Home Health Nursing

 

Karen Thompson, RN, BScN, MEd, CCHN(C), Cathy Walker RN MN CCHN(C), and Karen Lorimer RN, MScN, CCHN(C) on behalf of the Community Health Nurses Interest Group

A day in the life

Community Health Nurses Interest Group  A day in the life Jennifer is a home health nurse. She begins her day at her own home by reviewing the assignment that she downloaded from her agency’s website the night before. She organizes the documents, supplies and equipment in her car that she will need for the day. Jennifer drives out for her first client visit, to the farm of Jack who has ulcers on both of his edematous legs.

Jennifer changes the compression bandages on Jack’s legs and explains to Jack and his wife how using compression bandages has been shown by research to result in the fastest healing of his venous ulcers. Before leaving, Jennifer teaches both Jack and his wife about what they can do to help the wounds heal.

Jennifer then heads off to visit the next client, Antonio who is in the last stages of lung cancer.  Jennifer sits down beside Antonio and discusses with him and his wife Maria the plans that Antonio has made for the last month of his life. Jennifer reviews the ways in which the team of home care service providers will support the couple and answers Antonio’s questions about pain management.  Once in the car, Jennifer writes a report to the Case Manager updating him on Antonio’s condition and recommends another 20 visits for Antonio be authorized over the coming month.

The next client is Emily. She is a 4 year old girl with cerebral palsy who lives with her parents in a small village, and has developed a wound infection. Because the infection is caused by resistant bacteria, Jennifer dons a gown and gloves to care for Emily’s wound. Jennifer sees the wound is now progressing and needs a different wound care product so she goes to her car trunk and retrieves a more appropriate dressing. She updates the care plan to reflect this change.  Emily is receiving IV therapy so Jennifer also replaces the solution container on Emily’s IV pump with another 24 hours worth of antibiotics and reprograms the pump. She carefully assesses the central line site and reviews with Emily’s parents the signs and symptoms that would indicate the central line has become infected and would require a call to the nurse.

As Jennifer is on her way to the next client she gets an email on her BlackBerry from the office stating that a home support worker has reported that another client, Rashad is very short of breath and feeling unwell. Jennifer makes a detour to his house, assesses his worsening heart failure, discusses his condition with the physician over the phone, and then negotiates with Rashad and his family about when and how he will get to the local hospital. Jennifer compliments the home support worker on identifying Rashad's need for medical attention. Jennifer reschedules her lunch break and hurries off to see 3 other clients.  

After admitting Margaret, a new client for anticoagulant therapy and beginning teaching her daughter how to administer the injection, Jennifer sees several more clients. Jennifer then stops in at the office and completes reports to both the Case Manager and physicians. Finally, knowing that the clients have been seen and the paperwork is done, Jennifer reflects on her job as a home health nurse and feels good about the difference she has made for her clients on this day.

Background 

Prior to World War I the majority of nursing in the home was provided primarily by private duty nurses who were hired by affluent families. After the war, interest in health grew, and visiting nurses began to care for clients in homes, schools and workplaces. In the early years of community health nursing, public health and home health nursing were closely intertwined. The Victorian Order of Nurses (VON), established in 1897, initially focused on public health, TB and maternity care. It was in the 1930s that the VON began focusing on home nursing care of the sick. The last 20 years has seen nursing care traditionally provided in hospitals shift to the community. Home health care nurses now deliver a broad variety of interventions in the home such as IV therapy, chemotherapy, advanced wound management, palliative care and ventilator care.  With the teaching and support of home health nurses, clients and families are successfully managing increasingly complex conditions in the home. An important source of change in home care has been the development of technology solutions; home health nurses now rely on advanced technologies to communicate with other health professionals (e.g. smart phones), to access knowledge databases such as electronic information on evidence based care, and to deliver care to clients (e.g. ambulatory infusion pumps)
Specialty EducationHome health nursing is a specialized area of nursing practice in which a nurse provides care in the client’s home, school, or workplace. A baccalaureate degree in nursing with two years of experience is preferred for nurses wishing to enter this field or nurses with a diploma and several years of experience also thrive in this working environment.

CNA certification in Community Health Nursing is a voluntary recognized credential for registered nurses who meet specific nursing practice criteria,   continuous learning and exam-based testing requirements. The credential, which must be renewed every five years, confirms that a RN has demonstrated competence in a nursing specialty/area of nursing practice by having met predetermined standards.

Scope of Practice

Clients, their designated caregivers and their families are the focus of home health nursing practice, and home health nurses integrate health promotion, teaching and counselling within their clinical practice. Home health nurses require proficiency in traditional clinical practice ompetencies with an emphasis on systematic interviewing, in-depth holistic assessment skills, and the ability to judge the appropriateness of options, priorities and resources and to provide client-relevant teaching. The Canadian Community Health Nursing Standards of Practice form the ‘core expectations’ for community health nursing practice. There are five standards of practice –

 

• promoting health,
• building individual/community capacity,
• building relationships, 
• facilitating access and equity, and 
• demonstrating professional responsibility and accountability. 

 

The Home Health Nursing Competencies were developed in 2010 and are the integrated knowledge, skills, judgment and attributes required of a nurse working in home health to practice safely and ethically.

Practice Environment

Home health nurses practice in a highly independent and autonomous manner, managing the care of clients with a broad array of diagnoses across the lifespan and the health-illness continuum. The practice environment is as diverse as our clients’ places of residence, work, and school. Using their car as their office, the places where home health nurses practice include large urban areas, the inner city, smaller towns and villages, rural and isolated communities. In some regions, nursing clinics have become popular allowing clients the convenience of an appointment time, while freeing nurses from traveling so that this time can be spent seeing more clients during a work day. In Ontario, members of the public may access home health nursing care by contacting their local Community Care Access Centre (CCAC), by referring themselves directly to a health service agency, or by having their physician or other health care provider make a referral to the health service agency or CCAC.

Clinical Laddering

The skills acquired while working as a home health nurse are invaluable. There are many opportunities to grow and develop in the full spectrum of acute, palliative, and chronic care competencies. Home Health Nurses can develop their leadership skills and be successful as a clinical nurse specialist / leader / educator, supervisor, or manager. In addition to certification in Community Health Nursing, there are also opportunities to specialize in other areas such as health and wellness, wound care, mental health, pediatrics and palliative care.

Liability Protection

As a result of Bill 179, nurses will soon be required to be personally insured against professional liability. By virtue of membership with RNAO, members are automatically eligible for protection through Canadian Nurses’ Protective Society (CNPS).

Current Status

With hospital restructuring and bourgeoning budgets, there has been an increased focus on home care emerging as an essential element of the health care system to provide more efficient and effective care. The majority of clients prefer to receive care in their home. Home care clients have become increasingly complex, and nurses require well-developed critical thinking skills, as well as a broad spectrum of clinical skills. 

There is a movement towards focusing on specialization in working with certain home care populations in order to improve client outcomes. The thought is that certain populations require a specific skill set in order to ensure quality care. The Integrated Client Care Project in Ontario is focussing on these populations beginning with wound and end of life care. This project has the potential of impacting home care delivery and the role of the home health nurse.

Links

Community Health Nurses Initiatives Group (RNAO) http://www.chnig.org 
Community Health Nurses Association of Canada http://www.chnc.ca 
Canadian Home Care Association http://www.cdnhomecare.ca 
Community Care Access Centre http://www.ccac-ont.ca

References

1. Victorian Order of Nurses. (2010). History – A Century of Caring. VON: Ottawa, ON. Retrieved from: 
http://www.von.ca/en/about/history.aspx 

2. Community Health Nurses Association of Canada. (2008). Canadian Community Health Nursing Standards of Practice. Toronto, ON: Author. Retrieved from: 
http://www.chnc.ca/documents/chn_standards_of_practice_mar08_english.pdf

3. Canadian Nursing Association. (2010). Home Health Nursing Competencies. Ottawa, ON: Author. Retrieved from: 
http://www.cna-aiic.ca/CNA/nursing/certification/default_e.aspx 

4. Stanhope, M. et al. (2008). Community Health Nursing in Canada. Toronto: Mosby Elsevier.