At the age of 74 and with years of experience in home health nursing, this commentary does not reflect my need to reminisce about the good old days. Instead, I am writing to challenge the direction of the future. I question if there is now a widespread failure to recognize the home health nurse as the patient's key to wellness in the community.
An initial home health nurse visit usually includes questions like:
* How are you remembering to take you medications?
* What are you doing for pain relief?
* How are you eating, sleeping, going to the bathroom, coping with it all?
* Can you wash your hair?
* Are you worried about what insurance will pay for?
* What will you do in an emergency, such as when your caregiver gets sick?
* Do you feel safe here?
* Does your doctor know you have decided not to take all your medications?
* How are you going to get out of the house to your next appointment?
* What do you do for fun?
The patient's response may be something like, "I thought you would just change my dressing and that would be all." Thus the relationship takes root and grows with the discovery of specific needs of the patient and family for education, as the home health nurse becomes the friend and teacher. This discovery process can take three to four visits by the same nurse for the relationship to solidify and develop enough trust for the wellness breakthroughs to unfold.
I wonder if we have failed to communicate in plain enough language the scope of caring that a home health nurse brings to a visit. Home health nurses are like an unknown ingredient of individual wellness. This is because they meet the patient on the patient's terms and turf. Maximizing self-care is the cornerstone of home health nursing. Patients do better in their own home with "friendly bacteria," familiar surroundings, and the feeling of being in control.
This home environment is the ideal setting to introduce the patient and family to the differences between illness and health. Helping the patient and family recall how the first thing a physician asks about is the illness is the patient's "chief complaint." The home health nurse seeks out what is primarily on the patient's mind, and finding this out can be seen as an art form. For example, the physician is concerned about the surgery: how the surgical wound is healing, how the medications seem to be working, and how the patient is feeling after surgery. The nurse is concerned about everything else: health behaviors; physical, emotional, and social health; and the healthy relationships of a patient. The nurse assesses the patient and family status related to the Healthy People 2010 Objectives (Sebastian & Martin, 2008). Based on the identified needs or risks the home health nurse can explore resources and coordinate care with other agencies as considered necessary to promote optimal outcomes.
Self-care in a patient with diabetes is always a challenge. One can sometimes find Twinkies, which were kept out of view, or tucked in a chair pillow, as the reason for a patient's uncontrolled blood sugar. Then there are those patients who cannot draw up the insulin as they were taught in the hospital because there is no tray to put things on like they were shown while an inpatient!!
In addition to challenges of teaching patients about self-care are the difficulties for establishing the home medication routine. Patients can become very creative in methods for remembering and taking their medications. Some patients pour all their pills in a dish every morning. Some have their prescription bottles all over the counter but take the six located in front. I have had patients to show me a bag of pills-even a jar of pills-and then try and tell me what they are, what they take, and why. Nurses try everything: calendar markings; use of hardware drawers and washers for markers; prefilled syringes; pill planners, envelopes taped to a calendar, or whatever else the patient thinks might work for them. The key is monitoring what is working and what is not working.
When unusual situations surface, the home health nurse coordinates the changing needs of patients and families and helps them manage the situation. We all have numerous stories about vermin, dirt roads where snow plows do not go, the late Friday afternoon admissions with incomplete discharge plans, and the dependent patient delivered to his home in which there is no caregiver at home.
Home health nurses are very aware of the standards of home nursing practice. The Home Health Nursing Scope and Standards of Practice contain both Standards of Care and Standards of Professional Performance (ANA, 2007). Not only do home health nurses know what they know, but with experience, they can recognize what they do not know. They find the resources needed to fill in the gaps. This is especially true with situations such as pediatric ventilator patients, chronic wound care patients, and geriatric patients with multiple limitations. For instance, when the physician orders catheter care, the nurse identifies the source of the supplies, teaches the person who will carry out the care, and helps the family adjust to their new life and responsibilities.
Patients can get on the right track to wellness with the tutoring offered by home health nurses. Patients trust their nurse to listen to all their concerns and help them. The nurse usually says, just before leaving, "Is there anything else?" When the patient replies, "There is one thing," the nurse puts down her home health nursing bag, sits down, and listens to the heart of the patient.
Because the home health nurse unlocks the door to wellness for the patient and family, we must become proactive to communicate the message to those planning changes in our healthcare delivery system. Home care can be the foundation for that change.
REFERENCES