Working together apart: how home care and home health care collaborate on medical tasks in Sweden

Background: In light of Sweden’s stay-at-home policy for the elderly, the increasing complexity of care needs has led to a growing reliance on collaboration between registered nurses in home health care and home care providers in relation to medical tasks. However, few empirical studies have been conducted that follow how nurses and home care providers operate in conjunction on joint medical tasks.

Approach: This study examines the collaboration that takes place between nurses and home care providers in relation to shared medical tasks within Swedish home care and home health care services. The study comprises observations and interviews conducted in three communal settings between 2023 and 2024. One is a large city, while the other two include smaller cities and the countryside. Two home care and home health care groups were observed in each setting. In 9 participant observations, workers were followed in their work for a day shift and an evening shift in home care, and a day shift in home health care, with each shift lasting for 8-9 hours.

Observational notes were taken. Semi-structured interviews were also performed with the workers who were followed and with co-workers within the same unit. A total of 53 interviews were conducted with 39 home care providers, and 14 nurses, divided between the three settings. The interviews were 20-60 minutes long and were conducted at the workplace, at the researcher’s workplace, or by phone.

The study used strong structuration theory to analyse how internal and external structures shape daily practices and interactions between nurses and home care providers regarding joint medical tasks.

Results: The findings reveal that differences in structures both promoted and challenged what and how informants could act in relation to joint medical tasks, while the shared tasks could be used to act and to mitigate differences and manage external structures. While trust and shared routines both facilitate and are a result of joint action, structural differences and role expectations can create tensions and power imbalances. Several external structures supported joint medical tasks: the delegation process, organisational rules and guidelines, the managerial role of the RN, and the digital systems in use. However, these structures could be handled through internal structures to both further support and refuse medical tasks.

Implications: The study contributes knowledge on how structures connecting to normative expectations and external conditions are utilised for joint action, as well as influence working conditions and tasks. It also widens the understanding of the nurses’ and home care providers’ positions vis-à-vis each other in understanding the internal as well as external structures, and how they can be used in order to act. Nurses thus had a clear say in an organisation of which they were not a formal part. Home care providers, while expected to accept delegations to the letter, could refuse or amend medical tasks by adhering to structures connected to their normative expectations as home care providers, working for elderly persons in their home.