الفهرس 
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Abstract
In response to all dynamic changes in global health issues; it was necessary for governments to find alternative care strategies to meet the demands of the patients and their families. Home health care (HHC) is a type of health care strategies that favors the actualization of new forms of care production and interdisciplinary practice. HHC provides health care to patients in their homes and enhance their sense of security without having to be in the hospital after the stability of their condition, protect them from hospital acquired infections, decrease the readmission of elderly patients and those with chronic disease.
Home health care nursing is a specialty area of practice that promotes optimal health and well-being for patients, their families and caregivers within their homes and communities. Home health is a unique field of nursing practice that requires a synthesis of community health nursing principles with the theory and practice of medical/surgical, geriatric, mental health, and other nursing specialties.
Nursing standards is very important in determining what the profession expects from its members. It promotes, guides, and directs professional nursing practice. Also, it is important for self-assessment and evaluation of practice by employers, clients and other stakeholders. It provides nurses with a framework for developing competencies. Additionally, it aids in developing a better understanding and respect for the various and complementary roles. It provides a baseline for evaluating quality of nursing care and helps supervisors to guide nursing staff to improve performances. Moreover, it helps to clarify the nurse’s area of accountability and clearly define different levels of care (ANA, 2015).
In Egypt, home health care is not taking its professional form yet. A Large number of agencies have expressed themselves as specialists in providing home health care services. These agencies are not affiliated to the Ministry of Health and not subjected to any regulating law. Its nomination for the patients ranged from private nurse (which is very costly) to home helper who passed a three months first aid course (to relatively decrease the net cost). In both situations, there is no responsible authority held accountable in case of any nursing error or malpractice (Osman et al., 2017). Attempts are being made for establishing standards in many nursing specialties; however, home health care nursing is still an area in need of standardization. This especially true since no job description for home health care nurses is available, no previous studies on the area of the study in Alexandria Governorate have been done, and no official statistics about the number and distribution of both home health care recipients and providers are exist.
This study was conducted to identify basic competencies required for home health care nursing practice in Alexandria Governorate and establish valid basic standards for home health care nursing practice in Alexandria Governorate.
An exploratory sequential mixed methods research design was used to accomplish this study. It had been carried out in
• All academic departments of Faculty of Nursing / Alexandria University,
• Directorate of Health Affair / Ministry of Health and Population (MOHP) in Alexandria Governorate,.
• Hospitals and home health care agencies (Gamal Abdel-Naser health insurance, Al-Salama, Alexandria Medical Center, Mabart-El Asafrah, Royal and Louran hospitals, Care-Hub agency)
• Homes of the recipients of home health care nursing.
The present study subjects included:
The subjects of this study were consisting of three main groups:
group I: Expert panel:
o Ten professors of community health nursing department.
o Twenty-four professors from each of eight other faculty departments.
o Three directors of the central nursing administration affair, curative nursing sector, and preventive nursing sector.
o Seven nursing directors working in each of the selected hospitals.
group II: Nurses:
o Thirty nurses were participated in Focus group Discussion sessions.
o Other thirty nurses were included in the study to train them on the established standards and evaluate their home health care practice.
group III: Home Health Care Recipients:
o Twenty recipients of home health care
Tools of the study:
Three main tools were used to collect the necessary data. These tools were categorized according to each group of the study subjects:
D. For expert panel: Tool I (a and b)
➢ Expert panel opinion regarding home health care interview schedule to elicit their opinion regarding the knowledge and skills required from nurses as a home health care provider and establish the standards of home health care nursing practice.
➢ Expert panel agreement on established standards (Delphi questionnaire) to obtain the experts’ panel agreement score on each structured standard statements.
E. For nurses: Tool II (a, b and c)
a) Focus group Discussion (FGD) Guide for nurses to identify nurses’ point of view and experiences about provided home health care and to investigate the different factors that affect the provided care.
b) Home Health Care Nurses’ Knowledge Structured Questionnaire Sheet to evaluate home health care nurses’ theoretical knowledge related to the direct nursing care that should be given to home health care recipients.
c) Self-reported evaluation checklist to evaluate nurses’ practice during providing home health care nursing.
F. For recipients: Tool III:
Recipients’ Needs for Home Health Care Unstructured Interview Schedule to identify the recipients’ point of view about received home health care and to investigate the different factors that affect the provided care.
The tools were tested for validity and reliability. Approvals were obtained for conducting the study at the specified settings. A pilot study was carried on (5) home health care nurses to test the developed tools. The study was conducted in a period of 42 months (from June 2019 to December 2022). Qualitative and quantitative data was collected by the researcher then appropriate analytical statistics were carried out.
The main findings obtained from the study were as follows:
Tool I (b): Expert panel agreement on established standards (Delphi questionnaire)
- Standards of licensure requirements for the home health care agencies agreement percent raised from 99.3% in the second round to 99.6 % in the third one.
- The standards of professional requirements for the home health care nursing agreement percentage raised from 97.3 % in the second round to 99.65 % in the third one.
- The standards of practice for home health nursing following the nursing process agreement percent raised from 97.7 % in the second round to 99.32 % in the third round.
- The total agreement rate of experts on the established standards is increased from 98.09% in the second round to 99.6% in the third one.
Tool II (a): Focus group Discussion (FGD) Guide for nurses
- The majority of interviewed nurses were male.
- All of them were licensed nurses with bachelor’s degrees working at non-governmental hospitals.
- Years since graduation ranged from one to less than three years for half of them, more than one quarter graduated in the last year and one-fifth graduated in the previous three to less than five years.
- The highest percent (46.6%) of nurses’ years of experience ranged from one to less than two years of experience, while more than one quarter (26.7%) of them have either less than one year or more than two to five years of experience.
Tool II (b): Home Health Care Nurses’ Knowledge Structured Questionnaire Sheet
- More than half (53.3%) of attended nurses were female.
- less than two-thirds (60%) of them were licensed nurses with bachelor’s degrees and less than half (40%) were technical nurses.
The highest percent (63.3%) of them had less than five years of experience, and slightly more than one quarter (26.7%) of them had five years to less than ten years of experience. One-tenth (10%) of nurses had ten years and more in the home health care nursing specialty.
- Slightly less than three-quarters (73.3%) of nurses provide care for patients with Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19). The same percent (10%) of them were provided care either for patients with stroke or non-communicable diseases (hypertension, diabetes mellitus, cancer, or obesity). Less than one-tenth (6.7%) of them provided care for aging patients.
- Nurses’ knowledge Concerning the importance and process of nursing standards raised from 90% in the pretest to the maximum in the posttest.
- Their correct answers about elderly status by 2030 are increased from less than three quarters (70%) in the pretest to 90% in the posttest.
- One-fifth (20%) of them answered correctly in the pre-test about home health care nursing situation in Middle- East countries and in Egypt comparing to half (50%) of them in the posttest.
- Less than half (43.3%) of nurses have correct background about absence of job description for home health nurse in the pretest and this percentage has been increased to 80% in the posttest.
- Regarding the Home health care situation in the current Egyptian health insurance system, more than one third (36.7%) of nurses answered correctly in the pretest and later, the majority (86.7%) of them had correct answer in the posttest.
- Concerning the advantages of home health care, the percentage of correct answers boosted from more than one quarter (30%) in the pretest to 46.7% in the post test.
- Definition of home health care was recognizable by nurse since the correct answers raised up from 80% in the pretest to the maximum (100%) in posttest.
- One-fifth (20%) of nurses gave complete answer about ultimate goal of home health care nursing and function of advisory committee in the pretest for each, and this percentages equally risen to slightly more than half in the posttest.
- Marginally more than one-quarter (26.7%) of nurses were aware of eligible patients for home health care nursing in the pretest. This level of knowledge grew to slightly less than three quarters (73.3%) in the posttest.
- About educational qualifications of nursing supervisor, the percentage of nurses aware about it grown from less than three quarters (70%) in the pretest to the majority (83.3%) in posttest.
- Regarding nursing process, the level of nurses’ knowledge related to planning and implementation phases amplified from 26.7% and 36.7% respectively in the pre-test to 50% and 63.3% in the post-test.
- Knowledge level regarding documents and procedure improved from more than one-quarter (30%) in the pretest to majority (86.7%) in the posttest, while it was raised from less than half (46.7%) in the pretest to 80% in the posttest regarding standards of professional development.
- Concerning communication, the percentage of complete and partially complete answers was raised from half (50%) in the pretest to 86.7% in the post test for the barriers of communication, and the percentage was raised from less than one fifth (16.7%) in the pretest to 93.3% in the posttest regarding the enablers of communication.
- Knowledge about hazards at home rose from more than one third (36.7%) in the pretest to almost maximum (93.3%) in the posttest.
- Regarding the six ethical principles, the knowledge level was totally increased from less than one fifth (18.9%) in the pretest to slightly more than two thirds (67.3%) in the posttest.
- The percentage of nurses with low knowledge decreased from (90%) in the pre-test to more than one-tenth (16.7%) in the post-test. Regarding the nurses with moderate knowledge, the percentage raised from one-tenth (10%) to less than half (40%) in the post-test. Progress is remarkable in the percentage of nurses who acquired high knowledge from the workshop increasing from zero to less than half (43.3%) in the post-test.
- A statistically significant relation was detected between attending the training workshop and the level of knowledge of home health care nurses (X2= 33.525, P= 0.000*).
Tool II (b): Self-reported evaluation checklist
- The majority (80%) of nurses correctly assessed the eligible home health care patients using valid assessment tools.
- Less than three quarters (73.3%) correctly concluded proper nursing diagnosis based on collected data.
- Less than three-quarters (70%) develop a patient-tailored plan of care.
- The majority of nurses admitted that they were adherent to implementing the predetermined plan effectively.
- Less than three quarters (73.3%) continuously evaluated short-term objectives and long-term goals of patient care with proper analysis and documentation of the results.
- Less than two-thirds (63.3%) of nurses reported that they identify learning needs and participate in ongoing educational activities to maintain professional development.
- The majority (80%) of them admitted that they identified barriers to effective communication and make appropriate adaptations to communicate with the patient, family, other caregivers, and healthcare team members,
- The same percentage reported that they cooperate with other team members and apply group discussion and negotiation techniques with patients, families, caregivers, and the interprofessional healthcare team to achieve health outcomes.
- Slightly more than two-thirds (66.7%) of nurses assist the patient and family in resource utilization through estimating costs, risks, and benefits in decisions about treatment and care at home.
- The majority (86.7%) of them correctly follow all infection control measures during providing care at home.
- The highest percent (90%) of nurses apply all risk reduction policies and procedures that guarantee nurse’s best practices in a safe environment for nurses, patients, and caregivers and they report any environmental risk factors to the clinical supervisor.
- The majority (83.3%) of nurses follow the code of ethics for the Egyptian nursing profession [issued by the general nursing syndicate] with its interpretive statements to guide their practice.
- The majority (83%) of nurses reported a total satisfactory level of practice, one-tenth (10%) of them reported partially satisfactory practice, and only (7%) reported unsatisfactory practice.
Tool III: Recipients’ Needs for Home Health Care Unstructured Interview Schedule
- The majority of interviewed recipients were female.
- less than half aged between 61 and 70 years old
- All recipients lived with their families except only one recipient reported living alone.
- Half of them were seeking home care due to either non-communicable diseases (Hypertension, Diabetes Mellitus, or obesity) or severe acute respiratory syndrome coronavirus 2 (COVID-19), while less than half of them were due to aging diseases or have immunity diseases (e.g., systemic lupus), the minority reported accidents / injuries as a main cause of seeking home health care nursing
- the duration of received care for more than half of recipients ranged from one weak to less than six months, and for more than one quarter was ranged from one year to less than five years.
- The majority received care from licensed nurses and less than one quarter rely on sitters.
In light of the present study findings, the following recommendations could be made:
a. Shed light on the actual situation of home health care on Alexandria governorate, to determine strength, weakness, threats, and opportunities (SWOT) analysis.
b. Develop an approved home health care program with a clear vision and mission.
c. Establishment of a central hospital for home health care affiliated to (MOHP), with all recent equipment, qualified health care team and advanced electronic filing and documentation system.
d. All private home health care agencies should be licensed by (MOHP), otherwise they will be subjected to legal accusation.
e. Develop policies, regulations and job description that explicate duties and responsibilities of home health care nursing.
f. Conduct personal interviews, well prepared cognitive and practical exams to ensure the nurses’ capability to specialized as a home health nurse.
g. Makes effort to get rid of all informal care givers who tarnished the reputation of nursing and cause many health and psychological problems for patients.
h. Inform faculty students about the postgraduate programs, and that home health nursing is one of the diploma programs and elective courses that offered by community health nursing departments.
i. Organize health convoys to increase the community awareness about the new services and the importance of combating informal care givers.
Recommendations for further research:
a. Establishing advanced home health care nursing standards, categorized by care for different medical conditions, age group, or nursing specialties.
b. study the impact of conducting a training program about the new advanced standards on nurses’ knowledge, attitude, and skills.
c. Replicate the current training workshop with a larger number of nurses for longer period and more specified information.
d. Assessment of the extent to which home health care agencies and nursing personnel adhere to the home health care standards.
e. Evaluate the satisfaction of home health care nurses and recipients regarding the provided care.