ABSTRACT
Collaboration among healthcare providers is regarded as a promising method to improve care quality and patient outcomes with limited human and financial resources. In Norway, “hospital-at-home” refers to care given by teams from the hospital pediatric wards who provide treatment and care in the family’s home. When children need home visits multiple times daily, the hospital-at-home often reaches out to municipality healthcare providers, asking them to share this task. We aimed to explore the collaboration between stakeholders to gain knowledge on matters concerning the transfer of pediatric competence between hospital and home-based care, and to gain insight into how to set up the service for children in the future. We conducted three focus group interviews. The results showed that managing hospital-at-home collaboratively came with various challenges concerning unclear responsibilities between hospitals and homecare services and several obstacles to setting up cooperation across service levels. Thus, positive collaboration experiences between hospital and homecare settings were shared. Formalizing this collaboration was considered important for future collaboration. Building competence and learning from and with each other ensures better conditions for success if the collaboration is organized and facilitated through agreements between the hospital and the municipalities.
Introduction
Current health policies in most Western countries call for more effective delivery of accessible, continuous and comprehensive services. Internationally, collaboration among healthcare providers is regarded as promising means for improving care quality and patient outcomes with limited human and financial resources (Kuhlmann & Annadale, Citation2012; Ma et al., Citation2018). These new forms of organizing services require not only the implementation of new structures but also development of new clinical practices based on collaboration (D’Amour et al., Citation2008). Additionally, the healthcare sector is expected to collaborate and coordinate more efficiently across geographical, institutional, disciplinary, and professional boundaries (Ellingsen & Monteiro, Citation2006; Martinussen et al., Citation2017). In Norway and other Western countries, healthcare is supposed to be carried out closer to home, in the municipalities where people live and to a more limited degree in hospitals (Belfield & vanPoucke, Citation2019; Meld St 47, Citation2008–2009; Meld St 29, Citation2012-, 2012–2013). Following this development, various hybrid service models combining hospital and home treatment have emerged in recent decades (Gonçalves-Bradley et al., Citation2017).
Background
In Norway, healthcare services are divided into two delivery levels, primary and secondary healthcare services, which are subjected to different governmental levels of funding systems, laws, and central regulations, and they are also characterized by different cultures (Hellesø & Fagermoen, Citation2010; Romøren et al., Citation2011). Furthermore, the primary healthcare sector consists of both large and small and sparsely populated municipalities (Martinussen et al., Citation2017). This organization has been shown to challenge collaboration between professionals and between the two levels of healthcare (Lemetti et al., Citation2017; Melby et al., Citation2018; Seaton et al., Citation2021).
“Hospital-at-home” (HAH) for children offers treatment to children at home who would otherwise require hospital admission (Parab et al., Citation2013). HAH may either be provided by hospital-based outreach services, community-based services, or as a collaboration between hospital and primary healthcare (Gonçalves-Bradley et al., Citation2017; Parker et al., Citation2013). Norway has a model in which health professionals from hospital pediatric wards give treatment and care in the family’s home to carefully selected hospitalized children with various diagnoses (Aasen et al., Citation2018). When children need home visits beyond the capacity of what the hospital can offer, the hospital often reaches out to municipality healthcare services, asking them to assist HAH in conducting the visits (Aasen et al., Citation2021). Still, the hospital retains primary responsibility for the treatment of these children. HAH has been reported as medically safe, and parents often prefer this type of care when offered for their children rather than staying in hospital (Aasen et al., Citation2018; Detollenaere et al., Citation2023; Parab et al., Citation2013; Parker et al., Citation2013). However, certain preconditions have been found to be important to parents’ experiences of HAH: their trust in the services is based on their perception that the professionals have the competence needed to care for sick children at home (Aasen et al., Citation2018).
In a previous study, we found that parents experienced insecurity when homecare nurses were not prepared to conduct the visits (Aasen et al., Citation2022). They also found it straining to receive visits from several different homecare nurses (ibid.). Castor et al. (Citation2017) found that some homecare nurses regarded themselves as having insufficient knowledge in caring for a sick child, causing them to fear losing face if the family were to find out. In the same study, some nurses also found themselves unable to care for children and emphasized that they regretted having chosen to work with pediatric homecare. Various difficulties at organizational and practical levels have been reported in a UK study on pediatric homecare (Spiers et al., Citation2012). Capacity pressure was a recurrent theme in accounts of service delivery, primarily due to low staffing and insufficient competence among the professionals involved. Earlier research on pediatric homecare has also shown difficulties with collaboration between nurses in municipalities and hospitals (Castor et al., Citation2017; Reid, Citation2013). Homecare nurses experienced insufficient discharge planning, were not always adequately involved in the planning or were given insufficient time by the hospital to arrange services locally (ibid.) Furthermore, a lack of pediatric training, mechanisms to support collaboration and systems of information sharing has also been reported (Castor et al., Citation2017; Jibb et al., Citation2021; Law et al., Citation2011; Quinn & Bailey, Citation2011; Samuelson et al., Citation2015). The need to collaborate on the service is distinct but challenging.
There are multiple terms for collaboration, such as “multi-/-interdisciplinary,” “interprofessional practice,” “collaborative relationships,” or “teamwork,” which are used interchangeably and in different contexts (Perreault & C, Citation2012). In this article, we use the term “collaboration” to refer to healthcare professionals working together to deliver care within and across services, which also includes nurse collaboration across service levels.
Research papers refer to good patient-centered collaboration as sound communication, role understanding, mutual trust, and respect (D’Amour et al., Citation2005; Wei et al., Citation2022). According to the WHO (Citation2010), collaborative practice occurs when multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care. Engaging in collaborative practice is a professional expectation and a required competency for nurses in many countries (Prentice et al., Citation2020). Collaboration between nurses improves health outcomes and decreases healthcare costs by reducing duplication of services, error rates, length of hospital stay and staff turnover (WHO, Citation2010).
There is extensive literature regarding collaboration in healthcare, particularly related to older patients (Lemetti et al., Citation2015; Røsstad et al., Citation2013; Rotter et al., Citation2012; Seaton et al., Citation2021) and on interprofessional collaboration (Shot et al., Citation2020). This research show that good collaboration in healthcare helps in reducing readmissions but may be difficult to achieve because of the differing perspectives on care and different organizational structures. To our knowledge, there is limited research exploring experiences and reflections about conditions facilitating and hampering collaboration between healthcare professionals across service levels, specifically regarding HAH for children.
In this article, we aim to explore collaboration on HAH for children between stakeholders employed in hospital, homecare services and education when HAH is implemented as a shared task between hospital and homecare services. Furthermore, we aim to explore stakeholders’ reflections on how to strengthen transfer of knowledge between hospital and home-based care, and how to set up the service in the future.
Method
Study context
The setting of the study was HAH services, established in 2008 and 2016, at two large hospitals in eastern Norway. These services are offered to children ranging in age from newborns to 18 years old with various diagnoses. The children must be in a stable phase of their illness, and the care considered medically justifiable by a pediatrician. The most common treatments are intravenous antibiotics, intravenous nutrition, and tube feeding, and examples of diagnoses are infections, cancer, and newly diagnosed diabetes. The distance to the hospital from the family’s home cannot be more than a one-hour drive by car.
Design and data collection
In this study, we used a qualitative method with a descriptive design. We conducted three focus group (FG) interviews with stakeholders -who all were educated as healthcare professionals. They either had experience with collaboration across service levels on HAH for children or worked with nursing education or competence building between healthcare professionals and collaboration across service levels. Each FGs included four to six participants, comprising a total of 13 individuals, age varying between 34 and 68 years and with a working experience from a few years to over 40. The study participants were recruited with assistance from their respective leaders. We conducted the interviews during March and April 2022 at a university hospital. We used a purposive sampling strategy, covering stakeholders representing different professional backgrounds and work positions. The sample included nurses in HAH and homecare services (Interview 1); leaders from HAH and homecare services, together with nurse educators in bachelor’s in nursing (Interview 2); and pediatricians, a physician from municipality and an administrator from the hospital’s Department of Integrated Healthcare (DIH) (Interview 3), as depicted in . In accordance with the recommendations of Braun and Clarke (Citation2013), we sought to put together groups based on some similarities within the groups, to create a comfortable situation, and to provide a shared basis for discussion and also enough diversity to bring forward different perspectives and a broad discussion.
Table 1. Demographic data of participants in the three focus groups (n = 13 participants).
Two facilitators led the interviews (LA and AK), and a moderator took notes ahead (AW). In each of the three FG interviews, we provided a brief presentation of results from two previously published papers (Aasen et al., Citation2021, Citation2022), as a prompt to discuss experiences with collaboration on treating hospitalized children at home. The interview guide contained four themes with open-ended questions pertaining (1) how HAH for children should be organized to be good and safe services for the families in the future when both hospital and homecare services are involved, (2) how training and sharing of knowledge should occur, (3) what the two services knew about each other’s work, and (4) what is crucial to emphasize in the nursing curriculum.
Ethical considerations
This study followed the ethical principles for medical research involving human subjects of the Declaration of Helsinki. The Regional Committee for Medical and Health Research Ethics, Southeast Norway, found the project to be outside the remit of the Act on Medical and Health Research (ref. 47184). The study was approved by the national IRB (NSD-723356) and the local privacy legislation authority at the two hospitals (ref. 2019_134,19/29832).
Written informed consent was obtained from the participants before data collection. The participants were informed that their participation was voluntary, that the collected data would be kept confidential and that they could withdraw from the study at any time without any consequences. All quotations used were anonymized by assigning the work position of the individual participants.
Data analysis
The FG interviews were audio-recorded and transcribed by the first author. A six-step thematic analysis method was used to analyze the data (Braun & Clarke, Citation2006). The research team routinely met during the analysis process to discuss the coding and themes. Transcripts were read several times, and initial ideas were noted to allow for familiarization with the data. Initial coding was undertaken across all the data. We discussed the coding until we reached agreement. In this way we brought forth variations and nuances in the data material with regard to topics and sub-topics to include in the codes. During this phase, we became aware of the complexity of setting up collaboration across service levels when hospitalized children receive treatment at home. The codes were collated into potential themes, and we gathered the coding around them. The differing views of the participants were mostly based on their professional affiliation or where they worked, that is, hospital or homecare settings. In the preliminary themes and sub-themes, we focused on how they experienced the HAH collaboration across service levels and their reflections about how it should be set up in the future. The themes and sub-themes were reviewed and refined until consensus was reached among the four team members (Braun & Clarke, Citation2006).
Results
We identified two main themes with subthemes: Managing hospital-at-home together despite various challenges, and Preconditions for collaborations between the homecare service and the hospital on HAH in the future.
Managing hospital-at-home across service levels
Establishing collaboration between HAH and homecare services was regarded as a demanding task by the HAH professionals, implying many obstacles. A barrier discussed was how to get the homecare service administrations to agree to collaborate on visiting hospitalized children when they receive treatment at home. Despite the challenges, both homecare services and HAH shared positive experiences from the collaboration in the FG interviews.
The most apparent problem when discussing barriers with setting up HAH as a shared task, was related to the fact that the two service levels of patient care had different funding, laws and regulations and were differently organized. Furthermore, the participants in all interviews revealed uncertainty about whether it is within the mandate of the municipalities to take responsibility for all patients regardless of age – and even for hospitalized children. A homecare nurse said:
Well, I don’t believe the homecare service can refuse to take on any patients, regardless. I don’t think that is legal. I think we have to say yes, no matter what, actually.
The DIH participant stated:
I think it is incredibly important to be very clear about our roles. There are for instance cases where terminal children with cancer are going to die at home, and the HAH needs help from homecare services, then the question comes up – OK, but isn’t this clearly a specialist service?
In addition to the differences in how the two levels of care were organized, the various municipalities were also organized differently. What was an excellent way to collaborate in one municipality was difficult to achieve in another. Particularly, the participants in FG 2 discussed the time-consuming work of setting up collaboration on HAH with homecare services. A leader in HAH expressed:
When we think we have figured out how to set up a collaboration within a municipality, and really think we have understood how to collaborate, we get another child in another municipality and realise we must start from scratch again, because this municipality is completely differently organised.
It was problematized that the hospital and the homecare services had sparse knowledge about each other. What HAH nurses considered as “an easy nursing task” were differently understood and perceived by homecare nurses. They did not know much about each other’s competence and method of working. A HAH nurse said:
Because we’re like, – Can’t everyone set an antibiotic IV? That’s something every nurse can do. For us, we think this can be handed over as an easy task. But we have realised that the matter of this task, being done to a child, is a challenge in itself.
A leader from homecare services argued that today’s dominant digital communication resulted in insubstantial knowledge about sectors and healthcare organizations in general. All agreed that collaboration had a personal aspect. Using electronic messages could not replace face-to-face communication.
Despite all challenges with collaboration in setting up HAH for children with homecare services, the participants still regarded HAH for children as an important service for the child and the family. According to the hospital professionals, it was easier to achieve proficient collaboration with smaller municipalities. The nurses and leaders from the municipalities said this could be explained by small municipalities having lower levels of nurse turnover and less bureaucracy. Furthermore, the HAH nurses would often also find homecare nurses in smaller municipalities, with a high level of dedication for sick children and families, engaged in the matter at hand, in which setting up collaboration across service levels went smoother and quicker. A leader in HAH said:
It is much easier within a small municipality. There you sort of bump into one or two nurses thinking, OK – we will help this family no matter what, and we’ll find a way to manage this. When meeting the larger municipalities, we never find these kinds of nurses.
The homecare nurses stated that good collaboration with HAH implied developing a relationship where they knew each other. They also specified that collaboration meetings before the child came home enabled them to learn from each other so that a shared vision of how to work with the individual family could be developed. This also ensured a higher level of security for homecare nurses, who had scarce experience caring for children. A homecare nurse said:
It is so much easier to manage the situation when you know for certain that you can reach the HAH nurses. They were like, – “Call us any time around the clock!” There was always a yes, and there was never a problem when we had a question, and that was really wonderful. That makes everything so much easier.
Preconditions for collaboration between service levels in the future
After sharing experiences of collaboration between HAH and the homecare services, participants in all three FG interviews discussed how the collaboration and the service should be set up in the future to establish and maintain stable competence in pediatric treatment and care in municipalities.
The participants were concerned about the non-existing formalized collaboration agreements between hospitals and municipalities, where responsibilities, laws, roles, and economy regulated care for sick children.
My experience with these services is that we struggle because we haven’t sorted out the important issues regarding responsibilities. I am really concerned about the legal matters. Let’s say you work in the homecare services, and HAH for children is defined as a specialist service. You make a mistake, and something really fatal happens, who is then responsible? (DIH)
It was also emphasized that relying on finding the “dedicated nurse” to help establish collaboration between hospital and homecare services on HAH did not contribute to a robust system. It could even hide the need for resources and competence building, the participants claimed.
There was considerable agreement in all three interviews about the fact that competence building among nurses in homecare services was time-consuming and should be carried out systematically to maintain competence within the municipality. In FG 2, nurse educators and leaders from HAH and homecare services discussed the lack of pediatric curriculum in the nurse education.
In homecare services you have to be a generalist, you must have both medical and surgical competence – you must know how to communicate and all other things. Paediatric care has been given less priority in this curriculum for many years. Maybe it is time to strengthen family-centred care and the perspectives of the family members too. (Nurse educator)
Moreover, close collaboration was stated as being important in building the competence needed for the homecare nurses to provide treatment and care to the sick children and their families. A leader of the homecare services said:
It is so important to enable partnership between the HAH and the homecare service in order to achieve the competence needed.
A nurse educator replied:
There is something very important about how we safeguard necessary information, so that the homecare nurse knows exactly what they need at all times; it could be regarding the children’s diagnoses, prognoses perhaps, and the course of the disease. When a homecare nurse is updated on these issues, I think this also will make them feel safer in their nursing role.
The nurses in HAH and homecare services underscored the importance of training on the procedures together. In all three interviews, the participants emphasized that the transfer of competence and training on procedures should take place in the child’s home and with the family attending, maintaining the feeling of security for all parties involved. All professionals experienced that doing the procedure in the same way increased the homecare nurses’ and parents’ experiences of security. A homecare nurse highlighted:
The times we have successfully carried out home visits to a child, we had visits alongside with HAH nurses, and that has been great! Then we had the opportunity to learn the procedure and also look at how they performed this. Afterwards we conducted it in the exact same manner. We even made a written procedure for all homecare nurses to follow, so the parents would not experience that we did it differently from the HAH nurses. We didn’t want the parents to be anxious about it.
The relationship between the parents and the homecare nurses was also discussed, particularly in FG 1 and 2. Issues of trust between parents and homecare nurses were debated. The HAH nurses stated that more emphasis should be made on transferring trust from HAH to homecare services. If the homecare nurses were safer in their nursing role when visiting sick children, this would also increase the parents’ feeling of security.
A HAH nurse said:
We really have to reflect on how we talk about the homecare nurses towards the parents. If we have a child in our care … the [parents] trust us. Then it becomes part of our work trying to transfer that trust over to the homecare nurses too. Because we’re thinking about the collaboration with the homecare nurses as help, not just for us, but also for the family.
In all three interviews, the participants suggested building municipal resource teams to preserve the competence gained.
A leader in homecare said:
I believe that if the municipalities have their own teams, they will build their own competence, and then several [homecare nurses] will recognise the task at hand as something they have experienced before.
These teams could be responsible for training inexperienced homecare nurses visiting children receiving HAH. The participants also emphasized that building sustainable competence and make it remain within the municipality where training has been given, must be managed systematically. A pediatrician underscored:
Well, I think if we could obtain a model were both primary and secondary healthcare services have responsibility, I mean in every way, - legally, economically … that both parties have an ownership in it - then maybe something might be achieved, like a system.
Discussion
The results of our study demonstrate the complexity of setting up collaboration between hospitals and the homecare services when treating hospitalized children in their home. Despite all challenges, occasional collaborations for children receiving HAH were possible, often because in the smaller municipalities there was easier to find a dedicated nurse, who was committed to help the family. The results also demonstrated the importance of information exchange and communication between the two levels of care and the value of the relational aspect in such collaborations. In the subsequent section, we discuss the impact of the results and methodological considerations.
The relational aspect of collaboration
Our findings suggest that a relational perspective within collaboration with emphasis on partnership, reciprocity, interdependence, and autonomy might be important to address when deliberating organizational issues and knowledge mobilization between hospitals and homecare services.
Previous studies have found that meetings facilitating social interaction, contributed to the development and maintenance of collaborative relationships among nurses (Moore et al., Citation2021; Woodward & R, Citation2022). In our study, face-to-face interactions with the professionals from the hospital before the child came home were considered important for homecare nurses to take on the tasks. This may also inflict on quality and patient safety, as the homecare nurses in our study stated that in close collaborations, it was easy to reach out to the hospital nurses when having questions. This is in accordance with earlier research (Ma et al., Citation2018; Sheehan et al., Citation2007; Wei et al., Citation2018).
Paulsen et al. (Citation2012) found in their research that municipal nurses were more dependent on the hospital nurses regarding information than the other way around. In our study, we found that the two parties were more dependent on each other. In most cases, the child would have had to stay in hospital if the homecare services had not carried out the extra visits needed. In this way, the hospital nurses are dependent on support from the homecare nurses and their benevolence for collaboration. The homecare nurses needed knowledge, skills, and training to provide children with treatment and solid collaboration with the hospital led the homecare nurses to feel more secure in their work with children. This reciprocity in each other enhanced the collaboration and was also likely to increase the motivation for collaboration for both parties. Other studies on pediatric homecare services have shown that the individual homecare nurse’s experience of caring for children was strongly influenced by the kind of support received from the hospital (Castor et al., Citation2017; Jibb et al., Citation2021; Samuelson et al., Citation2015).
According to D’Amour et al. (Citation2008), collaboration cannot occur without a complementary learning process. Our results indicate that when there was a close relation in the collaboration, the transfer of competence was likely to increase, and hence, the learning processes also enhanced the collaboration. During learning activities, the two parties became familiar both with each other and the families. When the homecare nurses were given the opportunity to exercise procedures in the child’s home with the family attending, they also had an experienced pediatric nurse beside them. Our study illuminates that trust was distributed from the HAH nurses to the homecare nurses in this manner. Accordingly, the relationship between the homecare nurse and the parents stand to benefit from this practice.
Sutherland et al. (Citation2021) found that healthcare workers emphasized the importance of time in establishing a solid trusting relationship through iterative cycles of communication and working together. These cycles were reinforced by collaborating on patients multiple times. In an earlier study, we found that almost none of the homecare nurses had more than one acquaintance with a child in their service (Aasen et al., Citation2022). Although a good relationship in a collaboration about a specific child was established, the lack of extended collaboration was likely a hindrance, as they always had to “start from scratch” and learn to know each other, each collaboration a new collaboration started.
Enhancing knowledge, language, and competence across service levels
In this study, all stakeholders revealed insecurity regarding whether hospitalized children were within the mandate of the alleged tasks of a municipality. Additionally, what professionals from the hospital thought was an easy task to hand over was not perceived in the same way by the homecare nurses. The homecare nurses felt a lack of competence and experience in caring for hospitalized children. Practices both within and across health care systems are characterized by separate systems (Glouberman & Mintzberg, Citation2001). According to Robinson and Street (Citation2004), ward nurses in hospitals have, at best, limited knowledge of services available to support older people following discharge and need assistance to increase this expertise. Furthermore, in Norway, caring for sick children is generally conducted by specially trained nurses and is considered a task for nurses with further education than a bachelor’s degree in nursing. We question whether there is enough focus in the current nursing curriculum and in clinical practice on collaboration as a skill that must be learned and systematically trained on.
Divergent education, training, socialization, and structures for professional groups adversely influence knowledge mobilization because the various professionals delivering healthcare may not share common perspectives or language (Currie & Fox, Citation2015). Consequently, if nurses are using the same words but mean different things – patient safety will be at risk. When professionals can deliberate what the information about the child’s treatment and care clearly implies, the chance of misinterpretations is diminished, and patient safety will increase. Sheehan et al. (Citation2007) found that interprofessional teams that functioned well were characterized by their use of inclusive language, continuous sharing of information between team members and a collaborative working approach. In this sense, inclusive language is one of the hallmarks of an interprofessional team (Sheehan et al., Citation2007). Then, it is likely that face-to-face communication will also enhance patient safety in HAH care for children.
Collaborations across service levels
Governments internationally have committed to improving the integration of healthcare services for the growing number of people experiencing chronic disease. Traditional, siloed, organ-based care approaches have failed to provide the holistic, accessible, “linked-up” care now required (Mitchell et al., Citation2015). Much of the criticism of the Norwegian Coordination reform subsists of ineffective collaboration across organizational levels (Paulsen et al., Citation2012).
Samuelson et al. (Citation2015) concluded in their study on HAH for children that there was an urgent need for developing formal policies of transmural collaboration to train and support homecare nurses to deliver adequate care to sick children and their families at home and safeguard good outcomes. Our results suggest that collaborations across service levels regarding HAH may be facilitated and are prosperous for the children and the families when there is an existing close and relational collaboration between the hospital and the homecare services. Thus, the current study also shows many similar collaboration obstacles as in earlier research both in Norway and internationally regarding the elderly population (Gautun & Syse, Citation2017; Martinussen et al., Citation2017; Shot et al., Citation2020; Steihaug et al., Citation2016; Woodward & R, Citation2022).
Our study illuminates the focus on how to maintain acquired pediatric competence within the municipalities. Creating teams, either within or across municipalities, were suggested by the participants. Earlier research has shown that because of the small number of encounters with children, acquired competence may be lost (Castor et al., Citation2017; Law et al., Citation2011; Samuelson et al., Citation2015). In the Norwegian context of this study, the HAH nurses often found a dedicated homecare nurse in small municipalities, with a commitment to help out the family, who served as both “the glue” between the homecare services and the hospital and the catalysis for the collaboration to take place. However, this makes the system less robust and more vulnerable when systematic organization or legally binding agreements between the hospital and the municipality are absent.
Models of care that feature vertical integration of healthcare between service lines have recently become a source of interest from government and in research (Belfield & vanPoucke, Citation2019; Mitchell et al., Citation2015). Such models should feature good coordination by personnel with an understanding of community and specialist-based care (Mitchell et al., Citation2015). The creation of teams could also imply that the professionals would have more opportunities to establish multiple cycles of working together, as suggested by Sutherland et al. (Citation2021). This will also impact the relational aspect of collaboration. It is a goal of the Norwegian authorities that more responsibility is shared between hospital and municipality so that the service become more seamless (Meld St 7, Citation2019–2020; Meld St 26, (Citation2014–2015). Thus, the collaboration between the service lines in Norway is still described as challenging (Steihaug et al., Citation2016).
Implications for practice
Collaborations across service levels concerning HAH, based on partnership, reciprocity, interdependence, and autonomy, are important to address when deliberating organizational issues and knowledge mobilization between hospitals and homecare services. The establishment of a seamless and secure HAH-service may be facilitated by the authorities to enhance its robustness, implying the need for legally binding agreements between the hospital and the municipality.
Methodological considerations
In this study we explored collaboration on hospitalized children who receive treatment and care at home as a shared task between healthcare professionals working in hospital and municipality healthcare services.
In accordance with recommendations of Braun and Clarke (Citation2013), we sought to put together groups based on some similarities within the groups, but also enough diversity to bring forward different perspectives and a broad discussion. We are aware that some homecare nurses are somewhat negative to having children in homecare services in a collaboration with the hospital. Unfortunately, we were unsuccessful in making them participate. Having their voices come forward could have provided a richer understanding of the collaboration. The variety in age and working experience of the participants is substantial, but the participants had only sparsely experienced collaboration between HAH and the homecare service.
This study was conducted in a Scandinavian context, and the results reflect collaboration across organizational levels where each sector belongs to separate levels of public administration; local and national. This could limit transferability to other countries. However, the international literature describes similar challenges regarding collaboration between different healthcare systems involving the elderly population. This research could be relevant for other countries that set up new services comprising different professions and different service locations.
Conclusion
The study illuminates important perspectives of health professionals on the collaborations around the HAH service, and points to the value of developing structures that strengthen relationships between professionals. This study shows that collaboration across different service levels for HAH patients can be enhanced and is likely to be advantageous for the child and the family when there is a preexisting close and relational collaboration between the hospital and homecare services. Moreover, developing structures that strengthen relationships between professionals is an important investment for the success of good and safe home-based services for children. Building competence and learning from and with each other ensures better conditions for success if the collaboration is organized and facilitated through agreements between the hospital and the municipalities.
Author’s contribution
The first author, Line Aasen, had the primary responsibility for the data collection. The study design, analyses and article writing has been done in collaboration with the second author, Anne Werner, and Anne-Kari Johannessen, the last author. The first author made the interview guide, conducted and transcribed the interviews under supervision of the co-authors. The third author Ingrid Ruud Knutsen contributed to the study design, data analysis and suggested improvements to drafts of the manuscript. All authors read and approved the final manuscript.
Ethical approval
The study followed the ethical principles for medical research involving human subjects of the Declaration of Helsinki. The Regional Committee for Medical and Health Research Ethics, Southeast Norway, found the project to be outside the remit of the Act on Medical and Health Research Act (ref. 47184). The local privacy legislation authority at the two hospitals approved the study (ref. 2019_134,19/29832).
Written informed consent was obtained from the participants before data collection, and the participants were informed that their participation was voluntary, that the collected data would be kept confidential and that they could withdraw from the study at any time.
Acknowledgments
The authors are grateful to the parents the homecare nurses who participated and shared important experiences, thereby making this study possible. We also wish to thank the head nurses of HAH services and the homecare services, who facilitated the recruitment process.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
Notes on contributors
Line Aasen
Line Aasen is a Research Fellow in Oslo Metropolitan University, Department of Nursing and Health Promotion.
Anne Werner
Anne Werner is a Senior Researcher at Akershus University Hospital, Lørenskog, Norway.
Ingrid Ruud Knutsen
Ingrid Ruud Knutsen is a professor and works as head of studies at Department of Nursing and Health Promotion at OsloMet.
Anne-Kari Johannessen
Anne-Kari Johannessen is an associate professor in Oslo Metropolitan University, Department of Nursing and Health Promotion.
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