Background
This study is about how older persons receiving home health care in ordinary housing can have a sense of security during the evenings and nights. With longer life expectancies, more than half of the increasingly aging population [
1] is diagnosed with multiple illnesses that impose major consequences related to increased health care utilization [
2]. Even with well-known health problems, many older persons express a desire remain in their residences that do not offer specialized services, in so-called ordinary housing, and receive help from home health care and/or relatives [
3‐
6]. Home health care for older persons involves a give and take of autonomy and dependency [
7]. To improve autonomy and independence, older people must be able to make their own decisions, manage their health and daily lives, and maintain social contacts. When they are no longer able, they may engage the use of caregivers as an extension of themselves [
7,
8], people they know they can get help from [
8].
However, deficiencies in the home health care delivered to those living in ordinary housing are reported in many countries [
9,
10]. Deficiencies have been attributed to fragmented home visits [
11,
12], the staff’s lack of time [
13‐
15], and visits that are too hasty [
12]. The care can focus on “doing,” where daily tasks are performed mechanically without regard to the person’s individual needs [
12]. People who are dependent on home health care are not always getting the help they need [
16]. Older people have to move to nursing homes because in their ordinary housing they lack a sense of security; furthermore, due to physical or cognitive impairment, they can have difficulty managing routine activities and keeping up with daily life [
17]. Their sense of insecurity may be relative to the time of day, with the greatest levels occurring in the evenings and nights. However, there is a lack of knowledge regarding this, as only a few national and international studies have focused on the evenings and nights, and most of these are from nursing homes [
18]. The challenges in nursing homes with older people with dementia and perceived sleep disturbances at night are exacerbated by insufficient staffing levels [
19]. Older persons often have to adapt to the staff’s working hours, which means they get up early, and those requiring the most assistance spend more than the average 11 h in bed at night and significantly more hours awake in bed [
20].
There are challenges even for older people who choose to remain in their ordinary housing with relatives as their informal caregivers providing comprehensive care during the evenings and nights [
21,
22]. The relatives describe poor sleep quality and symptoms of fatigue [
22]. Older persons with care that includes nightly monitoring checks may simply stay awake, waiting for staff to come [
23]. Those who receive help may have unmet needs due to illnesses and medical treatments required at night [
24].
The World Health Organization [
25] stipulates that older persons in ordinary housing should be able to have a sense of security as well as freedom. The Swedish Social Services Act guarantees that older people will have the opportunity to live independently with dignity and in conditions conducive to a sense of security [
26‐
29]. The individual should be the focus, and help should be given quickly, whether it is during the day or in the middle of the night [
23]. Although it is stipulated that the health care system must ensure this sense of security [
26], it may be difficult to achieve it [
18].
Security has been described in different ways, and Segesten [
30,
31] describes it as a sense that no one can mediate, but one for which the conditions can be created. As such, there is a need to take into account the perspectives of older persons receiving home health care in ordinary housing [
11], and to ask them what creates a sense of security for them during the evenings and nights. It is also important to listen to those who can create the conditions for a sense of security, that is, relatives, nurse assistants (NAs), registered nurses (RNs), and managers, and to ask them what a sense of security for older persons can entail.
Results
We asked the stakeholders how conditions for a sense of security could be created during the evenings and nights among older people receiving home health care. Additionally, due to the design of the research, we learned and reached a consensus together with the stakeholders. Therefore, there were no prominent differences between the stakeholders’ statements, as all the different groups agreed on the general concepts. However, the older persons and the NAs focused more on their interactions and how the environment interplays with the older individuals’ habits and routines. Relatives talked more about the older persons’ situations and what it was like to grow old. They saw a need of extra night supervision from the nursing staff. The RNs focused somewhat more on self-determination and creating opportunities for participation by the older persons. The nursing staff and managers also had more discussions on how to prevent falls.
Five subthemes were developed from the data, which give structure to the two main themes, To confirm the self-image and To create interaction in a sheltered place. The two themes are interdependent conditions. The person’s self-image must be confirmed to create interaction in a sheltered place, and through the interaction, the self-image is confirmed (see Fig.
1).
To confirm the self-image
This main theme can be characterized as the home being seen as a reflection of the person’s identity. NAs and RNs helped the person with habits and routines in the manner that the person wished. Furthermore, they sought to maintain the person’s self-determination. Altogether, this helped to confirm the person’s self-image, which created conditions for the older person’s sense of security.
To see the home as a reflection of the person’s identity
We learned together with the stakeholders that seeing the home as a reflection of the person’s identity created conditions for the older person’s sense of security. In this subtheme, among the conditions were the design of the home, the aesthetics, and its location. Another condition was that a familiar member of the staff could facilitate the older person’s ability to stay in place. While providing continuity, the caregiver helped the person to carry out their habits and routines, taking guidance from the older person to become their “hands and feet” in daily life.
We learned that the design of the home, the furniture, and the location of the home were all-important for the person to be as they always had been. The older people showed their homes to the researcher during the evening observations spontaneously and with pride. Some had created their homes elegantly and others more functionally. They showed photos and shared their memories. Several of the older persons lived in the home they had lived in for decades, in an area that was familiar, but where others had moved away because they lacked a sense of security. The community outside could give them a sense of insecurity, and there were those who did not go out in the evenings, even if they could. Older person: “I don’t know what goes on outside the house.” Even relatives and nursing staff reported that the community could create a sense of insecurity. They kept a watchful eye and warned the older persons of relevant dangers and told them if they saw something unusual.
We also learned from the stakeholders that the living environment was important to the older persons’ sense of security. Relative: “It is important to live where it is beautiful.” Observations revealed that health care aids, equipment, and other mobility aids were often left in plain sight. When we asked the older persons about this, they remarked that they perceived these things as intrusions in their homes that increased their sense of insecurity. However, they expressed ambivalence about these items, since the aids were also recognized as lifelines that contributed to a sense of security.
The NAs also stated that the older persons should live in a familiar environment that they were used to. They also told us that they had become a part of the older persons’ sense of security, where the older person guided them. NA: “They show us how to be their hands and feet, and their contact with the outside world.” Staff continuity was important in creating the conditions for a sense of security for both the older persons and the nurses that is, meeting the same person, a person they knew well. Obstacles to this were nursing staff stress and staffing problems that could lead to lack of continuity.
The older persons found it was a struggle to maintain habits and routines, that is, walking and moving, dressing, or going to the bathroom, because “their bodies did not obey them.” Pain could also be an obstacle to their mobility. Older person: “I can’t put on my shoes, and that’s irritating. In the winter, someone has to help me dress. I don’t manage it myself, I have pain; it gives me a sense of insecurity.” The NAs remarked how they saw the older persons’ sense of insecurity. NA: “People can become insecure if they can’t manage going to the bathroom by themselves.” According to the relatives, the ability to move, to get out, and to feel independent is conducive to a sense of security. Since the older persons had limited mobility, the stakeholders reported that the older persons needed assistance in their struggle to maintain their habits and routines.
The older persons said that the nursing staff should see what is needed and perform the tasks in the same manner as they would. Older person: “Yes, they should see what needs to be done, and be precise. Most put the things by the sink away. It is second nature for them. The nursing staff here is outstanding.” It became important for the NAs to get to know the older persons, to understand and learn their habits and routines, so they could learn how to perform them as the older persons had done previously. The NAs tried to adapt to the older persons’ limitations in different ways. Additionally, the nursing staff told us that the older people could have advanced nursing care in their homes, which could create continuity and a sense of security, since the home represents the person. Some NAs explained that, for the older persons, just knowing they could stay in place until their death created a sense of security.
To maintain self-determination
We learned together with the stakeholders that the ability to maintain self-determination created conditions for the older people’s sense of security. In this subtheme, one condition was to be able to rely on themselves and to still be someone to count on. Among the other conditions were the ability to choose who would provide their care, and to participate in decision-making. The older people’s self-determination should be strengthened, and they should not have to adapt. However, sometimes the nursing staff was unable to meet the older people’s needs.
Further, we learned together with the stakeholders that conditional to a sense of security for older people was being able to rely on themselves. They knew what home health care they wanted and how it should be given. The older persons dared to complain about their care. Several of the older persons told us that they called directly to the manager and expressed their views, which gave them a sense of security. Older person: “A person can complain, and I know I can complain if there is something. It is reassuring to know that it’s okay.”
The observations revealed that more personal care was performed during late evenings and at night. Some needed help going to the toilet or replacing incontinence aids, and several needed help with their personal hygiene. Such care made it even more important for the older persons to be able to choose who should give the care. Some female older persons did not want male staff members to help them, as this was considered too intimate and created sense of insecurity.
The NAs pointed out that the older persons had the right to choose. However, this was considered a problem and a challenge in their work. NA: “It is strange, because we need to bring men into the nursing profession and be 50–50, but the older women have the right to refuse the guys.” There were male staff members who perceived it as difficult when someone refused to let them help with a shower. The managers agreed that men working in nursing could create conditions that lead to a sense of insecurity, especially for women from other cultures.
Older persons had experienced obstacles to their sense of security when they were excluded from decision-making. It was important for them to participate when decisions were being made. Older person: “The health care system gives me a sense of insecurity. The doctor took away the pills without seeing me, without speaking to me or examining me.” Older people explained that they wanted feedback regarding their health, medical follow-ups, and care planning. The other stakeholders reported that sometimes it was not always possible to meet the older person’s right to determine their care, which is an obstacle to their sense of security. NAs explained that if the older person is sleeping soundly, they are experiencing a sense of security, and therefore it is important to not awaken them unnecessarily. However, this poses a problem when analgesics are prescribed for 06:00, as that entails waking someone who has perhaps only slept a couple of hours and would not be able to fall back to sleep again. This causes insecurity, especially if the older person has to wait for the day staff. NA: “The day shift wants the night shift to wake them up early and give them a pain killer so they can get them up. Then they are awake, and the day shift doesn’t come until several hours later. To be able to sleep is important, but the night is poorly respected.”
To strengthen the older person’s participation in decision-making was important to the nursing staff. The RNs were aware of the importance of always informing the older persons about their care and encouraging them to participate in planning it. They were especially mindful to inform them about changes, and include them in all pertinent decision-making. RN: “We must inform them, include them. Absolutely never do something over their heads that creates insecurity.” The nursing staff emphasized that it was important to strengthen the older person’s self-determination. By doing so, the older person could be made stronger from within, which creates conditions that enhance participation and their sense of security. This inner strength could enable the older persons to make decisions and take command. NA: “It is important to strengthen the person, so they can feel a sense of security from the inside.”
It was also important that the older people not have to adapt to the nursing staff or the organization. They should be able to do as they had done before and remain the people they had always been. RN: “If there is anything a person could do to help older persons to have a sense of security, it is allowing them to be the person they have been.”
The RNs explained how the relatives could be helpful if they shared what they thought the older person’s needs were, since they knew the family member best. Actively inviting the relatives into discussions could be a way to get them to participate in their family member’s care. The relatives agreed that they and their family members could have a better sense of security if they were invited to participate in the care.
To create interaction in a sheltered place
This main theme is characterized by the nursing staff interacting with the older people while they “undress the power.” Additionally, for a sense of security, the interaction should be in harmony with the environment in the home. Therefore, nursing staff need to create control and lifelines; they also have to ensure a good sleeping environment. Altogether, this could promote interactions in a sheltered place that result in older people having a sense of security.
To undress the power
We learned together with the stakeholders that when the nursing staff undressed the power at the front door, they created conditions favorable to the older persons’ sense of security. In this subtheme, to act as an equal, to greet and relinquish the power before starting a conversation, and to be compliant and adapt to the older persons were among the conditions.
We learned that the older persons wanted the staff to see them as competent adults and not act superior or consider themselves better than them. Older person: “You should be able to feel equal. If someone is arrogant, a person can have a sense of insecurity. It’s also not good to be ridiculous or treat us like small children; it fosters insecurity. It’s feeling like an equal that gives a sense of security.” The staff should see the person and not just the illness. They should also act naturally, which means engaging in small talk and other things than just what is immediately apparent. Older person: “And be a little familiar with and able to talk a bit about the royalty and such. They should be able to talk about different things and what happens here.”
In striving for equality, the NAs would relinquish their power when they greeted the older people at the front door. They rang the doorbell before they opened the door with the key. They loudly announced who they were as soon as they got inside the door. Before entering, they removed their jackets and took off their shoes or put on shoe covers. The NAs explained that it was also important not to show that they were stressed. NA: “We’re not the ones with the power; it’s the older persons. It’s their home, and they have the power. It is important to take off your jacket. If you don’t, they’ll think you are in a hurry, and that’s something they absolutely shouldn’t think.”
The NAs smiled while they chatted and gave compliments regarding, for example, someone’s hair or clothing. The observations also revealed that the nursing staff could talk while they performed the care or while sitting at the same level or lower than the older person. They engaged in small talk, including about recent news and what was happening in the community, and listened to the older person’s life story. The NAs stressed that it was important to act naturally and as an equal. NA: “A sense of security is also about acting natural, so that they feel things are as usual. That the staff isn’t full of themselves or above them.”
The NAs explained that they had to be compliant and adapt to the older person and the person’s way of being and living. It was important to try to understand their situation. They considered it inappropriate to walk into someone’s home, and with their own values and views, tell the person what to do. The observations and conversations with the NAs clearly showed that they changed how they interacted with each individual they encountered. NA: “You have to change your approach all the time. What you do and how you meet people is different from person to person. Everyone is different, and you have to adapt yourself to each person.” The nursing staff could not refuse to make a home visit if it involved something they considered “difficult” or “unpleasant.” They had to adapt and solve each situation separately.
To create control and lifelines
We learned together with the stakeholders that to create control and lifelines creates interactions between the older people and their environment, which are conditions for an older person’s sense of security. In this subtheme, the conditions were the need to have control over habits and routines, to be one step ahead before something happened, and to prevent falls by employing, for example, equipment aids and nursing measures.
We learned from the stakeholders that the older persons had difficulties with moving, seeing, and hearing, resulting in limited mobility, dependency, and a fear of falling; all of which were obstacles to their sense of security. A sense of insecurity could arise from a limited and monotonous life caused by these difficulties. Older person: “I don’t see so well anymore and I am dependent upon my children and home health care. Not being able to manage what I used to be able to, gives me a sense of insecurity.” Those with a hearing impairment found it difficult to participate in conversations. The relatives explained that to manage daily life and feel independent are conditions for a sense of security. Relative: “It’s independence a person strives for. Not being a burden on someone else. When the body work, you can feel free.” Therefore, measures that give older people control over their daily lives, habits, and routines need to be created.
The older persons told us that if something unforeseen occurred, such as an NA being delayed, it could disturb the everyday “rhythm” of their habits and routines, and a sense of insecurity could ensue. The NAs therefore used different strategies to be one step ahead. Making schedules and plans together with the older individual was one method used to stay one step ahead and to create control and conditions for security. NA: “It’s our duty to promote security. It is part of the job. When we make our first visit, we can give structure to the evening. Perhaps we don’t take the hardest thing first; instead, make plans to do it later the next time we come, so we can prepare the person.”
We also learned that many older people fell during the evenings and at night, and all the stakeholders commented on this fear of the older person falling. The older people were afraid of falling and could not trust themselves, which created a sense of insecurity. The consequences of falls could be fatal. RN: “Many older people fall a lot and hurt themselves. Many fracture their hips. If they are debilitated and 98 years old, they don’t recover.” Relatives wanted their family members to have extra supervision from nursing staff at night, when they were afraid that something would happen. Older people had fallen both indoors and outdoors, and some had even sustained hip fractures. Older person: “My blood pressure dropped when I was here in the apartment and I fell. I broke my hip. Now I can only go with a walker or use a wheelchair. I don’t manage without something. Before I broke my hip, I used to do all my own shopping. You become quite fragile when you break bones and get older. What makes me insecure is the fear of falling again.”
Stakeholders saw the aids as lifelines and a condition for a sense of security, while at the same time, older people saw them as intrusions in their homes. With the help of a walker, older people could ambulate and go for a walk. They could also sit on the walker when they washed themselves or prepared their food. A security alarm gave them direct contact with the staff. Incontinence aids could also give a sense of security, as they allowed them to live in a usual manner and sleep the entire night. Older person: “Security means not having to get up in the middle of the night. I have an incontinence aid. It is reassuring that I can sneeze and laugh—that’s real security.”
In an effort to prevent falls, the NAs would do “security checks.” Before leaving the older people’s homes, they would make a visual “survey,” scanning the room to see that everything was in order and that everything the older people needed was placed close to them. NA: “Yes, and everything is nearby that should be nearby. And that everything works.” The managers and RNs also stressed the importance of security checks and of taking the time to ask the older persons if they needed anything else. It was also important that the older persons dared to ask for more help if they needed it.
The RNs, NAs, and managers said that many of the older persons managed their activities of daily living rather well during the days, but their abilities declined during the evenings and nights. They explained that ways to prevent falls were to have staff “walk” with the older persons during the day, and to make sure they had proper nutrition and plenty of fluids. To aid in this, it was suggested that the alarm center telephone the older persons and remind them to do some of their exercises and drink an oral nutritional supplement or other fluids. The managers also suggested that occupational therapists could be helpful in preventing falls, if, in addition to assessing the status of the older persons’ activities of daily living for the daytime, they also assessed them for the evenings and nights, since these often differed. Manager: “At night it can be more difficult to see and move than during the day.”
To create a good sleeping environment
We learned together with the stakeholders that to create a good sleeping environment was to create conditions that enhanced a sense of security. In this subtheme, the condition was to have help with the small details that promote good sleep, which enables the older persons to interact harmoniously with their sleeping environment. Other conditions were to have nightly monitoring and to create individualized sleeping environments.
We learned that it was important for the older person’s sense of security to be able to sleep well, and that they had different strategies for this. It appeared in the observations that some of the older people slept sitting up, while others slept with the radio or television on, and some slept with their pets in their beds. Older person: “I go to bed in the evening and fall asleep to the music. I wake up in the morning when the night staff makes their last visit and turns off the music.” Others did not fall asleep until into the morning. The stakeholders agreed that a good night’s sleep was important for the older persons. The NAs helped them with the small details that could help promote sleep and create harmonious interactions between the older persons, the nursing staff, and the environment. Examples of this were having a glass of water on the nightstand or having a lamp lit.
The stakeholders explained how the nightly monitoring checks contributed to the older people’s sense of security, and enabled them to sleep. Some waited for the night staff’s first visit and could not fall asleep until they arrived. When the NAs came the second time, the person might be sleeping soundly.
During the observations it could be seen how the nursing staff interacted with the older people to create individual sleeping environments. When the nursing staff entered the older people’s homes at night, they were careful to not wake them if they were sleeping. They moved quietly, with restrained body language, and with their backs smoothly rounded. The NAs went to the bed and bent over the older person, and if the person did not talk or move, they checked that the person was breathing. NA: “Best of all is if they snore when they sleep, because then we know everything is fine.” The NAs reported that they were attentive and flexible regarding the arrangement of the individual sleeping environment. The observations revealed that the NAs helped those who needed to turn in bed so they could rest well. They arranged pillows and blankets in different ways and raised or lowered the head of the bed. The goal was that the older person would be asleep when the staff came back, but if the person was still awake and wanted to talk, the NAs stayed with them for a while. NA: “You have to get to know which ones will want to talk at night.” The older persons could use a security alarm to call for help, if they did not feel comfortable in bed. Nursing staff were observed returning several times to help persons rest comfortably in the bed. The managers stressed that the NAs were to arrange the individual sleeping environment to create conditions that promoted a sense of security. It was therefore important that there was documentation on how the older people preferred to sleep.