Who cares?—The unrecognised contribution of homecare nurses to care trajectories

Background

Organisation of patients' trajectories is a critical element of nursing practice. However, nursing practice is mainly expressed in terms of direct patient care, while the practices through which care is organised have received little attention, are poorly acknowledged and lack formal recognition.

Aim

To examine the management of care trajectories as provided by homecare nurses.

Design

We conducted focus group interviews with 29 Danish homecare nurses. The analysis drew on the evidence based and theoretically informed framework care trajectory management. Care trajectory management is conceptualised as comprising of three organisational components: (1) Trajectory awareness, (2) Trajectory working knowledge and (3) Trajectory articulation.

Findings

The organising work of homecare nursing is both complex and unpredictable requiring advanced organisational, collaborative and clinical competences to secure concerted actions in alignment with the needs of the individual patient. Without having any formal obligation homecare nurses took on the responsibility for the coordination of the different activities of the professional actors, and for securing concerted actions. Care trajectory management as provided by homecare nurses reflected a high degree of commitment for patients and illustrated that this type of organising work was driven by the values of the humanistic ethos of nursing.

Conclusion

The study highlights the strength of the invisible and ongoing organising work of homecare nurses. Care trajectory management in homecare reflects the moral foundation of nursing. Consequently, the professional logic of nursing reflected as direct patient care alone is too narrow. We need to acknowledge the organising work of patients' trajectories as a core task equal to direct patient care. Our study highlights the need for articulating the organising work of homecare nurses and for presenting problematic organisational structures to policymakers and managers. If not, the important organisational work of homecare nurses is at the risk of remaining invisible.     

Can we measure how changes in the nursing workforce affect patient care?

Ward staff are the largest staff group in the hospital workforce and constitute the biggest budget item for most acute trusts. The nature of the ward workforce has changed considerably in the last 30 years but it is unclear what impact the changes have had on patient care. Understanding the link between resources and staffing levels on the one hand and outputs and outcomes for patients on the other is vital, particularly if further changes to the workforce are planned. In order to explore them, this article examines: (1) some of the reasons for changes to the workforce, (2) some of the research already available, and (3) the nature of research and information required. Finally, it looks at the work that the Audit Commission carried out in 2000 and which is currently being repeated by the Healthcare Commission.