INTRODUCTION
The choice for the nurses’ work in
the home scenario results from the substantiality that this space imprints as a
privileged locus of health care production, which is made possible by different
types and levels of health complexity. Thus the present study proposes to
enable the understanding of professional practice and, consequently, contribute
to the reflection and improvement of professional practice in this specific
scenario.
It should be noted that the nurse has
the possibility of performing a fundamental work in home care, acting as a link
between the health team and the family of the patient under his/her care. Thus,
the research is built from the possibilities of investigation of how care has
been given in activities and strategies used to establish a therapeutic
relationship with the patient and his/her family.
Home health work does not propose to
delegate to the family the responsibility for the care to be given to the
family member. This condition imprints the need to understand the home as
fruitful, as a space for action and effectiveness of health work (1).
In this aspect, the home visit
emerges as an obligatory instrument to the possibility of nurses' performance
in the home setting. Historically, the introduction of the Family Health
Strategy in the 1990s and the proposals for home care and social reintegration
of people with mental disorders in the field of health care in Brazil, there is
an intensification of the publication of experience reports and official
documents emphasizing their importance and the real advantages for the success
of public health enterprises (2).
The household scenario as a space for
production of care corroborates for the effectiveness of new health care
practices, with the possibility of greater autonomy of families in relation to
the development of the therapeutic project, implies new ways of acting, and
recognizes the patient as an active and participatory subject throughout the
care process (3).
In this way, the nurse’s home visit
enables the production of a nursing care directed to the real psychosocial
needs of the patient/family. In the present study, we consider care as
characterized by being existential, relational and contextual (4),
it is the object of nursing, which is its doing and the subject of care is the
being who needs it (5).
Thus, the characterization of the
role of nurses in home care emerges as a possibility to subsidize public
policies and health strategies aimed at strengthening primary health care,
contributing to a quality and humanized health care to patients/families in the
home environment.
Therefore, given the above, the
present study was structured from the following research problem: “How has
the work of nurses been developed in the home setting?”
In order to answer the research
problem, the objective was to characterize how the work of nurses at home has
been produced.
METHOD
This
is a narrative literature review, in order to synthesize the scientific
production already published. In this context, the narrative review proposes to
the survey of scientific knowledge, aiming at the reconstruction of thought
networks (6), in order to identify the state of the art on a
particular object of study, in the present work, characterization of the work
of nurses in the home setting.
Review
articles, as well as other categories of scientific articles, are based on
bibliographic or electronic sources to obtain results of studies carried out by
other authors, in order to theoretically support a specific objective (7).
Data
were collected in June/July 2023 in the following databases: Latin American and
Caribbean Health Sciences Literature (LILACS), Publisher Medline
(PUBMED/MEDLINE) and SciVerse Scopus (SCOPUS). The following combination of
descriptors was used to search for references: Nurses and/or Home Care
Services. The publications of the last 10 years (2013-2022) in Portuguese,
English and Spanish, published as a scientific article were considered.
References whose content of the article was not fully available were excluded
from the sample.
After
a first selection by reading the titles of the articles, the abstracts were
read and finally the references were fully read. After the selection of the
references, a textual corpus was elaborated, from the results and conclusions
of the selected articles, extracted from abstracts and submitted to processing
by the software Interface de R pour les Analyses Multidimensionnelles de
Textes et de Questionnaires (IRaMuTeQ) version 0.7 alpha 2, developed by
Pierre Ratinaud in 2009, using the processing from the Descending Hierarchical
Classification (DHC) and the Word “Cloud”.
In
this aspect, the software provides another form of presentation of the results,
from a correspondence factor analysis made from the DHC. Based on the chosen
classes, the software calculates and provides the most characteristic Text
Segments (TS) of each class. Such classes of TS are composed of a
classification according to the presence or absence of a certain vocabulary.
Regarding the word cloud, the software groups the words and organizes them
graphically according to their frequency. They are presented with different
sizes, and the larger words are those with greater frequency in the corpus, and
the smaller ones have lower frequencies. The former are placed in the center of
the graph. It is a simple lexical processing. However, it is graphically
relevant, since it presents an initial idea of the content and extracted from
the textual corpus (8).
RESULTS
The selection
included 17 articles that met the inclusion criteria, which are presented below
in the chart with the characterization of the articles concerning title,
journal, objectives and year of publication, allowing an expanded view of the
subject to be confronted:
Through
the reading of the 17 selected articles and the processing made by IRaMuTeQ,
three interpretative categories were identified: 1. Complexity of Home Care:
between the Objectivity of the Technique and the Subjectivity of Care; 2.
Characteristics of Services and the Public Receiving Home Care and; 3. Work
Tools and the Directionality of Home Care.
DISCUSSION
The nurse needs to be able to see the
home context beyond the physical space, considering it as a set of
interconnected elements, and built from objects, events and humans, with their own
uniqueness, processes of subjectivity and coexistence. To provide effective
home care, the nurse must be prepared to deal with a variety of situations,
requiring the application of multiple elements that make up his/her core professional
performance (14).
The care work is a process
intrinsically linked to the caregiver, reflecting his/her beliefs and personal
values about concepts such as life-death, health-disease, care-cure, among
others. Understanding the meaning of caring is a matter that demands individual
exploration, but at the same time can be developed and cultivated. In this
context, nursing education institutions play a fundamental role, since they
have the responsibility to facilitate learning and internalization of the humanistic
care dimensions (4).
Nurses’ work in the home context
transcends the mere execution of technical procedures, covering a deeply
humanistic and holistic dimension. Home care, under the nurse’s guidance,
involves understanding the unique needs, preferences and values of each
patient, in addition to considering the home environment as an integral part of
the care process. In this scenario, the nurse acts as a facilitator of the
adaptation of the patient and his/her family to health demands, promoting
autonomy and quality of life. In the meantime, the home care provided by nurses
must transcend the technical and clinical spheres, incorporating a
patient-centered approach that recognizes the complexity of the experience
inherent in the processes of suffering and illness and the importance of the
domestic context in the process of recovery and health promotion (25).
Care is an essential force that
permeates human experience, being manifested constantly at all times and
circumstances. Placing care at the center does not mean ceasing to work and
intervene in the world, but rather renouncing the approach that seeks to
control and reduce everything to objects, detaching them from human
subjectivity. In this regard, any form of authoritarianism and domination should
be rejected, and limits on the obsession with effectiveness at any cost should
be imposed. This involves replacing the dictatorship of impersonal and abstract
rationality with care, organizing work in harmony with nature and its
orientations. Moreover, it means respecting the interconnections that all
things maintain between themselves and with us, prioritizing the collective
well-being of society, the biotic community and the planet over exclusively
human interests (26).
The complexity of the care process in
the home scenario extrapolates the physical environment of the home, being
related to the actions and care developed to patients of the services, as well
as the inherent aspects of the organization of home care services. In this
context, in Sweden, home care began to be incorporated into Primary Health Care
services, being under the responsibility of the municipalities (11).
In the last 20 years, in many Western countries, health services have changed,
with an increasing proportion of services using households as a space for the
production of care (23).
Home care is a crucial element in
promoting care and building relationships of trust, bond and empathy between
health professionals and patients. However, its effectiveness requires close
articulation with the network of health services. In this sense, subjective
demands from health professionals emerge, which play an essential role in the
formation of a truly effective health care network (22).
Another aspect identified from the selected
articles is related to the work of nurses in the home setting that is anchored
in structural elements of home care services and the public that demands such
care. In this sense, primary health care services stand out in the production
of home care. Regular contact with generalist community nurses is associated
with a strong sense of safety about the immediate situation for home cancer
patients and their primary health care caregivers. Such a sense of safety is a
significant component for the physical and psychosocial well-being of the
patient and caregiver (27).
The puerperal period consists of an
interval of considerable challenges for health professionals, since it
concentrates a significant portion of maternal and child morbidity and
mortality in the national context. In this perspective, when we consider the
puerperium as a phase that often raises insecurities, especially in primiparous
mothers, whose uncertainties are more pronounced, the nurse needs to demonstrate
sensitivity to identify the specific needs of these women, especially in the
home environment (18).
The home can be considered a unique
space of significant relevance for the provision of health services, since,
through the understanding of the particular characteristics of this
environment, nurses can develop more contextualized and effective care
interventions. This gains prominence in the performance of nursing
professionals during the puerperal period, since, by improving their practice,
particularly in the educational context, they can help primiparous women in the
process of adaptation and coping with the challenges inherent to this new stage
in their lives. For this approach to be implemented, it is essential to carry
out comprehensive home visits, with priority for the health of both mother and
newborn. However, it is imperative to emphasize that the care provided by these
professionals should not be restricted to the purely biological aspects of the
puerperium, but should also include considerations related to social, cultural
and economic factors, which can be further explored and discussed in the patients’
home environment (18).
The monitoring of breastfeeding
practice emerges as another field of intervention of nurses at home. Thus, the
home lactation clinic allows performing health interventions in the context of
people’s daily lives, making an individual assessment of the couple and the
family, considering aspects of physical, psychological, affective, social and
contextual health that may be influencing the phenomenon of lactation. Part of
the success of a home lactation clinic lies in the therapeutic bond of trust
that can be formed between the nurse and the family, but mainly with the
mother, who is in the process of adapting to her new role (12).
Elderly people appeared as
intervention patients and receiving care in the practice of nurses in home
care. It is highlighted the access to health care of elderly patients who are
in the process of finitude and palliative needs at home, which require and
serve as an alert for health care programs and strategies, especially in the
home setting. Thus, the sense of home care implies the dialogical reflection of
the representation of the human and solidarity in the exercise of work in
public health services (22).
Another aspect to be highlighted
refers to infection in the home context. In this direction, there is a lack of
studies that address the assessment of biological risks in the scope of health
care provided at home. However, it is important to recognize that the home
environment, where care occurs, can expose both health professionals and
patients to risks, making it essential to consider all safety principles.
Several international guides have sought to guide and structure home care
practices. Given the uniqueness of the role of nurses in home care, especially
due to the absence of specific infection control programs in this environment,
the need for essential attitudes for the organization and effective development
of the work process is highlighted, valuing individual and collective awareness
as well as social and professional commitment (10).
Finally, the nursing care process at
home is supported by the use of professional tools such as home visits and the
application of the nursing process through the Systematization of Nursing Care.
About the subject, nurses who work in households through home visits can bring
benefits in the family care process, such as cost reduction, rapprochement with
the individual and his/her family, active listening, understanding people’s
life situation and identifying household risks. Moreover, the identification of
some difficulties observed during the visits is highlighted, such as the lack
of safety in the work environment and the presence of violence in the community
(16).
Home visits emerge as a significant
element in health promotion, and when properly employed by professionals,
especially nurses, have the potential to introduce substantial changes in the
care given to patients and their families (13,17). Nevertheless, in
most cases, family caregivers do not have an understanding about the role of
nurses in the home setting, which reflects in the insipient frequency or even
in the absence of visits. When the role of the nurse is recognized, the care
approach is often limited to performing technical procedures, failing to
establish a significant link between the individual, his/her caregiver and the
health professional (13).
The Systematization of Nursing Care
can be defined as a method used by nurses for the production of care, designed
to achieve significant results in the implementation of care, aiming to
minimize complications during treatment, as well as promoting patient recovery.
Its application in the clinical practice of nurses, in home care, can
contribute substantially to the well-being and safety of bedridden patients at
home (18-19).
Although the present study has
presented the characterization of the work of nurses in the home setting, a
limitation concerns the presence of other studies that did not return from the
search carried out from the proposal of a bibliographic research design of the
narrative type.
FINAL
THOUGHTS
This research allowed a thorough
understanding of the work of nurses in the home setting, revealing its
complexity and the challenges inherent in this action. The interpretative
categories, “Complexity of Home Care: between the Objectivity of the Technique
and the Subjectivity of Care”, “Characteristics of the Services and the Public
Receiving Home Care” and “Work Tools and the Directionality of Home Care”,
provide valuable insights for understanding this professional practice.
The data highlight the duality
between technique and subjectivity in home care, highlighting the importance of
balancing technical skills with empathy and understanding of patient needs.
Nurses should be able to develop solid therapeutic relationships that go beyond
clinical procedures, recognizing the value of the human aspect involved in
care.
In addition, the present study shows
the necessary adaptation to the specific characteristics of the home environment
and the particularities of the assisted public. Moreover, the consideration of
patients’ living conditions, cultural and social factors that influence care
and logistical challenges that can affect the production of care at home.
Understanding these nuances is essential to the success of home care.
Another aspect learned refers to the
need for appropriate tools to effectively direct home care. This includes
access to updated information, ongoing qualification and technical support for
nurses. The availability of adequate resources is a critical factor to ensure
the quality of care provided.
Therefore, this literature review
study provides an understanding of the work of nurses in the home setting. Home
care is a complex practice that requires a multidimensional approach that
combines technical skills with sensitivity and empathy. Nurses must be prepared
to adapt to the characteristics of the home environment and to the individual
needs of patients, in addition to receiving the support necessary to play their
role in an assertive and humanized way. This research contributes to the
improvement of the nurse’s practice in home care and, therefore, to (re)think how
the role of nurses in the home setting has been given and the care that has
been given to patients and their families in this challenging context.
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*Research originating
from the Course Completion Work (TCC) with the same title, defended in November
2023 at the Federal University of Mato Grosso do Sul (UFMS, Três Lagoas Campus
(CPTL).
Acknowledgment:
Universidade Federal de Mato Grosso do Sul (UFMS), Câmpus Três Lagoas (CPTL).
Authorship
criteria (author contributions)
1.
contributes substantially to the conception and/or planning of the study;
Cassia Luana Nespolis de Lima
Jessyka Barbosa Silva
Edirlei Machado Dos-Santos
2.
in obtaining, analyzing and/or interpreting data;
Cassia Luana Nespolis de Lima
Jessyka Barbosa Silva
Edirlei Machado Dos-Santos
3.
in the writing and/or critical review and final approval of the published
version.
Cassia Luana Nespolis de Lima
Jessyka Barbosa Silva
Anna Carla Bento Sabeh
Maria Eduarda Pregentino dos Santos
Carlos Alberto Selis
Sabrina de Almeida Silva
Edirlei Machado Dos-Santos