consumingly difficult to capture the uniqueness of the patients’ needs on the assessment form. She stated, “I try to be flexible with my patients, but the EMR I’m using doesn’t do flexible.” P10 also reported that his agency’s EMR could not capture the individuality of the patient. “The forms are so cookie cutter that you can’t say anything about each patient’s unique needs. You don’t get a good snapshot of what’s going on with this patient.”

Participants described how their EMRs made it difficult for other nurses on the team to identify patient priorities and preferences. P7 observed, “It is so horribly painful in our system. There isn’t a way to put your details right into the assessment. So you put it into your narrative. But when the next nurse looks back at your assessment, the narrative is in a different section, so they don’t see it. So they don’t follow-up as they should.”

Other participants commented on the lack of cues for good nursing assessments on their comprehensive assessment forms. For instance, P8 reported, “There is next to nothing on cultural and spiritual factors, only ‘Do they speak a different language?’ I mean, there’s really nothing else.” They complained that the EMR assessments did not provide a place to document other elements important to a nursing assessment (e.g., the patient’s specific concerns, strengths and weaknesses, current disease management knowledge, specific factors that make it difficult to reach goals, etc.). They felt that this characteristic of their EMR systems inhibited good assessment, care planning, and communication between nurses and other care providers.

Research studies about EMR systems indicate they are exacerbating clinician burnout.^20,21 In a study of 870 physicians of diverse specialties, settings, and geographical locations, the physicians primarily ranked their EMR systems as “not acceptable” and there was an association of lower EMR ratings with physicians’ intent to leave clinical practice. ²² This finding echoes study participants’ perception of their home healthcare EMR systems. The “usability” of the various EMR systems seems to create barriers to documenting professional care.

Industrialization of home health care

Whether they worked for non-profit or for-profit agencies, many participants felt that their agencies were applying “business” strategies to delivering care services that were inappropriate to the humanitarian endeavor of home health care. Typical comments included “The business model they impose on us doesn’t jive with patient-centered care. I feel a lot of our care is about the bottom line. It’s not patient-centered; it’s about the agency making money” (P3).

Fragmented models of care delivery

Despite evidence that continuity of care (same nurse sees patient for most visits)^23,24 and that a caring, trusting nurse-patient relationship^25,26 promotes better outcomes, several nurses expressed concern about trends which fragment care between different RNs and LPNs/LVNs. P10 explained that care in his agency was split between an admissions nurse, a case managing nurse and LPNs who made most of the visits. He added, “I think if a single nurse could do the admission and then do the subsequent visits that would help with continuity of care.” This nurse was pointing out the deficits of an assembly-line approach to patient care and how it compromised high-quality nursing care, which is based on an ongoing therapeutic relationship with the patient.

Case managing nurses expressed concern about delegating visits to LPNs. For example, P10 commented on his agency’s push to delegate more visits to LPNs. “I am OK with LPNs doing some task-y type things, like wound dressings. But LPNs are task-oriented. A lot of my patients need an RN because they are unstable and need ongoing assessment, extensive disease management, medication management, education, and follow through on things.” This nurse believed patients need an ongoing relationship with a professional nurse on an ongoing basis to assure high-quality nursing care.

Additional research has found a link between poor continuity of care and increased hospitalizations. ²⁷ In addition, continuity of care in home health care was associated with higher Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey scores. ²⁴

Inadequate resources

Participants felt that some business decisions deprived patients of services and resources that would help patients meet health goals. P3 said, “They are very tight on what you can and cannot do because the new owner is a business, and they want to make money. I have a patient who needs expensive supplies for her wound care. When I ordered more supplies, they said, ‘You can’t order that. She’s gone over her budget for wound care supplies.’”

P1 discussed patients whose mental health problems adversely affected the patients’ capacity to achieve good physical outcomes. She felt the patient-centered thing to do would be to refer these patients for psych-mental health services. “We had a mental health team, which the new agency owner eliminated, and we don’t have it anymore. There is no money in mental health and so nobody has a mental health team and it’s all about money.” Another nurse talked about how nurses were discouraged from referring patients for social work services even though they had financial, transportation, family caregiver, and other issues. According to P1, “The agency limits how many visits social workers can make, and they really want them to be task-oriented.”

In an editorial for the American Journal of Nursing, Kennedy ²⁸ claimed current healthcare industry trends to decrease the costs of patient care were decreasing the quality of care and should be reconsidered. She reported that business decisions were “squeezing the humanity out of health care. . .[by] “downsizing staff and services, placing profits over patients. . .., and the nurses left were hard pressed to provide the care and teaching their patients needed.” (p. 27) ²⁸ When this happens, she stated nurses “stop treating patients as real people and more like assignments to get through on a shift.” (p. 27) ²⁸ In other words, nurses felt they were forced to abandon patient-centered care and instead practiced task-oriented care, even as Landers et al ²⁹ claimed that patient-centered care is an essential element of home care in their Future of Home Health Care report.

Medicare

Several participants blamed Medicare for policies that were compromising the quality of their nursing care. P6 commented, “The government is not being patient-centered. They’re about saving money.” P11 said, “There are a lot of barriers in home care. One that is at the top of everyone’s mind are all the regulatory pieces that Medicare is continuing to put on us, more and more data to collect and more things to document.” P9 expressed frustration with Medicare’s documentation policies. She said, “I spend so much time in front of a computer for much, much more time than is necessary. And to me that is a burden to the nurses and is driving nurses away from home health.”

P17 tied inadequate ongoing clinical education in home health care to Medicare’s reimbursement policies. “I do think that nurses would love to have more clinical and diversity training with case conferences and inservices. But it can’t happen. Nurses need to make visits for the agency to survive. It’s all home care has turned into—nothing but making quick visits and meeting regulations.” Other participants realized the purpose of the regulatory requirements, but felt they were having unintended consequences on patient care. Their complaints focused on Medicare’s changing payment models and start-of-care requirements.

Payment model

Data collection for this study was conducted in 2020, the first 6 months of the new Patient-Driven Grouping Model (PDGM), and participants felt this payment system (and previous changes in payment) were decreasing the quality of nursing care. Comments about the new payment model included, “PDGM is a big deal and we’re just not sure what’s going to happen to the agency this year (P6),” and “I just hope Medicare doesn’t kill home health care” (P5). These nurses were reacting to how their agencies were responding to new Medicare initiatives with increasing productivity requirements and cost-cutting policies that were negatively impacting their ability to practice quality nursing care. P6 said, “I’m very frustrated with Medicare. They are killing agencies with their rules and regulations. I understand the reasoning for it all, but the more this happens, I am so fearful about what the quality of home care is going to be.”

OASIS

Most nurse participants, even when they felt that the OASIS had good points, believed the OASIS assessment created barriers to a good nursing admission assessment of the patient’s needs. Some felt the skills necessary to accurately collect data according to Medicare’s criteria is different from the approach needed for a patient-centered nursing assessment. For instance, P4 said, “The people that make up these OASIS assessments, they’re not making them, so this patient gets good care. They’re making them to meet Medicare’s statistical needs for reimbursement and quality data.” P9 stated, “OASIS is actually a data collection system to get a profile of what the Medicare population looks like. And that’s all well and good. I’m not opposed to data, but much of the documentation we collect is irrelevant to this patient’s needs, yet it limits the number of patients I can see and the time I can spend with them.”

Although a comprehensive nursing assessment for patients in their homes should include multiple non-OASIS factors to create an effective care plan—such as, assessments of patients’ unique concerns, priorities, learning needs, cultural and life style preferences, etc.—some participants felt that there was no time to do these assessments after completing the “90 minute to 2 ½ half hours it takes to complete an OASIS assessment” (P9). P19 commented, “Now I feel our assessments are not patient-centered. I feel they’re very checkbox focused. You have to make sure to fill in these boxes. I feel there’s no time left to get to the person’s unique aspects. I am collecting data that really doesn’t assess my patient’s situation, so I know what I need to do for my patient.” These nurses felt the OASIS assessment took time away from a patient-centered assessment. P19 said,

“If the OASIS didn’t take up so much time, I would use that extra time to discuss the patient’s preferences, health beliefs, and what they’re expecting, and their goals and how they plan to achieve them, and religious and cultural preferences. More time understanding the patient as a person, less about hitting the same check boxes over and over again. What is impacting this patient’s ability to get better? How they’re defining what getting better means to them? Just looking at things from the patient’s viewpoint. I rarely have time to do that.”

Effects of barriers on nurses

Most participants reported considerable stress due to productivity and documentation requirements. Many were frustrated with the non-paid hours they spent doing paperwork, and the loss of work-life balance. As P8 reported, “Every nurse on my team is 9 or 10 o’clock at night documenting.” She also said, “Home care nurses are absolutely run ragged to the point of exhaustion.” Nurses responded to the stress of their jobs with different reactions. Some accepted the situation of not being able to provide the care they would have liked to give. They tried to do the best they could during their 8-hour days, knowing they couldn’t do it all and just did the best they could with a task-oriented approach to care.

Several participants commented that their productivity requirements required nurses to abandon patient-centeredness for task-centeredness. For instance, P1 said, “When nurses become over-extended, they become task-oriented. Everybody becomes focused on checking off what Medicare wants. It is not about patient-centered care, it is really just about getting the tasks done.” Another nurse reported, “Nurses are so overloaded with the quantity of how many patients they have to see, so they just go in and do the basics, and then get out. So I don’t feel the care we are providing is patient-centered” (P18).

For some nurses, not having time to provide patient-centered care led to guilt. They felt guilty that they could not meet Medicare’s visit requirements, their agencies’ expectations, and their own and nursing’s standards for quality nursing care. P17 said, “I really do believe most nurses really, truly, honestly want to be the best clinical nurse they can be. They want that, but when it dove-tails with being overextended, [they can’t].” In this situation, some nurses experience moral distress, which is associated with intent to leave one’s job.

Effects of barriers on patient satisfaction

Participants in the study were concerned that high productivity requirements jeopardized patient outcomes and satisfaction with care. For example, P17 reported, “Pushing nurses to the absolute nth degree erodes the amount of time they spend listening to and truly understanding their patients.” P 20 indicated that patients are more satisfied with their care when the care is patient-centered, taking the time to understand the patient as a person. P 16 said, “When care isn’t patient-centered, patients aren’t getting the best care. They’re not being understood. They’re not having plans developed with them that are doable, workable. If you’re not spending the time with the patient to really get the whole picture, you can’t offer them high quality care.”

Effect of barriers on disparities

Participants were told that research indicates that home care patients of diverse cultures and lifestyles suffer health disparities^{30 -33} and were asked why they think this occurs. Participants felt that, aside from discriminative biases and a lack of knowledge about cultural care, disparities were related to time pressures. Several nurses felt that patients “different from the norm” take more assessment time and more time to adapt the care plan to the patient’s cultural and lifestyle needs. Another felt it required more effort and time to develop a caring therapeutic relationship with minority patients.

Several nurses said patients who did not speak English were particularly challenging. These visits can take twice as long as a “regular” visit because the discussion is going back and forth between 3 people. P9 reported, “Some nurses don’t like the language lines and so they spend the minimum amount of time with those patients. And rather than trying to use the phone, which makes the visit twice as long, they just don’t use it. They just do their physical assessment without any discussion with the patient and go to their next patient.”

Each nurse has an idea of how long each visit should take to “meet productivity,” and tries to keep visits within that time frame. Several nurses indicated that it was impossible to take the time needed to meet the communication, assessment, and care planning needs of patients at-risk for disparities and still meet their agencies’ or their personal productivity requirements in a pay-per-visit compensation model. P10 admitted to not using the language line on time-pressed days, meaning less information was obtained from the patient and less education was given to the patient. Nurses, then, are tempted to “cut corners” due to time pressures, putting patients at risk for not receiving the time needed for good outcomes. Research supports that time pressures affect the quality of care provided to minority patients.^10,34

Discussion

Although several participants felt they could still provide high quality care through their resilience, their willingness to accept “what is,” and their creativity and critical thinking skills, ¹ most nurse participants in this study perceived multiple structural barriers to high quality nursing care. Most barriers are related to insufficient time to meet the standards expected by (1) Medicare, (2) the agencies they work for, (3) professional nursing standards and ethics, and (4) their own desire to provide high-quality caring and compassionate nursing care. Because of the perceived barriers these nurses encountered to patient-centered, culture-sensitive, high quality nursing care, most felt frustration, disillusionment, guilt, anger, burnout (stress-induced depersonalization of patients), emotional exhaustion, and a sense of personal ineffectiveness. Some experienced moral distress when they couldn’t do all that was expected of them—and they expected of themselves. They felt that agency and Medicare policies and processes were forcing them into task-oriented care, causing them to abandon their patient-centered ideals.

Some of the root causes of this lack of time are (1) high productivity requirements, (2) pay-per-visit compensation, and (3) documentation requirements that are perceived as irrelevant and repetitious because they do not facilitate individualized care for the patient. Other barriers to high-quality nursing care are (4) EMR systems that inhibit “good” nursing assessments, care planning and communication with team members about the patient as a unique person and (5) agencies’ tendency to treat healthcare as a revenue-generating “business” endeavor, who then eliminate continuity of care processes and other evidence-based resources considered “too expensive.”

Nurse Values

Nurses tend to be committed to high-quality nursing care. The Scope and Standards of Nursing ² require this commitment. These standards insist that “caring is the essence and heart of nursing,” (p. 11) ² that nursing procedures must be practiced within a “caring nurse-patient relationship,” (p. 5) ² characterized by PC/CS care(p. 6) ² in which the nurse brings “compassionate presence to the patient as a unique person with individualized care needs.” (p. 11) ² The Code of Ethics for Nurses ⁵ repeats these care standards as ethical requirements and also requires the nurse to develop a caring, trusting relationship with the patient, to care about the patient holistically and to adapt care to the patient’s individualized needs and preferences. This vision of nursing is instilled into nurses during their professional nurse training. It is how most nurses expect and want to practice nursing. When barriers interfere with their ability to meet this type of care, they feel frustrated, which increases burnout, moral distress, and intent to leave their positions.^7,12,35,36

Study Limitations and Strengths

This study was at risk for the same researcher and participant biases that threaten qualitative interview studies. Bias could be introduced into the way interview questions are asked or during the iterative analysis process. The participants self-selected to participate in the study, which could introduce a sampling bias. Their answers to interview questions could be influenced by social desirability and recall biases. To minimize these biases, Corbin and Strauss’ ³ recommendations for promoting the study’s rigor and trustworthiness were used to strengthen they study’s credibility, dependability, confirmability, and transferability (e.g., constant comparison, continual reflection, memoing, maximal variation, descriptive quotes, etc.). Strengths of the study also included the diversity of the participants’ ages, agencies, geographic location, education and years in nursing and home health nursing.

Implications

In less than 2 years, Medicare will begin paying home healthcare agencies through the value-based payment system. ³⁷ Agencies’ quality ratings, and thus payment, will depend on patient outcomes and patient satisfaction scores. HHCAHPS scores measuring patients’ care experience may make the difference in higher or lower payment. At the same time, the job satisfaction of HHNs will make a difference in agencies’ ability to hire and retain nurses to provide the high-quality nursing care. In this payment system, the concerns of this study’s nurse participants require attention. Their perceptions are their reality, and their experience of practicing home care nursing in the current environment, is contributing to nurse burnout, the home care nurse shortage and unimpressive patient satisfaction scores.

Nurses are attracted to working environments that honor their nursing values and their input about concerns and recommendations. For example, hospitals certified with the Magnet^® certification ³⁸ (an American Nurses Credentialing Center [ANCC] program developed to enhance nurses’ working environments and patient engagement), attract nurses seeking employment. In a recent systematic review, Magnet^® certified hospitals were also associated with higher nurse job satisfaction (e.g., less burnout, greater retention), better patient outcomes (e.g., patient satisfaction, clinical outcomes), and even cost-savings, such as decreased orientation costs and less falls and pressure ulcers. ³⁹ In another study, McCaughey et al ⁴⁰ reported that patients treated at Magnet^® hospitals had greater satisfaction with their care, and they recommended hospital leaders implement policies and practices consistent with the criteria for Magnet^® hospital designation.

The ANCC now offers a newer but similar program to the Magnet program that is more home healthcare agency friendly. The Pathway to Excellence^® accreditation program has the same objectives as the Magnet accreditation program. ⁴¹ It is a comprehensive way to address the concerns voiced by the nurses in this study. The program supports nurse engagement, nurse retention, interprofessional collaboration, patient safety, quality of care, and better patient outcomes. It does this by promoting agency structures that support:

• nurse inclusion in decision-making about agency policies that affect their practice by establishing a shared governance model within the agency,

• nurse well-being, supported by nurse working environments that minimize stress and burnout, honor nurse contributions, and promote work-life balance,

• quality of care based on nursing values, patient-centered/culture-sensitive care, evidence-based practice, and continuous quality improvement initiatives that result in optimal patient health and well-being outcomes. ⁴²

Jarrín et al ⁴³ found Pathway standards to be strongly and significantly associated with better home healthcare patient care and nursing workforce outcomes. By seeking Pathway to Excellence^® accreditation—or even by including their standards in their agencies’ policies and processes—home healthcare leaders can respond to what the study participants want their home health leaders to know about the structural barriers to high-quality home healthcare nursing. The Pathway to Excellence^® provides agencies with a comprehensive plan to increase nurse satisfaction with their jobs and to promote better patient outcomes. This is consistent with the Quadruple Aim of healthcare: (1) patient outcomes (population health), (2) patient satisfaction (patient experience), (3), health care provider satisfaction with their jobs, and (4) high quality care at the least cost. ⁴⁴

Conclusion

HHNs in this study had many concerns with their agencies’ and Medicare’s current policies and procedures, which they perceived as structural barriers to patient-centered, culture-sensitive, and high-quality nursing care. These barriers included: (1) inadequate time to achieve all that is expected, (2) high nurse productivity requirements, (3) pay-for-visit compensation systems, (4) inordinate documentation time, (5) difficult-to use EMR systems, and (6) “industrialization” of nursing practice with fragmented care models (which inhibit continuity of care, clinical judgment and expertise) and with decreasing resources for patient care. They also felt some Medicare policies inadvertently created barriers to high-quality nursing care, such as the ever-increasing documentation burden.

Participants believed that the barriers they encountered negatively affected patient outcomes, even contributing to minority, vulnerable, and marginalized patient disparities. They also felt that the barriers were associated with decreased patient satisfaction with care and to nurse burnout and intent to leave. The American Nurse Credentialing Center’s Pathway to Excellence^® program is one way to address and mitigate the barriers to patient-centered, culture sensitive, and high-quality nursing care in a comprehensive way. With the advent of value-based payment, agency leaders need to give nurses a voice in decision-making to achieve Medicare’s quality-based goals.