Exploring Norwegian homecare healthcare professionals’ perceptions of risk and the link to high-quality care: a qualitative multiple case study

Abstract

Objectives

Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience.

Design

The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted.

Setting

The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case.

Participants

Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups.

Results

Four themes were identified: ‘professionalism is constantly prioritising and aligning care based on here-and-now observations’ ‘teamwork feels safe and enhances quality’ ‘taking responsibility for system risk’ and ‘reluctantly accepting the extended expectations from society’.

Conclusions

To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients’ condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Strengths and limitations of this study.

• Semistructured interviews and focus groups allowed for a deep understanding of how healthcare professionals perceive and act on risk in homecare.

• The use of an inductive thematic analysis, involving recurring discussions with the multiprofessional research team resulted in trustworthy data analysis.

• The study was conducted in three municipalities in Norway, which might limit the transferability of the results to other contexts.

• A highly diverse study sample in terms of age, experience and education provided the study with rich data.

Background

There has been a shift from institution- to home-based care in Western healthcare systems. Homecare is now the most rapidly growing segment of healthcare services. Homecare is considered key to meet the challenges of providing healthcare to an ageing population. It is argued that the shift is necessary from a sustainability perspective due to limited funding, lack of healthcare professionals and the growing population of elderly people.^1–10

Due to the shift to homecare, there is a rising number of homecare patients with comprehensive care needs, meaning the complexity of care also increases. Healthcare professionals within the homecare setting perform advanced healthcare procedures in the patients’ home.^{11 12} These home healthcare professionals often work alone and need to make rapid decisions during visits.^13–17 Previous research shows that home healthcare professionals handle what is often considered an overwhelming amount of information.^{14 18} In practice, continuous adjustments need to be made based on their situational awareness, assessment of risk information; their work invariably entails some uncertainty.¹⁹ Increased complexity and new procedures mean that home healthcare professionals will routinely have to address new situations when attending to sicker patients, maybe without previous experience with the issues at hand. A trusting working environment and adequate support are therefore crucial.¹²

Increased complexity and new procedures in the homecare setting are accompanied by new and emerging risks. Adverse event rates in homecare have been investigated in several studies.^{11 20–22} In Canada, a study concluded that 13% of homecare clients experience one adverse event annually.²³ The most frequent of these events are falls, wound infections, psychological or mental health problems, adverse drug reactions and pressure ulcers. These events often cause temporary harm to the patient and require extra healthcare resources.^{11 20} However, most of these events are preventable.²⁰ Offering high-quality care with a lower risk of adverse events is therefore paramount.^{24 25}

Quality in healthcare has traditionally been operationalised using clinical indicators of care quality.²⁶ The WHO defines quality of care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. Furthermore, they emphasise that quality healthcare should be effective, safe, people-centred, timely, equitable, integrated and efficient.²⁷ This definition is in line with how the Norwegian government defines quality in healthcare across care settings.^28–32 Yet, defining quality is challenging because it cannot be reduced to a single indicator against which performance can be assessed.³³ Pursuing multiple objectives along a range of performance dimensions may lead to conflicts, because higher performance along one quality dimension may come at the expense of performance along another. This means that quality and safety are context-dependent and heterogeneous moving targets in all healthcare contexts.^{28 34}

A growing body of research literature covers homecare, but there are still gaps in the knowledge pertaining to homecare as a healthcare system and how to improve quality and safety.¹ More specifically, there is a lack of knowledge on the implementation and impact of quality and safety interventions, as most such research evidence has been generated in hospitals.^{21 35–37} Also, while legislation, guidelines and screening programmes have been adopted to handle patient safety risk elements (eg, falls, nutrition), little is known about how healthcare professionals assess, conceptualise and talk about risk in homecare practice.

This study helps to close this gap. By applying a resilience perspective, emphasising how work is done and how adaptations are made to reduce or handle risk and accommodate the needs of homecare patients,³⁸ the study contributes new knowledge on how home healthcare professionals conceptualise risk and modify their performance in response to working conditions and patient- and family-specific issues in the home. The study centres on the complexity in homecare, addressing the daily emerging risks and the subsequent care adjustments.

Aim and research questions

The overarching aim of this study is to develop new knowledge of healthcare professionals’ risk perception within a homecare setting. Specifically, the study explores how risk is perceived and used to guide home healthcare professionals in their efforts to maintain resilience and provide high-quality healthcare.

The following research questions guided the study:

1. How do home healthcare professionals make sense of risk when aspiring for high-quality care in their everyday work?

2. What do healthcare professionals emphasise when acting on risk information?

Methods

The study design is a qualitative multiple case study of three cases.³⁹ We investigated the phenomena of risk perception, sensemaking and adaptations of care in the homecare context in three Norwegian municipalities. Each municipality was defined as a single case.

Recruitment

In Norway, municipalities are responsible for primary care services including homecare, nursing homes, general practitioners and ambulatory care. There are 356 municipalities, ranging from approximately 200 to 700 000 inhabitants.⁴⁰

Seven of these municipalities were invited to participate in the study. An email was sent to healthcare managers with information about the study. Online information meetings with municipal managers for health and representatives of management were held during the recruitment process with the municipalities that responded positively. The recruitment process ended when three municipalities had accepted the invitation to participate.

The municipalities were asked to facilitate the interviews by suggesting healthcare professionals for interviews and focus groups. The only criterion was that all the healthcare professionals worked in a homecare setting. The municipalities were assured that no participants in the study would be asked any person- or patient-sensitive questions.

Data collection

19 interviews were conducted. Of these, 11 (3+4+4) were individual semistructured interviews, and 8 (2+4+2) were focus groups (3–5 participants). The interviews were conducted from September to November 2022 at the local sites of the homecare units. The interviews lasted about an hour each and were all audio-recorded. The individual interviews were conducted by the first author (II-J), and the focus groups were conducted by the first author on-site and the second author (HD) present via Microsoft Teams. Table 1 summarises the time, number and types of interviews.

Table 1.

Time, number and types of interviews

	Time of interviews	Number of interviews	Type of interview	n	Informants (N)
M1	October 2022	2	Focus group	8	11
		3	Individual interview	3
M2	September–November 2022	4	Focus group	15	18
		4	Individual interview	4
M3	September 2022	2	Focus group	7	11
		4	Individual interview	4
		19			40

M, municipality.

There was one interview guide for the individual interviews and another for the focus groups. Theoretical framework of risk and risk perception,24 25 41 42 work-as-imagined and work-as-done anchored in resilience literature⁴³ and social amplification of risk^44–47 inspired the interview guides. Both guides contained questions about patient safety, adjustments of care, the quality system, guidelines, checklists and legislation, quality care, strengths and limitations of homecare.

The interviewed healthcare professionals were unfamiliar with the concepts of risk and quality. During the interviews, flexibility took precedence over structure to elicit rich data. The interview guide facilitated this process. The home healthcare professionals were encouraged to describe, in their own words, their everyday work. They were also asked how they perceived the concepts of risk and quality, but the emphasis was on how they created meaning and interpreted, prioritised and implemented measures based on their own observations of the patients. The way in which these observations and measures were shared with the team was also an important element of the interviews. The interviews differed in how the questions were formulated, how certain topics were followed up, in their depth and length. Asking them to describe an ordinary day at work was a frequent question. The answers were followed up with more probing questions about assessing, handling and discussing those situations. No identifying patient information was asked; we were more interested in the healthcare professionals’ sensemaking process.

The first author, II-J, conducted all the individual interviews. II-J is a physical therapist experienced in organisational risk management and auditing. The second author, HD, is a registered nurse with a PhD, experienced in homecare and qualitative research. HD was the administrator of the focus groups. II-J and HD’s respective backgrounds affected the interviews in terms of which issues were and were not followed up. KKB has expertise in psychology. SW is experienced in conducting research in safety science and has expertise in qualitative methods. All authors supported the preparations for the interviews and the analytical process. The authors’ background and methodological knowledge strengthened the study’s trustworthiness.

Contextual settings

Two of the three municipalities were in the western part of Norway, and the other was in the south. All had both city centres and rural areas, but there was a range in size, from less than 500 km² to more than 1000 km². The three municipalities also differed in population size, from approximately 30 000 inhabitants in the smallest to more than 100 000 in the largest. As of January 2020, all municipalities merged with at least two surrounding municipalities. All three municipalities organised their homecare in multiple units and departments located apart from each other, functioning as base stations for the healthcare professionals and middle leaders.

Five healthcare professionals participated both in an individual interview and a focus group, and 30 participated in just one interview. The overlaps of interview subjects were arranged by the heads of departments on their own initiative for practical reasons. The municipalities were not asked to arrange repeated interviews. However, having follow-up interviews with five healthcare professionals made it possible to ask if any thoughts or comments had come to mind since the previous interview.

One male was interviewed in each municipality; the other interviewees were females. Approximately 50% were nurses and the other 50% were nurse assistants. One unskilled assistant participated in the interviews. See table 2 for an overview.

Table 2.

Education of the healthcare professionals interviewed

	Municipality 1	Municipality 2	Municipality 3	Total
Nurse	5	6	4	15
Social worker	1			1
Nurse assistant	4	8	6	18
Unskilled assistant	1			1
	11	14	10	35

Age and professional experience among the healthcare professionals interviewed ranged from 20-year-old unskilled assistants to nurses and nurse assistants approaching retirement.

Data analysis

The first author transcribed all interviews and focus groups verbatim. Once transcribed and read, the interviews were uploaded and coded inductively in Nvivo. Data analysis was conducted according to Braun and Clarke’s six-phase thematic analysis.⁴⁸

The first phase of the thematic analysis was conducted when familiarising with the data when interviewing, transcribing, reading and rereading the data. In the second phase, interesting features of the data were coded systematically by searching for initial codes, case by case. In the third phase, these codes were then analysed to identify themes and subthemes. In the fourth phase, the initial codes were renamed, discarded, kept or merged multiple times as data analysis continued. In the fifth phase, the process was repeated with the themes and subthemes. In the sixth and final phase, the themes and subthemes were revised as necessary while the result section of this paper was being written.

The first author conducted the analysis process in Nvivo. The author team discussed and reached a consensus on the final four themes.

Results

The themes emerging from the analyses included several distinct subthemes that shed light on healthcare professionals’ experiences with and use of risk information as a guide to providing high-quality care. Table 3 summarises the themes, subthemes and codes from the analyses, complemented with relevant quotes from the interviews.

Table 3.

Themes, subthemes, codes and examples of code quotes

Themes	Subthemes	Codes	Examples of code quotes
1 Professionalism is constantly prioritising and aligning care based on here-and-now observations	High-quality care is achieved through trust, supportive leaders and professionalism, not by formality	The feeling of empowerment among the healthcare professionals is strong	M3: “The leaders sit in their offices, they do not know what is happening out in the field, we are the ones who work out there, we have to go to them and inform and describe if necessary, because it is very important that they know what we are doing, who needs more help and things like that, they are willing to help us, they are, but at the same time, we who work out there have to inform and describe, they only get a name and social security number, they don’t know who the person is and how the person is, it is our responsibility to tell”. M3: “If you come to a patient who is ill, we get them to the hospital […], you can’t call the manager every time, because it’s all the time, no, so we have to deal with it ourselves”. M3: “It’s something constantly, and I can see that, over all these years, we’ve got a much wider range of patients”. M3: “It’s almost only outpatients at the hospital, otherwise they’re at home with us”.
		Risk, quality and patient safety are not an integrated part of the homecare providers’ professional language	M1: “It can in some cases steal time from the clinical work, and it can steal time from the dialogue itself, being present when you are with someone, because you think about the things you have to do, then you can occasionally realize that now I was out the door a little too quickly, or now I got to do exactly what I wanted, but I didn’t really get to talk about how things have been recently”. M3: “Maybe it will turn out a bit like that, I don’t know, it will be an evaluation in a way, but I think it has something to do with the whole healthcare system […], that the municipal health service,[…]homecare, it has been talked down so much […], and then there are these quality controls, you know”. M3: “We don’t use that word daily, but we are very concerned with doing a good job”.
	Continuous adjustments to patients’ needs	The resource allocation department makes some sort of plans, but the homecare adjusts them independently to match real needs	M1: “And those of us who are a bit experienced, we don't need to ask a colleague either, that is, you see that now things have changed, now there are other needs, ok, we change it now, we’ll start tomorrow, because now this help is not good enough, now you need more help, so we do that continuously, both up and down the service”. M1: “We are always keen to catch things and we tend to see it very quickly, and I think we experience more and more often that people we get into the service are granted some help and care, but then the need is much greater, because they haven’t properly spoken to the person, or someone just called in to the administration and then they got the decision, and nobody have been to the person’s home once to see what it’s like there”.
		High-quality care is on-site adjustments and prioritising among patients	M1: “It’s not always easy, you have to be tough if you’re going to stay in this job, in many cases anyway, to assess what is most important and what isn’t, we assess it differently too, what is more urgent […], I think, as a rule, if there is something very acute then we would, if there is something with a heart attack or whatever, we have to deal with that first, and then it’s about you having to be able to stand tall in that situation, and then everything else has to come afterwards, right?”
		Identifying a gut feeling that something is wrong and putting numbers on it by applying NEWS scores	M1: “So they can have an infection that makes them sick, and we who go there on a daily basis, we will see the signs, okay, something is not right here, and then pick up that yellow bag and then we take measurements, blood pressure and all this, because we have to take that before we call the emergency room or the GP, and then they will guide us, making sense of what the cause might be, there is a lot of infection or sepsis going on that we must handle”.
2 Teamwork feels safe and enhances quality	No one is done before everyone is done	You never walk alone; there is always someone you can call to get help	M3: “But then suddenly […] information, a phone call from the hospital that, ok, we have a patient here discharged who needs to be moved, and so, he needs help from homecare, so we just must reschedule”. M3: “We would use the zone that has some spare time”. M3: “And then we help each other, it’s alpha and omega, we call each other and have contact and help each other”.
		There are 1 million interruptions and messages every day	M1: “We have something called the service phone and the phone number must be publicly available on the municipality’s website, that in our zone you can call this and that number, right […], it’s with us out, […] and it has become so intense, maybe 50–60 phones calls every day, I am not exaggerating […], it may be relatives who call to hand over messages, patients who wonder when we will arrive”.
	Discussing is everything in assessing risk	Good care involves assessing patient observations, gut feelings and worries together to validate and act on them as one team	M1: “We talk to each other, especially when we have summer temporary workers or unskilled workers, then as professionals we are able to pick up more, and it is also about helping them to put things into words and make reflections when we meet, because we usually work alone”. M2: “I think it is important that we do not go to the same person every single day, that we are different people who go to the patients […] because then we fight blind spots and are able to pick up on things, we always assess […] in the morning brief or morning coffee or between shifts, we maybe talk about a particular patient”.
		Oral reports are necessary to get the full picture; documentation is good, but not enough.	M1: “But it is not expected that everyone sees everything, that’s why we have each other, because then it could be that she sees something that I don’t, or he who has just started sees a completely new picture than what we do […], we are a good team, we see each other, and we see the patients and have different work experiences”. M1: “I think oral reports are essential, even if they take longer time”. M1: Many messages would be lost [without oral reports], lots of important observations, because observations cannot always be well described in a report, all that you observe, you cannot always get that down on paper the way you want, and then you may not always have time to write the report right away, anyway, and then it disappears from your mind and is lost”.
3 Taking responsibility for system risk	Homecare can only partially compensate for the shortage of residential care	Providing care for patients that need more than the homecare can offer	M2: “I think a lot of people think that the homecare service can do much more than what we can actually do, like, when the municipalities propose to cut back on residential care and making people stay at home longer, it’s very frustrating, I don’t think people are fully aware of what can happen […], we can only look after the patient when we are actually there and there are many people who really should have someone with them all the time, but we don't have the opportunity to do that, and then it is up to the relatives, and they become extremely tired, so I think in a way that society doesn't quite see that we actually don't have the opportunity to be with the patient from morning to night”.
		Lack of nursing homes and residential care means that homecare must deal with the risks of patients staying at home too long	M2: “In other words, it is so incredibly comprehensive, and the frustration we face when we are not allowed to help […] they live at home in their own house, and when they won't accept help, or you're not allowed to make them food, it’s so frustrating, because refusing help doesn't mean they will make food themselves, it often means that they don't eat that day, maybe not the next day either”. M3: “We have had fatal incidents, where they have gone into the river, there are things like that, and so, of course, we use welfare technology, GPS and things like that, but when they go, they have to be picked up […] worried about those with dementia, the service they get, it is not good now and it will be a big challenge […], the biggest worry, or challenge, is those who need to be granted residential care, but aren’t”.
	The frustration due to playing the part as the municipalities’ contingency healthcare system	Some patient groups miss out on high-quality care	M1: “We have a lot of drug addicts and mentally ill out in this zone, for many of them are we are just dispensing medicine and then we’re not going to do anything more for them […], sometimes you have to call an ambulance, because they are already influenced of drugs that maybe they shouldn’t get that Subitec or whatever they’re going to have, because you don’t know if that will end up in an overdose or not”. M1: “It is difficult because we don’t have that expertise, and if you come to someone who is psychotic […], we see that he is not himself, but it is so difficult to make an assessment, is it drugs or is it something else”.
		The problem with loneliness	M2: “We are told what to do, and then we carry out these tasks, but we are not robots and we do not work with robots, we work with people who have different days […], and a lot of the patients feel lonely, you notice that they are looking for a chat and we can’t do that, we’re not entertainment, we provide healthcare […], but we strive to give these small impressions that we take our time for them, we take off our jackets when we come in, even though we are short on time”.
4 Reluctantly accepting the extended expectations from society	Necessary healthcare is not clearly defined, nor is homecare	Caught in the middle, doing practical work because the role of homecare services is not well defined	M3: “I think that we should have the formal written decision in the patients’ homes, and then we will all know what to do and not, of course we can help and be kind, get the mail and such, that is not what I’m saying we never could do that”. M3: You don’t let an 80-year-old go out in the snow to handle the rubbish bin or get the newspaper, you do it for him to prevent he falls, and, you know, provide good care”. M3: “The problem is, if you start taking the rubbish bin and one day you don’t do it, relatives will call to make a complaint, you see, it’s all these expectations, it is that conversation that you didn’t have in the beginning that becomes a bit problematic for us”.
		Feeling obliged to help when help is needed, whatever it may be	M1: “There are great expectations from homecare, it’s almost like the relatives think it is the same as having them in a nursing home […], because we are expected to do so much, like, ‘gee, is this expected from us as well?’, ‘is this really our job to sort out?’ […], like when the patient runs out of bread, just as an example […], and then you have to go and buy it […], theoretically, we shouldn’t, (… but) most of us do […] or suddenly someone has problems with their finances and then they can’t afford to pay for their medicine, so we have to deal with that too, call a guardian or something like that”. M1: “We become a bit like relatives for some patients, and we are not supposed to play that role”.

M, municipality.

Theme 1: professionalism is constantly prioritising and aligning care based on here-and-now observations

As many home healthcare professionals pointed out, there is no time to confer with the leaders in the field, and the healthcare professionals reported having the freedom and the opportunity to make independent decisions. Although they assumed that this latitude was allowed, necessary and expected, they also considered it important to the provision of high-quality homecare.

Systems and checklists were often described as good in theory but fell short when it came to meeting real-world challenges. The realities of limited time and complex disease among patients required them to use more discretion than the quality system allowed. The service was also characterised by the unpredictability of everyday life, with many changes and patients in declining health. The home healthcare professionals also had to work in homes that were ill-suited to their presence. They had to make do with what was on hand, for example, using sheets to lift a patient or using a lamp to run an intravenous line.

Our results show that the home healthcare professionals did not use the term ‘risk’ or mention that their colleagues or leaders used it. On the contrary, the term quite often elicited responses to the term was unfamiliar. When they were asked directly about what risk entails, interviewees usually mentioned something negative.

Although healthcare professionals did not use the term ‘risk’, they elaborated on a high number of risky situations. Professionalism, confidence and independent judgement were emphasised as key to high-quality care. One of many situations where risk was assessed was when the healthcare professionals met the patient at home and came to believe that the patient was acutely ill. Sometimes, there was an obvious physical deterioration, but at other times they sensed that something was wrong. When the patient could not express what was wrong, the home health professional’s own experience and knowledge of the patient guided their reaction. Any deviation from earlier observations of the patient was taken seriously. The guidelines in these situations focused on the use of the National Early Warning Score (NEWS) to gather information about vital signs. NEWS is a scale for recording and assessing information about patients’ blood pressure, respiratory and heart rates, level of consciousness, oxygen saturation and temperature.⁴⁹ The scores then helped the healthcare professionals to assess the patient and determine how best to provide care. The informants explained that NEWS was often used in practice. However, medical equipment was required when taking scores, and the healthcare professionals did not always have such equipment on hand. NEWS was therefore only used when feasible.

Figure 1 depicts a flow chart of the decisions the healthcare professionals made when they thought there were important but not acute or life-threatening changes in a patient’s condition.

Figure 1.

Process map—risk assessments in situations taking vital signs (NEWS).

The figure depicts how the healthcare professionals must assess risk when they sensed something was wrong. The healthcare professionals spoke of these situations as recurring and as part of a job that comes with many ‘unexpected events’, that they ‘never know what they will encounter next’, and that they must ‘deal with the situation’.

The healthcare professionals said that they needed freedom to use their own professional judgement to make on-site assessments and adjust care. Having too much administrative work precluded immediate assessments of the situation, understood as the clinical part of the work, because it interrupted the professional observation and the clinical gaze. Another issue was that guidelines and checklists interfered with professionalism, assessing when and how to intervene. Several interviewees cited nutrition as an example. The guidelines tell them to map every patient, but the healthcare professionals emphasised that mapping nutrition status and taking measures should only be done when necessary, not as a default. Mapping all patients’ nutritional status seemed intrusive; especially if the healthcare was short-term. A third issue with extensive guidelines mentioned by the healthcare professionals was that they took too much time and attention away from talking to the patients.

Theme 2: teamwork feels safe and enhances care quality

In addition to self-confidence and resolute action, the results show that the healthcare professionals also leaned on each other’s perspective and observations when they put all the pieces of information about a patient together to see the complete risk picture. Our informants were organised in teams as part of their employment in a homecare department and a zone serving a geographical area within the case municipality. Moreover, the healthcare professionals did not mention being assigned to any particular team. Several of them insisted that healthcare professionals observe the patients somewhat differently and get to know them from several perspectives, such as with or without family present, in different physical settings, or in a range of mental, emotional and physical conditions. The healthcare professionals also emphasised how their diversity in terms of gender, personality, profession, age and experience. For this reason, they claimed, they obtained richer information about the patient when acting as a team. The information might be concerned with patients’ somatic status, but also family history, worries and passions, or likes and dislikes the patient had shared with the healthcare professionals. The informants insisted that sharing all sorts of patient-related information was crucial to providing and modifying care at the right time. Information was shared in diverse ways. Oral reports were used in formal settings such as shift handovers. Written medical records were considered important, but several healthcare professionals noted that written reports were no substitute for oral reports. Some departments also had a notebook for practical messages that had to be conveyed quickly. The healthcare professionals also described often sharing information about the patients over lunch, on coffee breaks, in meetings and wherever they physically met. They described these discussions about their patients as an important part of their workday.

Their spirit of teamwork also appeared in how they spoke of helping each other out. They often mentioned calling on each other when they had difficulty with their workload or to offer help when they could spare the time. This support was characterised as important not only to lighten the workload and facilitate cooperation but also for the provision of high-quality care. Constant adjustments on-site meant that some patients needed more time than the professional had estimated. Helping each other made it possible to spend more time with a patient who was ill or having a rough day.

Theme 3: taking responsibility for system risk

The healthcare professionals described many examples of patients who needed residential care but still lived at home. These patients might struggle with severe immobility, advanced dementia, financial issues, no family nearby (or no family at all) to help with practical tasks, loneliness, depression, anxiety or feeling unsafe at home. Every day, the healthcare professionals tried to compensate for homecare that did not accommodate the needs of these patients. They spoke of patients at risk: those who had gone out and forgotten how to get back home, leaving electrical appliance turned on, or falling down the stairs or tripping over rugs, injuring themselves.

The number of patients with dementia is expected to rise as homecare becomes the new standard. Our results showed the increased number of dementia patients led healthcare professionals to find homecare more demanding. The healthcare professionals changed their visiting hours to up to six times a day but expressed frustration having to leave some patients who could not safely be left unattended. When the need for care exceeded the capacity of the homecare professionals, they found it irresponsible for the patient to remain at home. These homecare professionals often fight for these patients to be placed in residential care and reported maximising their visiting hours and documenting the need in every possible way even though they had any decision-making authority. As homecare providers cannot grant residential care, they were frustrated by these situations and reported that they still felt responsible for the (un)safe situation of these patients who were no longer safe at home. These issues were challenging; the patients and their families often demanded additional healthcare services, while the healthcare professionals could not get the assistance their patients needed.

Theme 4: reluctantly accepting the extended expectations from society

The lack of what constitutes necessary healthcare has taken a toll on healthcare professionals. Examples given mentioned relatives who wanted more help than the patient did or wanted the healthcare professionals to force patients to accept care.

According to the results, the healthcare professionals claimed that society expects too much practical and domestic work from them. Although the municipalities gave patients literature about what to expect from homecare, this did not solve the problem. The healthcare professionals reported that many of their patients were living at home alone with no family in the area. In these cases, the responsibility for these patients’ well-being fell on the homecare service. However, as several homecare professionals contended, homecare is not housekeeping.

This discrepancy between what society expects of healthcare professionals and what these professionals considered homecare to be added ambiguity to the role of the homecare professional. According to our results, the homecare professionals thought that they had no choice but to do the extra work because not doing it could harm the patient or tarnish the relationship between the patient and the healthcare professionals. The healthcare professionals did as much as they could, but the expectations of what they were expected to do constituted more than homecare. As some put it, unintentionally playing the role of the municipal contingency healthcare system, homecare is caught in the middle. They recognised the problem but had no resources or opportunity to solve it. The healthcare professionals emphasised that the problem was the lack of a definition of homecare.

Discussion

In this study, we investigated the ways in which home healthcare professionals conceptualise and act on risk. We found that they assess risk situations daily, deal with uncertainty as individuals and as teams and modify care in a person-centred manner. However, they use terms other than risk to talk about risky situations.

Theme 1 shows how planned work is not necessarily assessed as proper or most important in the here and now. It depicts how the healthcare professionals prioritise self-confidence, self-efficacy and autonomy in how they make sense of and respond to risk information from their observations of their patients. The examples show how the theoretical framework of work-as-planned versus work-as-done, resilience and adaptive capacity may be spotted in real life. Theme 2 depicts how the healthcare professionals made sense of risk and quality. In a homecare setting, most healthcare professionals work alone. Our results, however, show that they find the team pivotal. Thus, our results indicate that acting on risk is a team effort. Theme 3 addresses how the healthcare professionals individually and collectively tried to compensate for system risks. Theme 4 shows how the healthcare professionals experienced role ambiguity and how it affected them. These themes 3 and 4 both depict how person-centred care, quality and risk are made sense of in practice when home healthcare professionals try to adapt to the situations.

Our results show that making sense of the situations is instrumental in the response of healthcare professionals. From a social constructionist perspective, risk information is related to what is specifically observed, as risk cannot be reduced to numbers.24 25 46 47 In our homecare setting, the team uses vital signs to guide adjustments to care, but this often comes second to their own observation of subtle signs of a patient’s deterioration. Vital signs alone are insufficient for the delivery of high-quality care. Knowing their patients well is crucial to a home healthcare professional’s ability to decide when to take vital signs. It is the healthcare professional’s task to notice the subtle signals that precede a decline in a patient’s condition.

From this perspective, the healthcare professionals make sense of risk by perceiving risk information as something that can be objectively measured. In addition, we found that the team’s joint assessment of the patient’s condition was crucial to arriving at a complete risk picture. Our study demonstrated how the healthcare professionals emphasised the need for discussing the patients’ risk picture, and the role of teamwork that enhanced quality and reduced risk as they took a collaborative approach to become aware of risk factors. In their view, checklists and guidelines often felt like distractions from the provision of high-quality, professional care. This contrasts with healthcare services governed by checklists and quality systems and reflects the ambivalence regarding quality systems and national guidelines expressed by the healthcare professionals in this study. Hence, our findings illustrate that the way in which society expects institutions to handle specific risks is not necessarily in line with what professionals think is the best way to handle risk. Bureaucracy and putting emphasis on checklists and guidelines may cause problems, not solve them.^50–53 This also relates to what other studies have found on healthcare professionals’ mixed feelings about quality improvement programmes, guidelines and checklists, such as screening for malnutrition^54–56 and vital signs.^{57 58} Future research should investigate this duality between checklists to reduce risk and the perception risk among healthcare professionals, which appear to differ significantly in practice.^{59 60} This also related to how some risks are noticed and acted on, while others may pass under the radar and increase.^{44 45 61}

Our study found that healthcare professionals expressed great frustration at being caught in the middle of role ambiguity in terms of what they were expected to do and what was possible. Adapting to the situations is referred to as work as imagined and work as done in the resilience literature.⁴³ The adaptations seen in our results may also be interpreted as boundary work, where boundaries are defined as constructions within social interactions.⁶² In our study, the results showed that the healthcare professionals found that the boundaries for what the society expects from the healthcare professionals within a homecare setting were overstepped. The results also imply that these expectations affect the way in which healthcare professionals made sense of the risk information. Because homecare professionals were expected to do more than provide healthcare, they amplified those risk factors (eg, the patients’ personal economy, domestic work and social needs). The healthcare professionals found that what they perceived as the original and real tasks of homecare was somewhat attenuated. However, system-level risks were described in diverse ways. Some healthcare professionals placed the responsibility on the politicians and government, stating that they would fight this transferred responsibility for system risk due to lack of residential care. Others argued they needed to compensate for weaknesses in the system by walking the extra mile and beyond for their patients.⁵⁹ Overall, the balance between ambiguity and professional autonomy showed a need for autonomy to enable adaptive capacity and adapt to the needs of patients and their families.⁶³ Also bearing in mind that how teams are constructed, both in terms of size and profession, will affect the teams’ formalisation and autonomy,⁶⁴ further studies should investigate this. The field of trade-offs, autonomy, ambiguity and role ambiguity related to risk, roles and responsibility for acting on risk information in the homecare setting have been insufficiently explored.

Based on our findings, we argue that training and awareness of a common risk language is required for the homecare services and healthcare professionals to gain traction and be heard. Language is power. How we understand, express and communicate risk matters, and what gets attention is not random.⁴⁶ Without a safety language, homecare risks might remain unarticulated, and risk being attenuated and forgotten, while other parts of municipal operations handle the safety language and gain attention.^{44 45 47} Awareness of risk could take place as part of everyday work routines and structures, such as morning meetings, handovers and the professional discussions about the patient’s condition and what are crucial elements to remember in treatment and care. Assessing, understanding, expressing and communicating risk information is clearly vital for the society and systems to make sense of and act on the information. Further research should be conducted to explore the use of risk terms in the homecare setting.

For policymakers, our findings demonstrate a need to consider adaptive capacity in homecare to a greater degree than currently practised. Guidelines, legislation and quality systems may come in handy. However, our study reveals that healthcare professionals often find that these measures interfere with the professional clinical gaze and with having the time to note subtle changes in the patient’s behaviour, mood or general condition. Autonomy and the role of the team are crucial for homecare practice. Policymakers should take notice because reducing risk and enhancing quality cannot be reduced to single indicators, checklists, guidelines or screening alone and as individual professionals only.⁶⁵ Bosk et al ⁵³ proposed that it is crucial to avoid assuming that a technical solution, such as a guideline or a checklist, can solve the problem of quality and risk reduction. Even robust checklists will be unused without attention to adaptive work, teamwork and the ways in which quality and risk are perceived and enacted by the healthcare professionals who are the intended users of the checklists and guidelines.⁵³

Limitations

Our study has two important limitations which must be addressed and discussed. First, the research design is a qualitative multiple case study. The transferability from a Norwegian setting to other settings may or may not be possible. We have therefore described the organisation of the Norwegian health service so that the reader can assess the transferability to other settings and contexts in line with recommendations for qualitative and case study research.³⁹

Second, inviting and recruiting relatively similar cases could be a limitation. Recruiting municipalities unlike each other, in terms of large cities or large municipalities with few inhabitants, long distances and few and small hospitals in the area (such as in northern Norway) could have impacted the findings and provided additional details to our research.

Conclusion

In this study, we have investigated how risk is perceived and acted on among home healthcare professionals. We found that healthcare professionals make sense of risk by using their clinical gaze, gut feeling and experience to detect subtle changes in the patients’ condition. Although home health professionals work alone, homecare is teamwork. Assessing risk information, as individual healthcare professionals and as part of a team, is crucial to the delivery of high-quality care.

Healthcare personnel emphasise the well-being, safety and soundness of the patients when acting on risk information. Their everyday work includes continuous adaptations to patients’ needs. Healthcare professionals act on their gut feeling, moral compass and clinical understanding of what high-quality care is for each patient. Adaptations to patients’ needs, contextual settings, team understanding and large mismatch between capacity and demands in homecare services our study shows that the homecare services constitute a key part of the municipal contingency healthcare system, which is taking care of the responsibility for system risk and maintaining resilience.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Ethical approval of all protocols was obtained from Sikt—the Norwegian Agency for Shared Services in Education and Research (reference number: 784787)—prior to participant recruitment and interviews. Sikt is formerly known as the Norwegian Centre for Research Data (NSD) and provides the ethics approval, information security and privacy services as part of the HK-dir. (Norwegian Directorate for Higher Education and Skills). Participants gave informed consent to participate in the study before taking part.