Nurses’ emotional challenges in providing home care in Norway

Abstract

The aim of this study was to examine registered nurses’ experiences of emotional challenges when providing home care for older patients. Previous studies have shown that home care nurses encounter increased responsibilities and emotional challenges when caring for older patients with multiple diagnoses. However, to date, what these emotional challenges consist of has been insufficiently investigated. A qualitative study, inspired by a phenomenological approach, was conducted. Eleven registered nurses employed in home care services in Norway were selected for semi-structured interviews, and three main challenges were identified using meaning condensation: time pressure, feeling provoked by the behaviour of a patient and feeling overpowered by emotions when a patient was in the terminal stage of his or her illness. Our conclusion is that when nurses are confronted with a patient’s vulnerability, they are also confronted with their own vulnerability.

Introduction

There has been an increase of more than six per cent in the number of recipients of nursing care in the period 2007–2011 in Norway, with the largest increase being in home care services. ¹ This increase can be explained in part by health service reforms and changes in healthcare processes. ² With the reduction in their resources, registered nurses in home care (home care nurses) struggle to meet the challenge of caring for an increased number of patients, and it is reported that older patients living in their own homes are consistently receiving a poorer healthcare offering. ³

Previous research claims that nurses’ emotional abilities have been insufficiently investigated.^4–8 This lack of research is due primarily to the emotional aspect of care having a lower status than scientific thinking and technological knowledge. The underestimation of the value of feelings is viewed as problematic because emotions are regarded as fundamental and essential in the care work that nurses perform.^5,8 Martinsen argues that excluding emotions limits a nurse’s knowledge because the patient is overlooked and is reduced to an object. ⁹ She emphasises that a professional nurse should introduce him or herself as a person who has feelings. Emotions are important for enabling a nurse to perceive how a patient understands his or her own disease, disorder or situation. Only then can a nurse be open to emotions such as shame, which tells the professional nurse that the patient’s dignity has been violated due to an insensitive act. ⁹

Previous research on the experiences of home care nurses describes stressful or painful emotions that occur because of time pressure or when the nurses view patients as difficult. Kirchhoff, for example, reports that home care nurses experience work-related stress when they have to infringe on the quality of healthcare because of time pressure. ¹⁰ In palliative care, home care nurses find their responsibility for the dying patient emotionally challenging. ¹¹ Michaelsen claims in her study that home care nurses were able to experience painful emotions regarding interactions with patients when the latter were viewed by the nurses as difficult. ¹² This could lead to an avoidance strategy, such as emotional distance, whereby the nurse withdraws either psychologically or physically, which could lead to the neglect of the patient.

In this respect, earlier research has established that emotional challenges can have negative consequences for the nursing care that patients receive. It may, therefore, be relevant to shed light on nurses’ emotions in home care services in order to achieve the eight principles of good care services outlined in the white paper Future Care. ¹³

Study aim

The aim of this study was to identify and examine the emotional challenges that registered nurses in home care services experience in their everyday work. The research question was as follows: What emotional challenges do home care nurses experience? Given that there has been little research conducted on the subject, the research question takes the form ‘what’ rather than ‘how’ because the purpose is to identify what is perceived as challenging.

Method

Selection and data collection

A qualitative research interview design, inspired by a phenomenological approach, was applied.^14,15 The study sample consisted of eleven registered nurses in home care services: one man and ten women from three different municipalities. The data were collected through individual semi-structured interviews. During a semi-structured interview, the interviewer can have predetermined questions but, at the same time, be flexible regarding changes in the order and wording of the questions. In this manner, the interviewer is not bound to a rigid script but can let him or herself be guided by specific answers and stories from the informants. The aim of this type of interview is, thus, to understand the informant’s own perspective on an experience from his or her daily life. ¹⁴ The questions were designed on the basis of previous research and literature, as well as around what was desirable to account for and discuss in the study. The interview guide consisted of 16 questions which were sorted into background, main and closing questions. The main questions were about the role of the nurse, positive and negative experiences with different emotions, involvement with and distance from a patient, rejection by a patient, experience with compassion, being influenced by emotions and feelings of inadequacy. The interviews were conducted in August and September of 2012, and each lasted 45–65 minutes. They were conducted at the workplaces of the informants and were tape-recorded and then transcribed by the first researcher.

Reliability and validity issues

In this study, the unit managers of the home care services knew which of their employees were participating in the study. This led to a dilemma regarding the anonymity of the informants and the reliability of the study. The researchers chose to follow the guidelines laid out by Fangen, who recommends prioritising the confidentiality of informants over the requirement of study reliability. ¹⁶

On the one hand, according to Kvale and Brinkman, a high degree of reliability during interviewing, transcribing and analysing is desirable to counteract any subjectivity. ¹⁴ On the other hand, such a demand reduces the creative thinking and variation that are important for maintaining the credibility of a qualitative interview study. ¹⁴ The interviewer was, therefore, careful regarding the use of leading questions that could unintentionally influence the informant’s response.

Transferability refers to the validity of an analytical research finding in other contexts. ¹⁴ The findings of this article cannot be transferred in a statistical context to the population level for all home care nurses nationwide. However, the findings of this article can be assessed against an analytical generalisation.

Analysis and interpretation of data

Meaning condensation, a phenomenological analysis process based on Giorgi, was applied to the data, as presented in Kvale and Brinkmann. ¹⁴ However, the analysis is modified from Giorgi’s descriptive method by critically interpreting the informants’ points of view. The analysis consisted of five steps. In the first, the data were reviewed in as unprejudiced a manner as possible to obtain an overall impression of the informants’ points of view. As the second step, the text was re-read, and meaning units from the transcribed interviews were extracted. The meaning units consisted of one or more quotations from the individual informants. The third step, which is the core of the analysis, comprised a summary of the natural meaning units from the informants’ points of view, and this information was written in a concise manner. The summary expressed a central theme that dominated the specific meaning unit – for example, disappointment, shame or grief. As the fourth step, we developed interpretations from the summaries of the meaning units. These interpretations were developed into more than solely the informants’ points of view, and the researcher wrote a critical understanding based on common sense. All the interpretations in this step were organised into the three main categories of the study findings: time pressure, provocative behaviour by the patient and death. By the fifth and final step, the interpretations were set against theory and previous research to validate the analysis from a research perspective.

Giorgi argues that the bracketing of the researcher’s pre-understanding is important for studying a phenomenon. ¹⁵ According to Malterud, such complete severability is impossible to achieve because the researcher’s pre-understanding will always, to some extent, affect the qualitative research both negatively and positively. ¹⁷ In this way, this article will not be a phenomenological study as a whole, as presented by Giorgi, ¹⁵ but will be inspired by a phenomenological approach.

Ethics

The project has followed the ethical guidelines for the social sciences, humanities, law and theology for informed and free consent. ¹⁸ The informants were advised in writing about the project before the research began. They were informed about the intentions of the project and their right to withdraw from it without reason and without consequences for themselves. In conjuncture with Malterud, ¹⁷ this was repeated orally before the interview started to ensure that the informants were adequately apprised. To ensure further anonymity, it was not revealed to the informants which municipalities were included in the study.

Results and discussion

The findings and interpretations of this project illuminate the emotional challenges that respondents considered important in their everyday work. The findings and interpretations show that these challenges were related to time pressure, being provoked by patient behaviour and death.

Time pressure

Time pressure is neither a new nor unfamiliar challenge in home care services.^3,19,20 Time pressure can be viewed from two angles: the real and the subjective. Real time pressure is the measurable use of time when the nurse does not have sufficient time in which to complete her tasks. Subjective time pressure is related to how the individual employee experiences the time pressure. This encompasses the individual’s feelings about the accomplishment of tasks in relation to his or her own and others’ expectations, in addition to the resources available. ²¹

The analysis indicates that the informants felt that time pressure meant that the practice of care was focused on the completion of tasks rather than on fulfilling the patients’ needs, which Martinsen describes on page 60 as ‘task-centred busyness’. ²² As illustrated in the following quotation, one informant expressed how she felt when she had just enough time to complete her work task but not enough time to live up to her own expectations of how best to care for the patient.

I have done all the chores, so to speak. But I might not have been quite as [good as] I wanted to be in a way to all the patients … I know that … I want to do more; I want more quality in what I do.

The informants expressed the view that time pressure could lead to negative consequences for patients. In these cases, the patients’ needs could not be met, and the informants felt shame because they had not been sufficiently attentive, or because they sensed how the experience had affected the patient. One example of this was when an informant was in a hurry and was supposed to help a patient to the toilet. The patient was stressed out by the home care nurse and was, therefore, unable to urinate. Situations such as these led to negative feelings among the informants regarding their own practice. The informants expressed that they were disappointed with their own practice when they did not live up to their own ideas of what good caregiving entails. Martinsen explains that not living up to the expectations of society can lead one to experience a sense of shame. ²² For home care nurses, this may be because they sense the vulnerability of the patient, how time pressure affects them negatively and that their practice is not consistent with their own expectations and ideals of care. Halvorsen warns against nurses being too idealistic, motivated by seeing themselves as people who fight for the weak in society. ²³ This is because the understaffing and heavy workloads that exist in today’s care professions can lead nurses to set unrealistic expectations regarding what can be provided in terms of help and care.

The informants expressed feelings of inadequacy when they experienced time pressure. Several informants explained that they would compensate on the days that they had more time and perform tasks that were not mandatory or to which the patients were not entitled. For example, one informant expressed this as follows:

I sometimes try to compensate a little; if I have time, I try to spend some more time if I had to hurry a bit more the night before. […] And the days that I have more time, I use it to do extra things like training with the patient. [This is] something I would love to do every day to prevent illness, but it is not a part of our brief.

The informants were challenged by their own vulnerability when they experienced inadequacy. This finding can be seen in the context of Vike et al.’s study on home care services. ¹⁹ They argue that in the concrete, face-to-face relationship between the service provider and the service receiver, a dilemma arises between the disparity in welfare goals and limited capacity. This means that home care employees must take responsibility for what the organisation has undertaken, but cannot afford, to do. One informant differed from the others by expressing that it was not she herself who was inadequate but the resources that were insufficient. She was also critical of the practice of doing more for a patient, due to guilt, than was in the brief. She stated that this was problematic because it reduced the time spent with other patients. Tønnessen, Førde and Nortvedt point out that when time is limited, home care nurses do not prioritise patients fairly. ²⁴ In their study, they showed that home care nurses gave a lower priority to those patients who were more understanding and had spouses who could help, even if the spouses had illnesses or impaired health or function.

Being provoked by patient behaviour

The home care nurses in this study expressed that they felt closeness, or that they had a good connection, with the majority of their patients. These feelings were important for the informants’ satisfaction with their interactions or relationships with the patients. According to Manos and Braun, when nurses feel positively towards providing care for a patient, it is usually a sign that the care being given is of a good quality. ²⁵ For the informants in this study, there were only a minority of cases in which the patient’s behaviour was perceived by the informants as negative. When these cases occurred, the informants experienced emotional challenges that could be difficult to handle.

When the informants failed to meet the patients’ needs in the execution of the mandatory tasks, the home care nurses experienced provocative behaviour on the part of the patients. Sørensen and Hall argue that nurses’ professional pride is closely associated with their desire to do well. ²⁶ When professional pride was threatened, in the nurses’ experience, their notions of what constituted a good nurse were challenged, and they felt insecure and vulnerable. The informants expressed that they were engaged in the performance of the mandatory tasks in a caring way that satisfied both the needs and wants of the patients. In most cases, in the informants’ experience, patients were satisfied with how the nurses performed their tasks. Emotional challenges arose when patients were not satisfied with the assistance they received and expressed their dissatisfaction with a condescending tone of voice and comment. One informant said the following:

We have patients who think it is never good enough no matter what we do. And they look at us as if we are servants there to do their bidding.

There are indications that the relationship between the caregiver and the recipient become even more challenging when the patients are in the setting of their own homes rather than in institutions. ²⁷ This may cause the patients to experience the home as reinforcing their autonomy and, thus, cause them to become less controlled by an institutional culture. ²⁸ The results suggest that the informants found it difficult to talk to their colleagues if they had confrontations with patients for fear that they were the only ones who had experienced this. According to Manos and Braun, nurses do not often speak about being confronted by patients whom they view as difficult, as the nurses tend to perceive this as a private matter between the two parties. ²⁵

The informants experienced being provoked by the patient’s behaviour when they perceived that there was no underlying cause that could justify the behaviour. For example, one informant said the following:

If there is a patient who does not have dementia and who is alert and orientated and is receiving care for different things, and they have a bad day and let it affect me, then I don’t think it’s okay, and then I speak up.

The quotation above can be understood as the nurse thinking that such a patient does not live up to the normative expectations regarding the patient’s role. Some of the informants stated that they chose not to complete a task with a patient when they felt that their tolerance limit was crossed. The informants explained that they would try to understand and reason with the patient but would, in some cases, leave if they found the patient unreasonable and could not identify an underlying cause, such as dementia, that could explain the patient’s behaviour.

One dilemma that can arise relates to the home care nurse and her exertion of power. On the one hand, it is problematic if the exertion of power is used with the paternalistic purpose of gaining social control of the patient. This focuses the care on performing the tasks, and it is an inappropriate use of power that does not consider the best interest of the patient. On the other hand, the use of power can be an expression of boundaries as a basis for recognising patient values and their own values as professionals. The informants did not perceive engaging the patients when they were provocative as part of their role as professional nurses, but they felt that they had to remain both calm and resolute. It is, therefore, problematic if an emotional challenge caused by being provoked makes the home care nurse lose sight of the patient’s vulnerability. A provocation can also stand in the way of uncovering the actual circumstances concerning a patient’s situation. Even though the home care nurse does not perceive that there is an underlying cause that could explain the patient’s behaviour, this does not mean that there is no such explanation. ²⁷ Hellzen et al. claim that it may be appropriate for the nurse not to accept the provocative behaviour of the patient. ²⁹ In their study, they found that nurses who did not respond to patients’ provocative behaviour had no emotional commitment and appeared indifferent to such patients. These nurses would neglect such patients when they were not deliberately engaged with the patients, including pretending that they did not hear what the patients said. Slagsvold and Solem claim that there are indications that tomorrow’s patients will challenge home care services in a different manner from today’s patients. ³⁰ The patients will possibly be less modest and more demanding, and they may want greater autonomy. This patient behaviour is different from the normative patient behaviour that is more common today.

Death

Dying and death is a complex and unpredictable situation. Human beings encounter one of life’s most vulnerable stages when they are in the terminal phase of illness. ³¹ In this way, it can be understood that, in the asymmetrical relationship between the caregiver and the care recipient, the gap is large within palliative care and may even be one of the widest we can see in care work. Nevertheless, in spite of the distance between the dying patient and home care nurses, they can achieve closeness through striving for a common goal. The informants explained that they felt that this closeness was precious but, at the same time, emotionally challenging to deal with, as evidenced by the following quotation:

I like terminal care. Terminal care is so special, and you get so close with people, and you want so dearly for it to end well. It is an indescribable way to work … they are so dependent on your compassion … yes … totally dependent. And it feels so … intimate.

This closeness was described as special, as the home care nurse and the patient could experience reciprocity by working towards achieving a dignified death for the patient. This can be understood to lead to closeness through an affinity between the informant and the patient, even if they are far apart in the asymmetrical relationship. Luker et al. point out that it is essential that home care nurses have a sense of closeness to the patient to achieve continuity in the palliative care of terminal patients. ³²

Even though the feeling of closeness that the informants experienced with patients could be positive, it could, at the same time, be perceived as emotionally challenging and overpowering. The informants expressed that closeness was particularly prominent in situations in which the patients and the informants had developed a relationship over time. The informants expressed this closeness as demanding but also motivational in terms of caring for the patient. One informant said the following:

And, of course, I then put in some extra effort so that he [the patient] should have a dignified ending to his life. I took on extra shifts and … gave it my all. [I] felt it was my way of being of assistance.

The home care nurses in this study experienced a challenge in balancing between providing care for a dying patient and for patients who were not as emotionally challenging in terms of stress, unhappiness and frustration. The informants could experience difficulty in being as attentive to patients in a curative state compared to patients in a palliative state. One informant stated that she felt relief when a patient for whom she had cared for a long time eventually died, because she had long felt guilty that other patients had not received the care that she had wanted to give them. This finding can be explained by Wallerstedt and Andershed, who report that home care nurses find it challenging because they consider their responsibilities towards terminal patients as significantly more important than towards patients who are stable or not at a critical phase of their illness. ³³

Conclusion

The emotional challenges faced by home care nurses occurred when they encountered the vulnerability of other people and, through this, also encountered their own vulnerability. The challenge then consisted of managing to deal with their own and others’ vulnerability, and it was important for the informants to remain attentive towards their patients. Without being attentive, the informants could not perceive the patients’ feelings, which could cause the patients to be overlooked. These findings and interpretations provide a basis for claiming that home care nurses’ encounters with their own and others’ vulnerability play an important role in regard to their attentiveness to patients.