‘I Feel the Pressure of Racing the Clock’: An Institutional Ethnography Examining Home Care Nursing in Canada

ABSTRACT

Home care nursing is an essential component of health care in Canada, yet little is known about the work of home care nurses.

Aims and Design

As a part of a larger Canadian study on home care, this institutional ethnography (IE) focused on home care nurses in one health authority in Western Canada. The purpose of this research was to explore the work of home care nurses and to trace how this is organised and coordinated from the standpoint of the nurses.

Methods

IE is a methodology that focuses on day‐to‐day work from an established standpoint to uncover what is coordinating the work at a systems level. In this research, the standpoint of nurses was explored through interviews, observations and collected texts. Data were collected from March 2020 to December 2021.

Results

Nurses work in home care includes the determination, coordination and provision of care, documentation, supporting care givers, communication and referrals. The role is complex and uniquely autonomous. Texts that are used to collect information about home care nursing focus on task completion resulting in a representation of nursing practice that misses significant components including the organisation, relational and ethical work. Analysis shows that nurses' work, coordinated through electronic health documentation systems and texts, is influenced by dominant safety, efficiency and measurement discourses.

Conclusion

Home care nurses' time is increasingly spent managing their referrals, documentation and schedules eclipsing time spent on direct client care.

Impact

Understanding the invisible but dominant forces organising, and at times disorganising, the everyday work of nurses is a vital first step in creating change for home care nursing.

Patient or Public Contribution

None.

Contribution to the Wider Global Community

Globally there is an increasing need for home care nursing to be delivered effectively; this research provides insights relevant to home care systems across jurisdictions.

1. Background

Home care programmes, as a critical component of Canadian health care, provide services that ‘help people to receive care at home, rather than in a hospital or long‐term care facility, and to live as independently as possible in the community’ (Health Canada ²⁰¹⁶, para. 3) enabling those who want to receive care at home to have this option (Canadian Institute for Health Information [CIHI] ²⁰¹⁷; CNA ²⁰¹⁴). Home care is uniquely positioned in the Canadian health care system because it is not included in the national policy framework of the Canada Health Act (1985) and is therefore not designated as a fully insured and universally accessible service (Health Canada ²⁰¹⁶). As a result, there are varied services provided to clients and families (Canadian Health Coalition ²⁰¹⁸; Canadian Healthcare Association ²⁰⁰⁹; Palmer et al. ²⁰²²) and there is an ability to charge clients for services resulting in a mix of publicly and privately funded home care services across Canada (Canadian Healthcare Association ²⁰⁰⁹; Johnson et al. ²⁰¹⁷).

The need for home care is increasing as the population ages and more people are living with chronic illness that require and request care at home (Canadian Healthcare Association ²⁰⁰⁹; Canadian Home Care Association ²⁰¹¹; Canadian Home Care Association et al. ²⁰¹⁶; CIHI ²⁰¹⁷; CNA ²⁰¹³; Chappell ²⁰¹¹; Garland Baird and Fraser ²⁰¹⁸; Johnson et al. ^{2017, 2018}; Palmer et al. ²⁰²²). Additionally, a majority of Canadian's have a preference to age and be cared for at home rather than in institutional settings (CNA ²⁰¹⁴; Statistics Canada ²⁰²²). These factors have resulted in more significant needs for home care services.

Nurses provide the majority of professional care within home care programmes (CNA ²⁰¹³; Ganann et al. ²⁰¹⁹). The work of nurses is integral to home care services (CNA ²⁰¹³), as they provide care across the continuum of health and illness and the lifespan (Community Health Nurses of Canada [CHNC] ²⁰²⁴). Although nurses' work in home care varies depending on the province in which they are employed (Ganann et al. 2019), there is a common understanding that home care nursing work is a specialised autonomous area of practice, with the work of highly skilled nurses resulting in positive outcomes for clients and their families (CNA ²⁰¹³; Ganann et al. ²⁰¹⁹; Melby et al. ²⁰¹⁸). Discipline specific competencies for home nurses in Canada identify knowledge and skills to guide home care nursing practice (CHNC ²⁰²⁴). There are distinct contextual factors in home care nursing work as nurses enter the client's home, fitting into clients' schedules and needs, which is in contrast to nursing work in acute settings, where organisational structures set timing and control (Marrelli 2018).

While Canadians desire to have effective home care programmes, there are significant gaps in understanding the day‐to‐day delivery of nursing care within home care programmes in Canada (CNA ²⁰¹³; Ganann et al. ²⁰¹⁹; Melby et al. ²⁰¹⁸; Underwood et al. ²⁰⁰⁹). Given the increased need for home care services (Conference Board of Canada ²⁰¹⁵; Palmer et al. ²⁰²²), the impacts of these demands on nursing, the broader influences changing nursing work and the unmet needs of clients (Statistics Canada ²⁰²²), it is essential to understand what is happening within home care nursing, to examine the work of nurses and to identify what is coordinating nurses to seek opportunities for providing better care and systems change.

This inquiry was part of a larger project examining aiming to inform the development of promising practices for equitable and consistent access to home care in Canada (Stajduhar and Contandriopoulos 2018). This inquiry was a more focused study for the lead author's doctoral dissertation (Sanders 2023). Within the larger study (Stajduhar and Contandriopoulos 2018), there was an apparent absence of awareness of home care nursing in the public realm, including media, public information and scholarly literature, which appeared in contrast with an increasing awareness of the need for and complexity in home care. This sparked our questioning of what is currently organising—and disorganising—the work of nurses in home care and set out the approach to the study presented here, an institutional ethnography (IE) (S2022mith ^{2003, 2004, 2005, 2006}; Smith and Griffith ²⁰²²). In this paper, we describe the IE approach taken, identify data gathering strategies and analysis undertaken to identify dominating features organising home care nursing alongside recommendations for future change.

2. Methods

IE was used to investigate the social organisation of home care nurses' work from the standpoint of nurses. IE is a critical qualitative research approach developed by sociologist Dorothy Smith (Campbell and Gregor 2008; Smith ^{1987, 1990, 2005}; Smith and Griffith ²⁰²²). Influenced by social ontology and epistemology, an IE starts with people's everyday work, identifying a place of tension in their day‐to‐day work to show power relationships and dominant discourses, described as ruling relations (Smith 1987, 2005). The goal of IE is to identify how peoples' experiences are socially organised, examining patterns and ways relations are coordinated through texts, language and actions to explain the social organisation of their lives (Smith 1999; Smith and Griffith ²⁰²²).

The purpose of this research was to investigate the everyday work of home care nurses in one health authority in a Western Canadian province using IE to identify what the work of home care nurses is and to understand the ruling relations impacting the work of nurses in home care. We explored two research questions: (1) How do home care nurses describe their work providing care to clients every day? (2) How do the work policies, processes and institutional structures, as ruling relations affect nursing work?

2.1. Data Collection Methods and Context

Consistent with procedures for the national research study, three data collection methods were employed: interviews, observations and text retrieval. Data collection occurred from March 2020 to December 2021, a period where the COVID‐19 pandemic also impacted timing and approaches. Changes in data collection resulting from the pandemic included the move from planned in‐person to virtual interviews, and observations occurred only in home care offices and later vehicles, as researchers were not able to enter client homes during direct care visits for observations. Interviews were conducted on Zoom; an interview guide was used, and interview questions and probes supported a consistent structure to the conversation and ensured focus on nurses' standpoints by asking them to talk about their daily work. Details were elicited in each interview as we asked participants to provide an example of a client encounter and encouraged detailed descriptions of the work processes involved. For example, we asked questions such as how did you prepare for your visit, can you please talk through the steps you take on your visit, and what do you do after the visit to complete your care? Interviews were recorded and transcribed.

Observations were 2–3 days in length and focused on observing the nurses' work to listen, see and learn what they do and how they carry out their day‐to‐day work in home care. Over 50 h of observations were completed with participants in their office settings, and observations also occurred in the nurses' vehicles as they drove to client home visits. We completed free‐form narrative notes focusing on observation of the work processes, documents, discourse and emerging questions and inquiry.

Text collection included both paper and electronic materials as the home care offices started using an electronic documentation system in the spring of 2020. Participants referred to many documents, forms, procedures and charts during the interviews and observations. To help focus which texts to collect, we identified what was being used by nurses in their work. In IE, the purpose of collecting and analysing texts is to see how texts are used and how they coordinate work rather than an analysis that is separate from action, as might be done in discourse analysis. With this understanding, we collected texts used in the work being carried out by nurses (Table 1). From the three approaches to data collection, we generated interview recordings and transcripts, an observation notebook (from field observations), observation notes (electronic), texts and reflective notes.

TABLE 1.

Texts collected.

Texts used in nurses' work	Texts from health authority or government
Daily employee itinerary check‐in	Home and Community Care Minimum Reporting Requirements Visit Definition (Ministry of Health)
Documenting a staff safety and awareness plan	Health Authority Health Performance measures Home Care Professional Services
Assigned and delegated task grid—a general guide	Health Authority—Health Service Plans
Community Health Services client services agreement	Work Safe BC—Occupational Health and Safety Regulations and Guidelines Working Alone or in Isolation
CHS single client record prototype	Ministry of Health—Home and Community Care Policy Manual
CHS clinician documentation at a glance
Quick reference guides for PowerChart

Abbreviation: CHS, Community Health Services.

Two groups of participants were involved in this research, nurses who carry out the everyday work with clients in home care (N = 10), and nurses in leadership roles in home care programmes (N = 3). Convenience sampling was employed to recruit nurse participants. We shared an infographic about the study, attended team meetings in potential study sites and emailed the home care nursing team to invite participation. Following data collection and analysis with the nurse participants involved in direct care, nurse leaders who were purposely selected as expert informants to be interviewed. The leaders had different roles within the organisation however, they were all in formalised leadership positions and offered insights into the ruling relations emerging from the inquiry. The analytic interest in IE rests in the features of experience, discourse and social coordination of activities (Bisaillon and Rankin 2013). The goal of data collection and analysis in IE is ‘to make visible the ways the institutional order creates the conditions of individual experience’ (McCoy ²⁰⁰⁶, 109). With this understanding, and consistent with other qualitative approaches to sampling, the number of participants engaged in the inquiry was determined by the capacity to map the ruling relations, rather than ensuring a collection of complete perspectives on their individual experiences (Creswell and Creswell 2018).

Primary participants were nurses working in home care who consented to participate in the project. Participants included a licensed practical nurse and registered nurses who carry out direct nursing care. Participants' employment in home care ranged from less than 1 year to 14 years, and participants' experience in nursing ranged from less than 1 year to more than 20 years.

Nurse participants worked in four different locations; three health units were in a mid‐sized city and one health unit in a smaller community. All sites were within one health region in Western Canada and were engaged in the larger home care research project. Although the settings are unique because of the size and geography of the communities and the number of staff working in the health units, the governance is similar. This enabled ethnographic access and the tracing of ruling relations to identify trans‐local organisation, policies and practices that coordinate across different sites and communities.

2.2. Ethical Considerations

Ethical approval for the project was obtained from the research ethics review board through the harmonised process with the university and health authority (University of Victoria REB: H19‐00561), and the ethics protocol approved for the national research project was adhered to throughout this additional project. Participants were invited without coercion, consent was obtained for all interviews, participants data were recorded anonymously with no connections back to specific workplaces. Participants who consented to participate were assigned an identification number and subsequently pseudonyms for the purpose of anonymity and confidentiality in reporting findings.

2.3. Analysis

Data analysis in IE is an iterative process that requires the use of multiple approaches to analysis (Rankin 2017). Mapping, building accounts from the data and indexing were all used to identify work processes, highlighting text, language and coordination of work (Turner 2006). Analysis occurred over time as we read through transcripts, re‐read transcripts, sought out and reviewed texts, and made and reviewed observation notes. Analysis began by mapping out the work processes of nurses as recorded in interviews and transcripts. Notes from observational data, highlighting institutional language, added to the data for analysis, alongside interview transcripts and official texts, questions and ways in which theses texts interacted became part of a visual map and snapshot of activities and action between texts (Figure 1). Figure 1 is an example of the maps we created in the initial reflection and analysis of the data. As we reviewed the nurses' interviews about their work, we grouped activities into three categories (preparing for the visit, client home visit and after the client visit), as shown in Figure 1 as green circles. In the blue squares we identified texts, both electronic and physical texts, that nurses used to complete their activities. The nursing processes completed in each activity are indicated on Figure 1 in green, including setting schedules, collecting supplies, contacting the client, assessing, providing care and documentation. The mapping highlights the work that occurs over the day for each client, the information systems and tools used, the contact with clients and the follow‐up care that is provided. Narratives from the nurses that highlighted influences in their work could be linked to other texts and this analytic process showed the ways nurses' everyday experiences in home health nursing practice were coordinated.

FIGURE 1.

Map of nurses work for a home visit.

In addition to mapping, other analytical processes consistent with IE methodology were used. We reviewed transcripts multiple times, highlighting language, texts and tensions, adding questions and comments to institutional language and texts. Observational notes were reviewed, and we highlighted language and questions emerging from these notes. We indexed accounts and identified how the work across multiple sites was linked; indexing processes helped to focus the analysis on the material work and coordination of activities. Centering our analysis in the rich descriptions that the nurses provided of their work and the observation data maintained the focus on the nursing standpoint with the curiosity to understand how those experiences were organised.

2.4. The Itinerary Form as an Analytic Focus

In IE a problematic is identified, it is a way to explore the question and grounds the inquiry in the everyday work allowing the researcher to question how things are organised (Campbell and Gregor 2008; Smith ²⁰⁰⁵). Problematic is a methodological term in IE that ‘embodies and points to problems, tensions, and contradictions that arise in the relations between people and how society is organized … [and] is grounded in the social experiences that people encounter as troubling or difficult’ (Bisaillon 2012, 618). The itinerary form, a text used every day by home care nurses, was an artefact analysed textually for this inquiry as the problematic. Every nurse participant identified that they completed the itinerary form as a part of their morning work; however, participants shared different understandings of why they were completing this form and how it was used by the health authority. This difference in understanding and the consistent use of the form opened a line of inquiry into this authorised text to explore the tensions, uses and influencing relations.

The itinerary form is an 8 × 11 sheet of paper that nurses complete at the start of their shifts. To complete the itinerary process, nurses must do substantial work, use multiple documentation systems and access and update information on paper charts and from colleagues. The itinerary form requires nurses to complete specific tasks such as recording client information, identifying and recording the types of visits (home visit, phone visit) and transcribing safety assessment scores.

The information nurses are required to document on the itinerary form is informed by Home and Community Care minimum reporting requirements (British Columbia (BC) Home Health Standing Committee ²⁰¹¹) and WorkSafe BC (2008) policy. These policies set out requirements for what can be counted as visits and what the employer must have in place to meet provincial work safety policies. Examining how the nurses and the health authority use the itinerary form reveals how nurses' work is coordinated by policies outside their view and how the itinerary form is used to create a standardised set of data about their work.

2.5. Rigour

To ensure rigour, we utilised transcripts of interviews to support in‐depth analysis and documented when and how texts were used to ensure they were not viewed separately from how they are taken up in work (Smith 2006). We used multiple analytic processes including mapping, indexing and reflexive notes. These processes ensured we maintained a focus on the materiality of the data. We noted dominant institutional language and identified how it was taken up by the nurses and reflected in texts to maintain a focus on the tangible use and linkages of the work to text and coordination. As Rankin (2017) highlighted, the analytic threads and the structure of findings took time and a process of writing and thinking to expose the institutional links, using data and reflective, iterative, ‘relentlessness empirical’ (p. 10) processes. By mapping the text‐work processes of the participants we traced the tangible coordination of nurses work through texts. The tracing and showing of these processes built rigour as the we maintained a focus on the data from the perspective of the nurses and their work, focusing on empirical tracing rather than abstraction (Rankin 2017).

3. Results

From the analysis process a rich description of nurses' work came into view and previously hidden social relations were uncovered. Nurses spoke about their work building relationships with clients and families, the unique autonomy of their work and the challenges of the autonomy: ‘one of the hardest parts of this job is you go there and you don't have buttons at your side, you don't have staff to help you with, you are on your own and you are so autonomous in your practice…that's great bit it's also scary’ (Bob). Nurses identified their care coordination work, including referrals, documentation, determining care needs, supporting caregivers, determining next visits, collecting supplies, travelling to homes and communicating with colleagues, families, managers (Figure 1). As one participated shared, ‘We're a jack of all trades, honestly. Like there's so many different skills and scopes and things that you do’ (Kim). It was evident in their description and from observations that nurses work is socially organised from the time they start their day and swipe their cards to enter the building to the last fax and message for the day. Through the process of analysis, we identified discursive influences such as safety, efficiency, measurement and objectifying work that are organising nurses' work. Systems created to count, standardise, simplify and subvert complex nursing decisions and knowledge are used daily in home care practice.

3.1. Safety

Nurses transcribe safety assessment scores from the electronic chart of each client onto the itinerary form each time the client is seen. The safety scores are generated from an assessment completed by staff and nurses documented on the electronic system.

The initial assessment of the risk in the home and that screening first starts when the referral comes into our community access…they do that initial screening as well, and they'll look in PowerChart see if there's any violence alerts for client or other…that feeds the SSAP [Staff and Safety Awareness Planning]. The clinician does that assessment, [and] that assessment is shared with home supports as well.… And then it also informs how they do up their itinerary. (Sandy)

Some of the questions asked and the language used on the safety assessment form are verbatim to the WorkSafe policy language. ‘Risk mitigation’ plans are required as a part of this work. The safety discourse enters into nurses practice and informs their day‐to‐day work. ‘This itinerary sheet is used by admin to make sure that … they know where we are, if we don't end up coming back they can see around what time we were going to be somewhere, and then it shows the risk level’ (Kim). While this highlights safety as a priority, nurses identified gaps in safety that this work does not address. Participants noted that safety is more than physical safety; psychological safety needs to be considered as well. However, the safety scores on the itinerary form are tied to the WorkSafe working alone policy. As Bob shared ‘you're bouncing between all these different people and their different care needs and like I think there's a lot of empathetic burn out in the community because we're just kind of being yo‐yo'd around with like each client…[there is] empathic burnout of going to people's homes and seeing their family photos on their walls, seeing how they decorate their homes, seeing the people they love and who support them and just being privy to their life at such a vulnerable stage, it's very rewarding but it's also very exhausting’.

3.2. Efficiency

Nurses spoke about the need to ration their time and care, focus on tasks to be completed and the thinking work they do to select, prioritise and schedule their client visits each day. Nurses described the sense that they must complete more client care visits and use their time well. As Jen shared getting ready to for a visit, ‘this is a really simple thing that I missed…that if I had time to read the email or do the research I would have been a lot more efficient, or know all of the tasks they wanted me to complete’. Client referrals are assigned priority scores that nurses must review and plan for. Nurses described how efficiency feels in their practice as ‘feeling this pressure of myself racing the clock … and I could have done this better if I wasn't rationing’ (Jen). Non‐direct care tasks take time and while components are important this impacts the time that nurses have for direct client care. As one nurse described, a visit can result in 2 h of paperwork; however, this is still counted as one visit. The organising and communication work that home care nurses complete is essential and yet it is not recorded or a reported value in the electronic documentation system. The pressure felt to do more visits, or tasks, is emphasised by the reporting tools that identify the visit but not the time taken for the complex practice associated with the visit. The numbers of clients seen per day is the information collected on the itinerary form which becomes the quantification and description of the home care nurses' work.

3.3. Measurement and Objectification of Work

As discussed, the itinerary form creates a documented reality and efficiency agenda in home care. The number of home visits completed per day, are entered by clerical staff into an electronic system as the basis for managers to create productivity reports on the home care services provided. The definition of what can be recorded as a visit comes from a guideline from the provincial Home Health Standing Committee (2011). A visit is ‘an occasion in which care or service is provided to a client or an occasion when clinical direction that influences the care of the client is given’ (BC Home Health Standing Committee ²⁰¹¹, 1). The reporting requirements document identifies that ‘a clearer, standardized definition will result in increased accuracy of service utilization data’ (BC Home Health Standing Committee ²⁰¹¹, 1). The visit counts result in a ‘capture of volume’ (BC Home Health Standing Committee ²⁰¹¹, 1) for the specific service types in home care. The standing committee document clarifies that the visitation counts are not intended to measure workload, as that is captured through national management information system using Resident Assessment Instrument data reported to the Canadian Institutes of Health Information (BC Home Health Standing Committee ²⁰¹¹). However, nurse leaders described how they use the data created from the volume counts on the itinerary form to inform planning for staffing and workload. The itinerary form is ‘a way to collect this data …I actually don't think it's super accurate, the way we track data.… The remote visit, I think anytime you're working on a client you should be tracking that data, not just if you had a 10‐minute conversation with them, but now you need to do 2 h of paperwork on them. That 2 h of paperwork I feel should be documented as visit time. I just think we need to note that this data isn't all the information you have to look at’ (Tara). The type of visit and number of visits recorded on the itinerary form are defined and categorised by the BC Home Health Standing Committee (2011) definitions; therefore, the data recorded and then entered into the documentation system result in the information managers use and report on home care nursing work.

3.4. What Is Missing

While the itinerary form creates a representation of the number of nurses' visits per day and limited client data, the significant organising and coordinating work of nurses is missing from the counts on the itinerary form: ‘it can be quite a circus not going to lie, just sorting people out… I do get to work a half an hour early and I look through, ‘cause we get emails, a lot…and I try to keep up to date with my emails and from home support too’ (Bob). Relational and ethical work of the nurses in coordinating and providing direct care to clients is increasingly squeezed out of the working day while documentation, duplication to communicate through multiple records and methods, including phone, fax and computers, are increasing. As Jen described, the task on her visit was to refill syringes with a palliative client but ‘that task can take you three hours and time passes …him telling me his story was a big part of this process’, as she described the palliative visit and her approach of ‘mindfully taking time’ for the completion of the task was only one part of the visit. Recording the work as one visit, which is the value seen by the health authority, does not reflect the essential relational and organising work that nurses are completing.

Nurses spoke to the value of visiting clients in the home and how this is not represented in their counts and is a value being challenged by the focus on seeing more clients in a day. Providing care in clients home is identified by nurses as important as you come to know the client with greater depth, for example Ruth explained the nurse can see if they have ‘a case of full of sugar soda at that front door. You can tell if they have a hard time letting go of things, and maybe their mobility is changed, and they have a lot of clutter in their home …so it's just those other pieces that you would never see in the hospital, or like how an actual person functions and where they keep their medicine—if it's organized, if it's just there's medicine in every single room of the house’. Pat highlighted that providing care in the home is essential as an example when teaching a client about their colostomy‐ileostomy it helps to do it in the space where they will be independently completing this task rather that the bathroom at the health centre. Nurse participants described how the clinic setting is becoming the preferred location of nursing care for clients who are physically mobile, with the goal having clients travel in to reduce nurses' time for travel. A focus on time efficiency that has implications for nursing and client care.

4. Discussion

In our study, dominant institutional efficiency and safety discourses sat in tension with nursing values yet were strongly linked to emerging bodies of knowledge of home care nursing. Our findings point to how home care nursing is complex socially organised work. Examining how the itinerary form is used in practice, from both inside and outside of positions of institutional power, reflected the ruling relations that are directing home care nursing work. The numerical representation of home care visits and safety meets the needs of the health authority for reporting and recording; however, it also creates a textual reality of nursing practice that does not adequately represent the work nurses undertake in practice, while reinforcing dominant discourses of home care nursing. Smith (1987, 2005) identified the practice of abstracting the actualities of work into generalised, objectified and impersonal accounts as part of ruling work. The intentional subordination of individual knowledge alters the work of nurses across sites, lifting this work into a textual reality far removed from the everyday work in the setting (Smith 1987, 2005). The itinerary form is just such a text that directs, coordinates and standardises nurses' work into a count that renders invisible all the nuanced, complex and contextualised work.

Home care is increasingly influenced by the ideology to save costs and manage home care like a private business (Björnsdóttir 2018; Jakobsen and Lind ²⁰²²; Strandås et al. ²⁰¹⁹). Representing work numerically into counts aligns with the discourse of efficiency emphasising a focus on constraints of time and resources which reflect the values of the New Public Management ideology (Strandås et al. 2019). This work is informed by a market‐based system influenced by capitalism. Globally, the shift to an economic discourse in health care focused on efficiency and cost containment have led to rationing of home care services, rationing of care, standardisation of processes, a focus on task, measurement and a loss of holistic relational‐based care (Björnsdóttir 2009, 2018; Jakobsen and Lind ²⁰²²; Strandås et al. ²⁰¹⁹).

A challenge for nurses, as identified in this inquiry, is the misalignment of the focus on economy and efficiencies, and nursing values and the realities of nursing work (Strandås et al. 2019). Several nurses in this inquiry identified the importance of taking time to build relationships, spending time with clients when questions about their palliative care emerged, rather than popping in and out to merely complete IV medication administration or other tasks. The focus on time and task reinforced by the itinerary form undermines the core relational, caring, family‐ and client‐centered approaches in home care that are necessary for quality of nursing care (Fjørtoft et al. 2021; Jakobsen and Lind ²⁰²²; Strandås et al. ²⁰¹⁹). Home care nursing work is complex and involves knowledge, creativity, attentiveness and flexibility by nurses (Björnsdóttir 2018; Fjørtoft et al. ²⁰²¹; Riekert ²⁰²¹). Ensuring that nurses are engaged in the communication, documentation and coordination of their practice is essential. Nurses must be relieved of the system requirements of often duplicated and multiple layers of reported information that are not clearly reflective of practice realities, nor instrumental in the transfer of essential and meaningful information.

Nursing care documented in electronic systems produces data to meet accountability requirements that do not reflect the care and essence of nursing and can contribute to a ‘check‐list mentality’ (de Ruiter and Demma ²⁰¹¹, 27). This documentary reality is a significant concern when decisions made about budgeting, workforce planning and processes are made using the limited data and view of nurses' work created from the counts. The absence of a comprehensive understanding of nurses' work creates a vulnerability for inadequate funding, resource supports and replacement of nurses within the home care system. Additionally, as Tourangeau and colleagues (2014) identified, balancing documentation, reporting and client care is challenging for nurses and influences their intention to remain in home care nursing roles. This is particularly significant to address work pressures and retention in the context of a nursing shortage.

Electronic health systems in home care are coordinating the work of nurses. Poor design of information technology impacts client care and results in workarounds; it is critical that there is a change to the culture that has previously excluded nurses from the design and decision‐making processes regarding technology (Dykes and Chu 2021). Creating systems to accurately reflect the work and not adding more complexity to nurses' documentation could help with the gaps in what is currently being captured (Ibrahim et al. 2020).

An additional challenge of accurately reflecting the work of nurses in home care is that it is often unseen work completed in private homes (Melby et al. 2018; Sharkey and Lefebre ²⁰¹⁷; Purkis ²⁰⁰¹). Caregiving work, often identified with women and body work, is undervalued (Purkis et al. 2008). Identifying and articulating home care nursing work is an essential step in valuing the work. If the work is unseen and unknown, there is a limited ability to talk about and value it. Explaining what nurses do has been difficult; however, it is critical for nurses to be able to explain their work, as it informs workforce policy, including planning for adequate staffing and processes for ensuring their safety (Jackson et al. 2022). Oldman (2022) proposed home care nurses need to articulate what they do and the impacts of it; they know what works and what does not; therefore, nurses need to advocate for systemic change, as often they stay focused on client advocacy rather than moving into the political realm.

In Canada, discipline‐specific competencies for home care nursing identify that care coordination is a key element of home care nursing practice (CHNC ²⁰²⁴). Home care nurses spend a significant amount of time organising their work and client care. Organising work is often invisible and taken for granted, but it is also the ‘glue in the health care system’ (Allen 2015, 3). In her research on nurses' organising work in acute care settings, Allen (2015) identified, ‘Nurses have a central role in coordinating the ongoing organization of healthcare delivery and in order to undertake the function they must generate and keep in play a working knowledge of the evolving status of patient trajectories’ (p. 33). Organising work calls on nurses to create a working knowledge of what is happening for clients, identify and articulate trajectories of care, pass on care to others and identify patients' needs (Allen 2015). This practice is often discounted as not real work with clients; however, it is essential and needs to be included in understanding and allocating workloads (Allen 2015). Although the home care context differs from the acute care context, Allen's (2015) reference to the work of nurses being invisible and often undervalued is relevant to this research. Coordination of client care is highly complex and an essential part of home care nursing practice (Björnsdóttir 2018; Fjørtoft et al. ²⁰²¹; Melby et al. ²⁰¹⁸; Riekert ²⁰²¹). The complex work of care coordination requires registered nursing competencies and skills (Nilsson et al. 2009).

5. Recommendations

Through this investigation, opportunities for change have come into view. Recommendations in three main areas: (1) nursing voice and influence in decision making, (2) information system policies and development and (3) opportunities for future learning are identified.

Nurses' voices are essential to informing decision making and to increase understanding of the work carried out in home care. Home care nurses impact the health of clients they work with at the individual and family levels and have the potential to impact care systems when they are involved in directing and designing care delivery (Ganann et al. 2019). As Oldman (2022) and Purkis (2001) identified, home care nursing work is political and nurses must engage in processes to make their work visible. Engaging nurses' voices and experiences in decision making at multiple levels is crucial to creating positive changes. When nurses are involved in governance and decision making, organisations produce better outcomes for nurses and clients (Bartmess et al. 2022; Hamilton et al. ²⁰²³). Home care nurses can speak up about their work, sharing the complexities and unseen work they complete; however, increasing the presence and understanding of home care work cannot rest solely with the nurses who are engaging in direct client care day to day. At a macro level, nursing leadership and input are needed in decision making about information systems, resource allocation, systems flow and structures. Health care leaders and policy makers need to learn about home care and its impacts.

The development and refinement of information systems must include nurses who are using the systems to inform the use and changes to systems. As Ibrahim et al. (2020) identified, involving nurses (the users) in the design of information systems is necessary to create a usable system that fits with the complexity of their practice and prevents workarounds. Additionally, the concept of safety and safety policy needs to be better defined. Safety discourse needs to move beyond the focus on risk mitigation to understand the diverse challenges in safety, including the navigation of working in clients' personal homes, in spaces and places that present safety issues, and the psychological safety of nurses engaging in client care that is relational and offers a different connection because of the immersion in clients' homes and personal settings.

More research to build knowledge about home care and home care nursing is needed. Nurse leaders identified that they need evidence on resource allocation for workload in home care nursing, what is safe and how to plan for the number of clients nurses can safely provide care to. Home care is far more than a way to save costs from acute services (Ceci and Purkis 2011); therefore, research on home care must evaluate more than cost savings. As Contandriopoulos et al. (2021) found, there are mismatches between what is being evaluated in home care research and the specific intervention. Further evaluation research would also benefit the understanding of home care work and outcomes.

6. Limitations

Due to COVID‐19 restrictions during data collection, observations of nurses' work directly in client homes could not be conducted, though the nurses described their home visits in rich detail. Interviews and observations with clients could further offer additional information about nurses' work and provide opportunities for clients and caregivers to speak about their experiences and influence change. Diverse participants took part in this study; however, few of the nurses interviewed had more than 5 years of experience. More permanent, ongoing and experienced home care nurses would add a perspective to this work that could offer greater insights.

7. Conclusion

Home care nursing is a critical component of the health care system in Canada and yet nursing work is hidden and the complexity of the work of nurses is unclear. The managerial emphasis on safety, accountability, efficiency and measurement has reshaped how home care happens and is disorganised. Change is needed and is possible to improve home care. National standards for home care services, universal funding schemes for home care systems in Canada and policies to ensure support, education and training are essential. With the increasing calls for expanded home care in Canada, it is imperative to accelerate research and policy agendas for the advancement of home care nursing. Nurses' knowledge and their voices are essential to this imperative of enhancing and sustain quality of home care nursing and the broader system in the interests of the many and diverse populations who require and benefit from this essential form of health care delivery.

Author Contributions

Tanya Sanders, Susan Duncan, Sonya Jakubec, Kelli Stajduhar: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Involved in drafting the manuscript or revising it critically for important intellectual content; Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics Statement

Received from the University of Victoria—REB: H19‐00561.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data available on request due to privacy/ethical restrictions.