SPECIFIC CHARACTERISTICS OF HOME HEALTHCARE AND THEIR APPROACHES IN NURSING

Home-based care is a growing career opportunity for nurses in Brazil which requires trained professionals to provide quality care. This study aimed at identifying how the specific characteristics of home healthcare are dealt with during nursing professional training. It is a qualitative research using Grounded Theory. Five professors and eight undergraduate students at a state university in the South of Brazil were interviewed. Data was analyzed through open, axial, and selective coding. Results allowed researchers to identify the characteristics of this type of care and its teaching approaches. Professional performance at home is different and the peculiarities of this type of care should be dealt with in nursing undergraduate courses.


INTRODUCTION
In Brazil, the number of organizations offering homebased care is increasing steadily.Such organizations are private 1 or publicly funded by the Best at Home Programme 2 launched in November 2011.
Homecare aims at reducing the need for hospitalization and/or the length of stay.Currently, domiciliary care uses new therapeutic methods and technologies that allow treatments only available in hospitals.This type of care requires, however, the overcoming of physicalism in health care and the privilege of interdisciplinary knowledge; it calls for the collaboration between the subjects involved in the process: the health professional, the patient, the family and the caregivers. 3atients being treated at home demand comprehensive and continuous care.This circumstance contributes to anti-hegemonic practices and to the development of new health care aspects, such as palliative care at home, home care to patients with HIV, to patients with muscular dystrophy and home treatment of wounds, among others. 4ome care allows health professionals to work more closely with patients and families, enabling them to go beyond the biological aspects of the disease and to join different knowledge and practices.This makes patients and caregivers more independent; it establishes an atmosphere in which values, beliefs, the patients' projects, relatives, social networking and health workers play a part. 4n-home care potentiates care practices that bring more autonomy to families -in preparing treatment plans, in trying different approaches, in making sense of life and death -to the extent in which it recognizes the patient as an active and decisive individual in the whole process. 4n this sense, it increases health professionals' perspectives of home care as a career option and promotes "professional training for the planning, coordination and evaluation of actions in order to built an ongoing process of articulation with other sectors whose actions are related to the patient and family 5:860 ".
The concern with the professional training of those working at home is positive, as their performance is expected to be of superior quality and productivity. 3:1453 The objective of this study is to identify nursing education approaches to home care.

METHODOLOGY
This is a qualitative research using the Grounded Theory (GT) approach.
Data was collected through semi-structured interviews recorded from December 2009 to July 2010 at a site chosen by the participant.Questions were previously developed and changed, if need be, during the course of the interviews, as recommended by the authors of the method. 6Research sample consisted of eight final year undergraduate nursing students attending a state university in the south of Brazil.At this stage of the course they were more likely to have attended courses on home care.In addition to them, the researchers invited five professors at the same university who taught courses on the subject.Data collection was terminated once theoretical saturation was reached.
Data analysis consisted of open, axial and selective coding.Open coding occurred after transcription of the interview; each line was analysed and data separated into different parts, closely examined and compared searching for similarities or differences, so that categories (i.e.concepts deriving from data that represent the phenomena) were identified. 6n axial coding, data divided during open coding were put back together.The categories were associated to their subcategories to generate more precise and complete explanations about phenomena.There was exhaustive reading and rereading of the interviews comparing codes one by one to ensure their proper and orderly classification. 6elective coding, the process of integrating and refining the theory, was the last stage.Categories were organized around a central explanatory concept.The integration of categories took place from the first stages of the analysis to the final draft. 6ata analysis allowed the interpretation of the phenomenon "experiencing home care in the undergraduate nursing course".Inquiring into that experience six categories and several subcategories were identified; the category "expanding knowledge about home care" is explained and discussed in this study.
The study was approved by the Ethics Committee in Research of the institution in question (registration no.631.168.08.10) and received the Certificate of Presentation for Ethical Consideration (CAAE no.0062.0.091.000-08) in accordance with Resolution no.196/96 of the National Health Council.

RESULTS
At this stage, the category "expanding knowledge about home care" will be presented along with its three subcategories (Figure 1).

Understanding the char acteristics of home care
The home is the most private and intimate physical space of an individual; it is where people live and establish interpersonal relationships with residents of the same household, whether family or not; it is the setting in which a person feels welcome and inserted into a context.

"[…] in the home you are away from the infrastructure that the hospital gives you, away from other professionals who can assist you if necessary […]" (Interview 8).
In addition, nursing professionals realize early on that they must adapt themselves to each patient's schedule and that there are bath and wake up times that need to be respected.Therefore, nurses should be aware of different family routines and develop negotiation skills.

Identifying the personal qualities required of a home care professional
Effective health care depends on the skill and personal qualities of the health professional that provides it.
Effective home care will not happen unless the professional has scientific knowledge to solve any problem that might arise.It is necessary to have knowledge about the patient disease process in order to offer guidance and answer questions.Nurses have to be adroit at performing the required procedures; they have to single-handedly deal with the potential needs of patients and their families.

[…] and know […] about network support, how to observe, what to observe, a lot of reading, to investigate when in doubt […] to have scientific knowledge in nursing […] you need to have the ability to talk to people as well, interpersonal skills […] (Interview 3).
Nurses need to feel empathy, to have charisma and be able to connect and establish links that will enable the performance of their duties.
Patience is fundamental for home care professionals, because activities progress according to the patient's disposition.Being able to observe is vital, because their mere presence at the home does not guarantee effective and efficient care: it is necessary to observe the relationships and situations and act accordingly.
Nursing professionals are expected to adhere to the Code of Ethics for Nurses in any workplace.In a private residence, they often learn about private matters that were not directly reported to them, but perceived.It is imperative to act ethically in situations observed during home care.

"[…] ethical issues surrounding it [home care], you know how to behave; you accept that this is not your place [home] […]" (Interview 2). "Home is the place where people live, it is the private space where they interact with its other members; it is the personal space of an individual […] (Interview 1)
Hence home care is performed in the patient's own space, a role reversal because the rules are dictated by patients or their family.Each home has its peculiarities, reflecting the way the families live, their habits, beliefs and values that should be understood and respected during care.

Home care is quite different; roles change because at hospital you make the rules; in someone else´s house it is the owner […] it is very difficult, it is very hard, much harder than working at hospital […] (Interview 1).
Close contact with patients enables professionals to observe their relationships and household organization, to establish links and perform comprehensive and humanized care to patients and their families.Home care allows health professionals to go beyond the information given by the patient to the clinic, hospital or health unit.

[…] You need to get closer to the patient, daily […]; in their home you get to know the patients, their relationships, who they get along with, who they don't, who influences care […]. Home care is more comprehensive […], you are constantly with the patient […] you build up ties with that patient […] (Interview 6).
On several occasions, however, material resources and structural conditions are unfavourable and require the professional's adjustment, because they lack the infrastructure and human resources available in the hospital.

Understanding methods to get prepared for home care
The respondents sustain that it is necessary to study theories, papers, case studies, attend postgraduate and/or refresher courses on the subject in order to acquire an essential theoretical background.Scientific knowledge helps professionals feel more confident in their tasks.
Practice improved over time and experiences exchanged with other professionals are also welcome.

DISCUSSION
Although the demand for home based health care is growing, there are few studies that delineate its qualification process.This means that data analysed in the present study is not commonly discussed in the literature, albeit its importance.To recognise that this type of care has specific characteristics, contributes to a better teaching and learning experience: the home is an environment that requires specific attributes achieved through several types of training.Nursing students should experience home care throughout university to consider the area as a job prospect after graduation.
The subcategory "identifying the personal qualities required of a home care professional" pointed out elements expected from home care professionals.They are related to the articulation of knowledge, skills and attitudes in both behavioural and scientific spheres 8 , "since interventions in the home are dynamic and new nursing skills are daily required" 8:8 .
Among the various skills needed, the study stresses solidarity, creativity to overcome the limitations of the physical environment, the use of clinical reasoning, kindness, empathy, ability to identify and respect differences finding the best way to deal with individual differences. 9lthough instrumental and communicative abilities should go hand in hand, nursing internship students are unduly worried about the instrumental dimension of home care, to the detriment of the communicative dimension.The latter is an important element to unique and humanized care and should be promoted by professors. 10uch qualities are indispensable and begin to be appreciated during academic lectures and internships that emphasize the peculiarities of home care, as demonstrated in the subcategory "understanding the characteristics of home care".Thereaf-ter, students realize that the home is the patients' domain and reflects its residents' lifestyle.Thus, when providing that service, health professionals should consider "individual and family specificities, such as feelings, beliefs, values, habits, conflicts, and the careful monitoring of the family" 11:87 .
Another characteristic element of home care is the need of a caregiver to attend the patient.These caregivers -being a relative, neighbour, friend or a hired employee -are responsible for providing care that, in a hospital, the hospital health care team 9 would provide.
Health professionals should provide caregivers with training on the procedures they are expected to develop.Nevertheless, caregivers and family are relatively free in the performance of their duties, insofar as their feelings, habits and values are added to their practice. 9eaching relatives to take care of a patient is essential in home-based health care.However, nurses should respect such caregivers' comprehension abilities and skills.Moreover, the home may not be adequate to perform the task and adjustments of those who should carry it out 11 may be required.
The interviewees demonstrated they know how to get prepared to perform that type of care (elaborated in category "methods to get prepared for home care").Furthermore, a certain amount of self-knowledge may also influence a good performance: by identifying their aptitudes, difficulties or limitations, nurses find ways to maximize positive aspects and improve negative ones. 13ursing students should be conscious that changes in health care organization are needed for the consolidation of the Unified Health System (SUS) guidelines.These changes refer to the diversification of health technologies, the coordination of multidisciplinary practices and the rationalization of limited financial resources. 9ealth professionals working in home-based care are supposed to distance themselves from the clinical model of their academic training.Public interest in a specific training agenda for home care is incipient; higher education institutions rarely include the theme in its curricula and such indifference reflects itself in unprepared professionals and inadequate health care. 12ost nursing schools programmes are largely ineffective, given the country's current health care model.Health professional training of SUS workers has proven deficient since the eighties when there were no policies on human resources training and development, in qualitative and/or quantitative terms. 14ome care simulation training using dummies in different stages of life is an example of other countries' initiatives to approach home care specific procedures and situations.Simulation-based interventions provide challenges in a possible scenario that may include, e.g.animals or a dirty environment. 15utside Brazil many institutions adopt teaching with simulations.Students regard it as a positive and valuable learning for the teaching of home care.Thus, it is up to professors to follow the recommendations of the United Nations Educational, Scientific and Cultural Organization (UNESCO) on education for the twenty-first century in relation to the four pillars of learning, one of them being learning to know, which stresses that knowledge is infinitely multiple and evolving.The learning experience is not limited: it can be enriched by experiences, including those arising in the workplace 21 .Therefore, nursing students during their university course should seek to develop and improve their knowledge on home care.It is also up to health professionals who have not had the opportunity to experience home care during their undergraduate course to request its inclusion into continuing education programmes to enable a theoretical and practical approach to this type of care.
It is clear, therefore, that home care, which it has its own characteristics, is a reality in the health system and that skilled professionals for its management and implementation are required.

FINAL CONSIDER ATIONS
Home care has specific characteristics that set it apart from hospital care.Consequently, the professional's performance is different in each of these environments, since home care has to consider the patients and their families' context.
Objectives are often the same; however, the circumstances in which care is delivered are rather different.Health professionals require adequate training and not only the transposition of their duties from the hospital setting to a house.Thus, it is worth emphasizing that higher education institutions have to be aware of home care specific requirements and insert them in their programmes.Demands on health care professionals by employers, patients and families for the delivery of good quality home-based care are increasingly high.experience which encourages self-confidence, contributes to skill development, satisfaction and critical thinking. 15,16verall, simulations are preceded by lectures and discussions on student performance.They can include care for diabetic patients with altered glycaemic indexes and leg wounds, or, also, administration of medication to in-home patients. 15,16esides simulation activities, the learning needs of the students, professors properly trained for the task, best educational practices and partnership with local authorities should be considered. 15n-home health care training can be improved in Brazil by the incorporation of the aforementioned practices and the improvement of the existing ones, such as student participation in academic extension activities, including multidisciplinary and interdisciplinary activities. 17hus, in order to "mobilize national and international health and other sectors´ professionals, as well as citizens aiming at collectively building policies and interventions for the development of human resources for health", the Decade of Human Resources for Health (2006-15) was launched during the 7th Regional Meeting of the Observatories of Human Resources for Health, held in Toronto, Canada, from 4 to 7 October 2005.It was sponsored by the Pan American Health Organization in conjunction with the Canadian Ministry of Health and the Ontario Ministry of Health and the Long-Term Care 18:3 .
In Brazil, the Federal Board of Nursing and the Brazilian Nursing Association, concerned with human resources in nursing, drafted an agenda in support of quality training for nursing professionals, presented at the 12th National Seminar on Guidelines for Nursing Education in Brazil (SENADEN) in 2010.Among the proposals we highlight: to strengthen the quality of training of nursing professionals in educational institutions based on the National Curriculum Guidelines, the SUS and current social needs; to maintain and expand a permanent agenda of cooperation with the Department of Higher Education, the Department of Distance Education, the Office of Vocational Education and Technology, the Coordination for the Improvement of Higher Education Personnel (CAPES), the National Council for Scientific and Technological Development (CNPq); and to carry out researches to evaluate the impact of quality training of nursing professionals nationwide. 19n addition to investments in specific training, strategies to include the theme in further education projects should be considered: the workers' education includes learning and working experience, i.e. it should consider that training and professional development are dictated by the health needs of the population, as recommended by the National Policy for Continuing Education in Health 20 .
Despite these initiatives, changes aimed at the improvement of human resources for health care are still ongoing.Currently many educational institutions have no specific schedule