From The Floor
Home Health Nursing: Wave of the Future?
As medical care continues to evolve, I think we'll find an increasing reliance on the home health environment.
In my opinion, home health nursing is not a job for the meek. Due its independent, self-monitoring nature, it often gets a bad rap. Yet this form of nursing is just as important as any other and comes with its own challenges and difficulties. For example, you don’t have the usual nursing team to rely upon, you must be able to self-monitor and self-direct a great deal of your own work, and you must interact with the patient, their family and friends on their turf.
Once upon a time, I broke a promise I made to myself and allowed my affection for a young patient to weaken my resolve. I accepted a private duty assignment as the home health nurse for this patient, who was completely vent-dependent. I spent a few months on this assignment, which shed light on many of the challenges of this type of nursing. I worked my usual 12-hour shift, and my relief was a fellow RN who I knew from the local hospital. This arrangement seemed a good fit since the two of us knew each other and respected each other’s knowledge and skills.
Several weeks into the assignment, I began to sense feelings of ill ease from my relief. She grew increasingly unenthusiastic about the job, and her reports were perfunctory. It was about this same time that I noticed that the family, as they became more familiar with me, grew less inhibited and made comments that seemed to have a slight racial undertone. At first, I dismissed my suspicion. I figured that, since they were of Middle East origin, I was French and my relief American, perhaps what I was sensing was culture shock and the usual misunderstandings that can arise when people of such disparate backgrounds are thrust together not by choice, but from necessity.
A little more time passed and I became aware that the family’s comments were more strident and directed specifically at my relief. I realized it was time to express my concerns to our agency. I let them know that the family was showing intolerance due to possible racism and suggested that they either stage an intervention or reassign my relief nurse.
Unfortunately, the agency chose to keep its head in the sand and soon the comments became accusations of nursing incompetency. The family began to complain to me, and later to the agency, that the relief nurse was a “bad” nurse, that she didn’t know how to suction or monitor the vent or use the other equipment. I defended my coworker because I knew these accusations were completely unfounded, but without the support of our agency, the inevitable occurred: one day she didn’t show up for work. I had to cover a 24-hour shift with no relief for a patient who was ventilator dependent. I was ethically and morally bound to stay with her until relief was available, and later, the other nurse had to defend herself against a complaint of dereliction of duty.
Though some floor nurses may think that home health nursing is a walk in the park, in reality, it offers unique challenges and growth experiences. Most floor nurses can think of at least one patient whose family members overwhelmed them with constant questions and interference. Yet the floor nurse can always rely on the constraints of visiting hours, and at the end of the day, the hospital is the nurse’s turf. Whereas in home health nursing, the nurse is always cognizant that they are a visitor in someone’s home and thus at the mercy of the patient’s family and friends.
This different workplace dynamic often causes a nurse to alter her/his behavior so they fit more easily into the family dynamics. However, this is not always a practical solution and families can sometimes develop interesting quirks and pet peeves. One such example that comes to mind is about a home health nurse being asked by the family to bring her own water to drink, since they disliked it when she used their tap water.
However, sometimes the home health nurse can suffer from lack of direct supervision and this, in turn, can lead to the development of bad behavior or worsen a weakness that is already ingrained in the nurse. Not that long ago, I had the opportunity to speak with a diverse group of home health nurse managers. Towards the end of the group discussion, two members of the group came up to speak with me and we discussed their specialty: wound care. They shared their frustration that the nursing teams they supervised always complained that the agency or hospital were shorting them on their wound care supplies. These nurse managers suspected that this might not always be the case and that the nurses might not be following the care plan and the physician-prescribed dressing changes. The nurse managers wondered if this was indeed the case or were the nurses cutting corners?
Of course, this could easily be a case of laziness, but it could also be a case of a healthcare agency cutting costs. Most nurses can probably share stories of having to hunt and fight for equipment and supplies, so it’s not such a jump of logic to think that this could also happen in the world of home health nursing. Of course, the nurse could also be bad at organizing his/herself in a timely manner, thus leaving them poorly prepared and short on necessary supplies. Some nurses may prefer to blame the agency rather than take responsibility for their failure to adequately plan and forecast needs. However, this problem is shared by both the hospital-based and home health-based nurse—I don’t believe that either is the only one in this boat.
Home Nursing vs. On the Floor
Home health nursing has many facets. Working six, eight or 12-hour shifts is not the only assignment a home health nurse can look forward to. Many think of the home health nurse visit as a more typical assignment, which may entail a nurse spending several hours with the patient to administer meds, doing dressing changes, or other nursing related duties. This type of assignment means that the nurse will interact with several patients throughout the day, much like hospital-based nursing, except spread out over a larger territory.
In the end, I learned that though home health nursing was challenging, I prefer the hustle and bustle of hospital-based nursing. Although I suspect that, as healthcare technology continues to develop and become more widespread, home health nursing might just evolve into a well-defined and supported nursing specialty, which to date it is not since it is somewhat still in its infancy. Due to its non-hospital based nature, home health nursing may finally take full advantage of the telemedicine and health informatics tools that are already available, and pave the way for more extensive use of these tools.
Currently, many home health agencies still rely in great part on paper records and manual entry methods. However, as Smart Phones and PDAs are adopted by the everyday Joe, I think we’ll find nurses demanding the development of more nursing tools that can be transferred to their PDAs and Smart Phones, with simpler, quicker transfer of data back to their agency’s computer. Many tools already exist to support the nurse that chooses to use PDAs in their job and a slew of companies offer downloadable software from their websites. Many of these programs are offered in both platform types Palm OS and Pocket PC, with prices ranging from the very inexpensive to several hundred dollars and up. If you are using a PDA to support and track patient care, make sure you also practice good safety and security protocols to protect your patient’s privacy and medical information.
As medical care continues to evolve, I think we’ll find an increasing reliance on the home health environment. Since many studies support its added benefits, this nursing specialty will continue to grow. Just as nurses will play a pivotal role in defining home health care, they will also be instrumental in defining how the public and our fellow nurses view this specialty—will this be a respectable specialty or a “step-child” of our profession? In the end, it will be up to the home health nurse to decide this course as they carry out their nursing duties and responsibilities. Even when no one seems to be watching, it will be your actions that serve as the tool by which everyone will judge the home health nurse.
Geneviève M. Clavreul RN, PhD, is a healthcare management consultant who has experience as a director of nursing and as a teacher of nursing management.