When considering the editorial for this issue of Home Healthcare Nurse, I gave a great deal of thought to two important topics that are represented in this particular volume. The content focus is pediatric home care and the challenges that it presents to clinicians in the field. The second topic to be recognized is that the journal is embarking on its 25th year of publication in January of 2007. I felt that any venture that makes that milestone in this ever-changing world should lead to reflection on the past and a focus on the future.

My nursing career has now spanned three decades and has allowed me ample opportunities in the acute care practice of hospitals, home healthcare, and in the private sector in industry. In every situation, I cannot emphasize enough the respect that nursing has had from every aspect of society that I have encountered. The most appreciation, however, has certainly been from those I met in my home healthcare experiences, including patients, families, and other healthcare providers. The changes in our society during the past 25 years have also affected the home healthcare environment. Talk to any nurse who has spent any time in this specialty practice area, and she can relate stories of what she used to do and how regulations, accreditation, and financial goals have changed practice. What hasn't changed? The patients who need and appreciate the home healthcare nurse who can come into their life and try to make it better or at least more tolerable.

Health care in the 1980s was entering the early stages of managed care, with widespread development of health maintenance organizations, preferred provider organizations, and other healthcare reimbursement strategies to deal with rising health costs. Home health care was skyrocketing as hospitals used this care setting as a strategy to reduce their lengths of stay. More hospital systems merged together to try to strengthen their financial positions. This also was the time when we began to see layoffs or downsizing of healthcare workers, including nurses, as hospitals tried to maintain a budgetary bottom line. In home healthcare, more "high-tech" care was being initiated in the home setting, with increasing numbers of patients receiving intravenous therapies (total parenteral nutrition [TPN], pain control, antibiotics) and even more ventilator care in the home setting. Pediatric patients were also being referred home on some of these high-tech therapies. The challenge for nursing was finding staff with pediatric experience to provide care, teaching, and follow-up. The effect of hospital downsizing did assist home healthcare in some measure in that this is one place where nurses could go to continue using their skills.

In the 1990s, hospital downsizings continued. Home healthcare was still growing, but the high-tech side was not financially rewarding for many companies because of decreased reimbursement. The home healthcare nurse was now in the position where she or he was receiving a patient referral in which little or no teaching was completed in the hospital, and frequently the referral was made on the same day as discharge. The demands to make a safe plan of care fell on home healthcare nurses, requiring them to use the skills that they routinely use: adaptability, flexibility, and compassion.

The new millennium has carried over with the same challenges, with some new ones thrown in for good measure. We have an increasing need to demonstrate profitability, so productivity is measured in all settings. This pushes the home healthcare nurse to use critical thinking skills and adaptability in a very organized fashion. The referral process remains short, and teaching is almost nonexistent in the acute care setting. Gone are the days of having a week to train a home TPN patient before discharge. The regulatory issues increase, but patient safety is the public focus now, and rightfully so. The home healthcare nurse is the one person who can bring some calm to the whole process for the patient and family. No matter what is stirring around the patient in the whirlwind of activity in going home, in the end it is the home healthcare nurse who is welcomed into that home to make it all right.

Albert Schweitzer's words in the Yearbook for the German War Blind in 1957 probably best sum up what a home healthcare nurse best represents to others when he said, "Those who have had to endure what we have been spared have a right to have us treat them with a constant understanding and kindly readiness to help" (Robles, 1993).

When one reflects on the past and what we were in 1982 when Home Healthcare Nurse was first published, we can look back at what was considered popular at the time. "Gandhi," starring Ben Kingsley, received the Academy Award for Best Picture. The television series "Hill Street Blues" won the Emmy Award for drama that year, while "Cheers" won for Best Comedy series. "Rosanna," by Toto, won the Grammy for Best Record of the Year.

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