As the recommendation to develop international guidelines grew out of recommendations to create a document like the ANA Scope and Standards, and as two IHNCO taskforce members were also on the ANA Taskforce, we first approached the ANA about sharing the ANA Home Health Nursing: Scope and Standards for Practice as an exemplar and a template for international guidelines. We received permission from the ANA to do so, and we acknowledge the ANA's significant contribution to this project. Participants were provided with an electronic version of the ANA Home Health Nursing: Scope and Standards of Practice. The 16 standards within this ANA (2014) document, and one additional standard about cultural competency from the ANA's (2015) Nursing: Scope and Standards for Practice, 3rd edition, provided the basis for the initial round of reviews by the IPIR.
Role of the IHCNO Leadership Group (ILG)
The ILG consists of home healthcare nursing leaders in administration, practice, education, and research, who are primarily from the United States, but also with international representation (one member is from Singapore). In addition, several of the ILG nurses have extensive experience teaching and consulting in diverse countries about home healthcare nursing. Their expertise was valuable on a number of issues. For instance, at the beginning of the project, an ILG member with significant international experience expressed concern that naming the proposed document international standards could have unintended negative effects. Standards might be used by health ministries in developing countries to judge nurses as below standard even though the nurses were striving to achieve the highest level of practice possible despite resource limitations or downward socioeconomic pressures. Based on the insight of this home healthcare nurse leader, a decision was made to rename the project from its original name, IHCNO International Standards Project, to the IHCNO International Guidelines Project. The document developed would be aspirational, one that nurses would use to identify objectives, rather than in the judgmental way that the word standards may imply. Thus, the document would consist of “guidelines” rather than “standards.”
Recruitment of the IHCNO Panel of International Reviewers (IPIR)
In April 2016, we began to recruit a panel of international home healthcare nurses to help with the development of the guidelines. First, we identified international (not residents of the United States) nurses who had attended previous IHCNO conferences or who had expressed interest in the IHCNO since its inception, and thus were on the IHCNO E-Mail Distribution List. We invited about 70 nurses from 29 countries to participate in the project. Unfortunately, about 20% of the e-mail addresses were no longer active.
Initially 25 nurses from North America (Canada only), Asia, Africa, Australia, Europe, South America, and the Middle East expressed interest in participating. We attempted to broaden participation with Internet searches for home healthcare organizations in other countries, especially in Europe and South America. We also contacted the International Congress of Nurses for recommendations of nurses to participate in the project. These efforts were not fruitful and we concluded that identifying home healthcare nurses internationally is a difficult process related to the lack of an organizing structure to identify and support these nurses.
Another attempt was made to recruit European and South American nurses through the Omaha System's listserv of users. The Omaha System is a standardized community/home healthcare terminology system used by home healthcare organizations throughout the world. One European nurse and two Asian nurses responded to this recruitment effort. A barrier to recruitment was undoubtedly that the project would be conducted in English, and all recruitment efforts occurred in English. Ultimately, 28 home healthcare nurses representing 19 countries from Africa, Asia, Australia, Europe, North America, South America, and the Middle East expressed interest in participating in the project.
The process consisted of eight phases of reviews and revisions. We outline each of these steps below.
Phase 1: Review by IPIR
In June 2016, we provided details to the 28 interested international nurses via e-mail about how to participate in the project. The e-mail participation instructions stated:
In the first stage of this project we are evaluating whether the standards for home health nursing practice contained in the American Nurses Association's (2014) Home Health Nursing: Scope and Standards of Practice, 2nd edition can serve as a starting point or template for home health nursing internationally. We do NOT want to impose these standards as guidelines for nurses in other countries. However, if others think they are appropriate as a starting point, it is always easier to start with something than to start from nothing. So, we would like your reactions to these 17 standards as guidelines for home health nursing practice throughout the world. This will help us determine what our next steps should be.
From your perspective as a home health nurse in your country, evaluate if each standard is a good guideline for how home health nurses should practice. Our goal is to create an aspirational document, not a document that necessarily reflects current practice in your country. These guidelines are supposed to guide nurses towards excellent home health nursing practice. Their purpose is to be a document by nurses, for nurses, about what the professional practice of home health nursing should be in order to best promote the health and well-being of the patients we serve.
The participants were then asked to respond to each of the 17 guidelines via an e-mail survey, using SurveyMonkey®. Each guideline had a choice of 1) “Agree that guideline is appropriate for nurses in my country exactly as is,” 2) “Agree that the guideline is appropriate with the following modifications...” and 3) “Do not believe the guideline is appropriate because...” Each area allowed for further comments from the participant. There was a final question that asked if the participant had further comments or concerns about the project or any recommendations for additional guidelines. The survey was open from July 2, 2016, through August 2, 2016. Two reminders were sent on July 15 and July 23. A thank-you e-mail was sent to those who had responded after the survey closed.
Fourteen nurses responded to the survey, a response rate of 50% from nurses who had expressed interest in the project. The 14 nurses represented 10 countries (Table 1). Overall, participants agreed the ANA standards represented appropriate guidelines for the nurses in their countries. The range for the answer “Agree” for each of the 17 standards varied from 78.6% to 100% (Table 3).
Phase 2: Revision 1
During September and October 2016, the IHCNO Guidelines Taskforce (IGT) reviewed all the comments. Based on concerns raised and recommendations made by the international reviewers (IPIR), we revised the wording on several guidelines. We also noted that most of the comments were related to a lack of clarity about the scope, the purpose, or the process for activating the guideline. Based on this information, we determined that we should not only create a document that contained guideline statements for professional practice and performance, but that they should be accompanied by interpretative statements about the intent of the guideline and examples of how the guideline might be applied. Thus, we developed interpretative statements based on the questions and concerns of the reviewers.
Phase 3: Review by ILG
Mid-September 2016, we brought this second draft of the guidelines document to a teleconference between the taskforce (IGT) and the leadership group (ILG). The ILG members were asked to consider if the rewording of the guidelines was appropriate, if providing interpretative statements helped to clarify the guidelines, if the text in each interpretative statement was clear and appropriate, if the guidelines were appropriate for nurses in all countries, including those with underdeveloped and well-developed home healthcare programs, and if, with the changes, the document was still appropriate for American nurses. After a general review and recommendations by all ILG members, six ILG members including those with international experience agreed to carefully review the document and submit comments by mid-October 2016. ILG reviewers made multiple edits and recommendations. Examples of these suggestions included: edit multiple sentences to promote clarity of the guideline or interpretative statements; reorganize interpretative statement content such that “summary” sentences became “introductory” statements; include various concepts such as “advocacy” and “care coordination”; and use more descriptive terms, rather than more conceptual terms, for terms that might not be understood by international audiences.
Phase 4: Revision 2
We (IGT) then made many changes to the document based on the leadership reviewers' (ILG) recommendations, creating a third draft of the document.
Phase 5: Second Review by ILG
To assure we had captured the ILG's intent for the recommendations they had made for revising the document, the third draft was reviewed with the leadership group (ILG) during a teleconference in November 2016. Although several comments were made requesting some minor additional edits, the third draft of the Guidelines was approved for the next phase of the project with the minor revisions recommended.
Phase 6: Second Review by IPIR
Once again, we used Survey Monkey®, sending the third draft of the Guidelines to the original 28 international home healthcare nurses who expressed interest in the project. The instructions explained that we had carefully considered previous comments and concerns, and rewrote the document to reflect their previous recommendations. We then explained that we were in the next phase of project, and that we were asking if they could review the latest version of the Guidelines. The instructions read: “For each of the 17 guidelines, you can respond in one of two ways: 1) Agree that guideline/interpretive statement is appropriate or 2) Believe the guideline/interpretive statement should be revised. (Please explain the revisions you suggest or the concerns you have with the guideline/interpretive statement as written.)” Participants were also reminded that the document should reflect what they think home healthcare nursing in their country should be, as opposed to the way home healthcare nursing might currently be practiced in their countries. They were encouraged to contact Taskforce members if they had any questions or problems with the survey.
Despite reminders, 10 nurses responded to the survey, representing 10 countries (Table 1). Of the 17 guidelines, the nurses all agreed with 15 guidelines as presented. Two nurses each suggested minor edits to one of the guidelines, thus requesting that two guidelines be edited.
Phase 7: Revision 4
The Taskforce revised the Guidelines, creating the fourth draft of the document, as recommend by the international reviewers. We then sent e-mails to the two nurses who had requested minor changes to assure that we had captured their concerns. We determined that the edits were minor enough that it was not necessary or appropriate to request another review by all the international reviewers.
Phase 8: Third Review by ILG
In April 2017, the fourth draft of the International Guidelines for Home Health Nursing was brought to the ILG. The ILG reviewed the Guidelines for their appropriateness and clarity as international guidelines. The guidelines were approved. A suggestion was made that the Guidelines include an introduction. It was also suggested that a glossary should be added for certain terms that might not be familiar to international readers. Definitions of these terms should promote better translations and understanding of the concepts within the document. An introduction to the Guidelines was added to the document and approved by the leadership group in May 2017. A Glossary of Terms, which will be available on www.ihcno.org, is being developed.
Nurses from 14 countries ultimately participated in the development of the Guidelines: Africa (Nigeria), Asia (Hong Kong, Japan, Korea, Singapore, Taiwan, Thailand), North America (Canada, United States), Middle East (Saudi Arabia), Europe (Cyprus, Georgia, Turkey), and South America (Suriname). The final result of the development process is the International Guidelines for Home Health Nursing (Table 4). The Guidelines consist of a preamble, 17 guidelines with interpretive statements, and a glossary of terms. The preamble introduces the Guidelines, describes why they were developed, how they should be used, and how to contact the IHCNO should there be any concerns with them or recommendations for updates in future versions of the document.
The first six guidelines mirror the nursing process, nursing's science-based steps for helping patients achieve health and well-being, adjust to chronic health problems or die peacefully within their homes. Thus, the first six guidelines address assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The remaining 11 guidelines describe how home healthcare nurses practice, their objectives, and behaviors. Guidelines 7, 8, and 9 remind home healthcare nurses that they must practice ethically, that they must seek the knowledge and skills they need to help their patients through ongoing education, and that they must update their knowledge and skills as evidence accumulates that new practices should replace traditional ones.
Guideline 10 encourages nurses to promote quality care, that is, care that is safe, effective, equitable, patient-centered, cost-efficient, and timely. An important part of quality care is rigorous infection control procedures, as appropriate within the patient's environment. Guidelines 11, 12, and 13 encourage nurses to communicate and coordinate care in ways that promote quality patient care and to lead others through their commitment to quality patient care. Guideline 14 reminds home healthcare nurses that they must be accountable for the professionalism of their practice. Guideline 15 urges them to use resources effectively and in ways that are financially responsible, and Guideline 16 reminds nurses that waste products produced during patient care must be disposed of in ways that protect others and the environment. The last guideline, Guideline 17, reiterates the importance of treating diverse patients equitably, respecting and adapting care to their cultural and diversity needs and preferences.
The International Guidelines for Home Health Nursing represent a first attempt to define the principles that guide home healthcare nursing practice wherever it is practiced geographically. Originally, the Guidelines were suggested as a kind of “white paper” to guide nurses interested in promoting home healthcare nursing in countries with underdeveloped healthcare systems. However, as international guidelines, we realized the Guidelines needed to promote equitable care, which honor the needs of all patients no matter where they live. The IHCNO faced the challenge of developing guidelines that met the needs of home healthcare nurses who practiced in countries with different nurse education and regulatory licensing systems (Nichols et al., 2011) and with both robust and rudimentary home healthcare systems in both developed and developing geographic areas. Furthermore, it is entirely possible that governmental agencies in countries with “advanced” healthcare systems need home healthcare nurses to define the type of services they can and should deliver to promote optimal health and well-being for home care patients. Therefore, the task of this document was to meet the needs of all home healthcare nurses and their patients. The Guidelines attempt to outline the values and behaviors to which all home healthcare nurses should aspire. The document strives to define the core and essence of home healthcare nursing no matter where it is practiced.
One issue that concerned both the IPIR and the ILG reviewers was the importance and relationship of physicians to the practice of home healthcare nursing. Some reviewers suggested that the role of physicians, directing care in the home, should be more prominent (representing current health system practices), whereas other reviewers recommended that nurses should work collaboratively with physicians about medical issues, while retaining independence in addressing nursing/caring interventions. These reviewers argued that as professionals, nurses needed to take responsibility for their own practice. Without accepting this accountability for their practice, nurses could be subject to social or economic pressures that could compromise their values as professional nurses. Even the wording about who should “direct” medical care was debated: physician or healthcare provider, with healthcare providers including nurse practitioners and other physician-extenders. In the end, we attempted to reach consensus on the role of physicians by using the term “physician or other healthcare provider” and by including wording about how patients achieve the best outcomes when disciplines work collaboratively. The attempt to reach consensus by articulating values and revising wording was successful, in that during the following rounds of reviews, the concerns about the role of the physician seemed to evaporate. It seems that the inclusive wording “physician or other healthcare provider” and the emphasis on collaborative practice addressed previous concerns.
Although the IHCNO's International Guidelines for Home Health Nursing grew out of the ANA's (2014) Home Health Nursing: Scope and Standards of Practice, 2nd edition, it is a very different document, it is a very different document with a different scope and purpose. The ANA document includes a large section on the scope of home healthcare nursing in the United States and describes specific competencies that generalist and advanced practice nurses, working for home healthcare agencies in the United States, should meet related to each standard. The IHCNO document, on the other hand, outlines objectives that home healthcare nurses should strive to meet wherever they practice. The wording between the standards in the ANA document and the guidelines in the IHCNO document differ, broadening terminology in selected statements to align better along differing educational and cultural situations in which home healthcare nurses in diverse countries find themselves. The ANA document is 86 pages long, whereas the IHCNO document is 3 pages in length. Home healthcare nurses working in the United States are reminded that the document that governs their practice, in addition to the Nurse Practice Acts of the states in which they serve, is ANA's (2014) Home Health Nursing: Scope and Standards of Practice, 2nd edition.
One of the first steps for using IHCNO's (2017) Guidelines will be for nurses in other countries to translate the Guidelines into the language that the home healthcare nurses who will be using them will feel most comfortable reading. Then, home healthcare nurses in diverse countries can use the Guidelines to evaluate their personal nursing practice and the practices of the agencies and organizations for which they work. They can be used to develop policies and procedures that promote the development of home healthcare nurses and quality care practices for the patients for whom they provide care at the agency and national level. Home healthcare agencies and organizations could use the Guidelines to develop competencies appropriate for the care they provide in the geographic region they serve. They can be used as the basis for peer evaluation and to help nurses identify their own professional development plans.
Nurses attempting to start home healthcare agencies, particularly in geographic areas where home healthcare nursing is underdeveloped or nonexistent, can use these Guidelines to begin to outline what professional home healthcare nurses can do for patients. They can also be used to inform policy makers about what home healthcare nurses can do for patients who do not require hospitalization but do require additional or ongoing care. The Guidelines can also be used to develop job descriptions for home healthcare nurses and to develop education and inservice plans for nurses who are joining the unique home healthcare nursing specialty area of practice.
In this initial attempt to provide international guidelines for home healthcare nursing practice, the number and diversity of home healthcare nurses participating in the development process was small. Although North America and Asia were comparatively well represented, Africa, the Middle East, and South America had very limited representation, with only one nurse from each of those regions participating. Notably, there were only three nurses representing Europe and all three of these nurses were from eastern Europe, leaving western Europe unrepresented. There was no participation by Australian nurses.
The difficulty in attracting nurses to the project was undoubtedly related to conducting our recruitment efforts and the project in English. In addition, the number of international nurses on the IHCNO mailing list is limited. Nurses become interested in the IHCNO primarily through articles related to our activities in Home Healthcare Now and by participating in our conferences. Although Home Healthcare Now attempts to attract an international audience, it primarily attracts United State nurses. And because the IHCNO conferences have been held in the United States and Singapore, which attracted primarily American and Asian nurses, our mailing list included significantly more nurses from these regions.
Another limitation is related to our use of SurveyMonkey® to conduct the international review of each guideline. Due to a lack of funding, we used a free-access version of SurveyMonkey® that required us to break our review tool into two parts. We found that some reviewers only completed one part of the two-part survey tool, perhaps because they were confused by the two parts. We also believe that some reviewers were confused by SurveyMonkey's® imposed formatting. For instance, some reviewers responded to several questions with two responses—“Agree without modifications” and “Agree with the following modifications”—which are mutually exclusive categories. One Survey 2 reviewer did this several times without suggesting any modifications. In addition, we found that the number of survey respondents was below our expectations based on expressed interest in participation. We believe this may also have been related to using the free-access SurveyMonkey® tool, which may have been caught up in recipients' spam filters or academic quarantine programs.
The IHCNO Guidelines Taskforce (IGT) and the IHCNO Leadership Group (ILG) hope these Guidelines support home healthcare nurses in their quest to provide the best care to home care patients. Yet, we consider these Guidelines to be a work in progress, which will need to be revised for two reasons. First, healthcare and delivery systems across the globe are evolving and changing. As home healthcare nursing operates in a dynamic environment, this document describing the values and practices of home healthcare nurses will undoubtedly also need to change. Second, this initial version of the Guidelines is based on the input of a small panel of reviewers. With dissemination of this document, we invite additional review and recommendations to strengthen the document in its attempt to support home healthcare nurses around the world. Recommendations for future revisions or to volunteer for future review panels can be made by accessing the International Guidelines for Home Health Nursing page (http://www.ihcno.org/Guidelines) or by sending an e-mail to email@example.com.
The need for nurses who are expert at providing care to patients within their homes is growing throughout the world. Home healthcare nurses need guidelines developed by home healthcare nurses for home healthcare nurses to promote the professionalism of their practice. As professionals, home healthcare nurses are accountable to their peers, as well as being accountable to the patients, organizations, and regulatory bodies they serve. The International Guidelines for Home Health Nursing are an initial attempt to identify guidelines that home healthcare nurses throughout the world can use to structure and evaluate their practice.
The value and purpose of these guidelines is probably best described by nurses who participated in the project. Comments made by the international panel of reviewers (IPIR) included: “I think having guidelines is excellent, especially since in my country many of the guidelines are not fully accepted or practiced, but they should be.” “Our country does not understand how to use home health nurses. Guidelines will help us use home health nurses in more professional ways.” “We support this exciting and important work. It will help us and other countries in the development of home health nursing services.”
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