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My home healthcare career began in 1960 as a staff nurse with the Visiting Nurse Association of Eastern Montgomery County (VNA) in Abington, PA. As a staff nurse, in addition to providing professional care to the patients of all ages, clysis for hydration, enemas, and catheterizations were a frequent nursing responsibility.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

The policy and procedure manual when I started with the VNA was a 5 x 8 typed and copied 69-page manual (Old York Road Public Health Nursing Center, n.d.). Pages 1-62 were clinical policies/procedures and pages 63-69 were personnel policies. One procedure, called "Carminative Enemata," was composed of milk and molasses. Instructions were to heat 4 oz of milk, add 4 oz of molasses ... and cool. Administer the same as oil retention enemata.


NOTE: I always felt like I would rather be making cookies than the task at hand!


The personnel policy titled "Qualifications for Appointment to Staff" stated: "II D. It is recommended that nurse acquire a baccalaureate degree (BSN) approved for public health nursing within eight years. E. Membership in District, State, and American Nurses Association (ANA) and the National League for Nursing are required" (Old York Road Public Health Nursing Center, n.d., p. 63). These two qualifications for appointment to the VNA staff in 1960 were the initiatives to begin my education toward my BSN in 1960 that I completed in 1972 and membership in ANA that has resulted in lifetime membership (over 40 years).


The first printing of an updated VNA "Nursing Procedure Manual" is dated 1963. This manual update was under the auspice of the Montgomery County Committee on Public Health in cooperation with seven local VNAs. The next update of this manual was dated 1977, the same year I became the Executive Director of the VNA of Eastern Montgomery County.


There was a separate Maternal Child Health manual (VNA, 1973). The index included responsibilities for camp, day care, postpartum care, school nursing, and well-baby clinics. I had the opportunity to work in all of these areas. One workday could include home visits to care for adults and children, well-baby clinics in community sites, visit to school, and during summer months daily visits to a local camp in my assigned geographical area.


Maternal Child Health Visits

Another manual included "A Guide to Making Antepartum Visits" (Old York Road Public Health Nursing Center, n.d.). Periodic visits were scheduled to women who were referred from the local hospital's prenatal clinic. One aspect of a visit was to teach the women what to expect during labor and delivery. In 1963, I was given instructions on "How to Make a Knitted "Uterus" for Teaching" (Figure 1). I never knitted that "uterus" until 2011, when I remembered that these instructions were a part of my personal home care history and decided to follow the instructions as I was preparing this article.

Figure 1 - Click to enlarge in new windowFigure 1. Instructions for making knitted uterus from 1963 publication. Reprinted with permission.

Postpartum Visits

New mothers and their infants from the local hospital clinic were referred for follow-up visits. One responsibility was to weigh infants. During my years as a staff nurse I used the scale shown in Figure 2. The infant was placed inside a blanket sling and attached to a portable scale. I am sure these weights were less than accurate when compared with the digital scales home care nurses use in 2012. Another responsibility was to give a baby bath demonstration (Harris, 1997, cover, p. 869, 896) (Figure 3).

Figure 2 - Click to enlarge in new windowFigure 2. Photo of hanging scale.
Figure 3 - Click to enlarge in new windowFigure 3. Photo of the author giving a baby bath demonstration.

Comparisons: Past and Present

1. Per-visit cost and payment for care

Before the enactment of the Medicare benefit, followed by other insurers who paid for home care, the fee per visit ($3.00 in 1960) was paid by the patient. An adjusted fee based on a sliding scale or free service was available when a patient could not pay the stated fee. The adjusted fee was based on family income, the number of family members, and the number of visits per week. I determined the fee based on the sliding scale, collected the fee, and wrote the receipt.


2. Physician's orders and clinical records

Physician orders were needed for skilled care. I contacted the physician, hand-wrote and sent the orders, and kept track of timely renewals. Patient records were kept in a file in my desk drawer by date of visit. If I was not available to make a visit or had too many patients to visit on one day, my supervisor assigned patients to another nurse for that day. This early 1960 procedure was very different from the 2012 process based on regulatory requirements. Documentation was minimal rather than that associated with today's outcome-focused and point-of-care electronic documentation.


3. Generalist versus specialist

In 1960 I was a generalist/community health nurse who provided skilled care and health promotion services to all age groups. Today many home care agencies employ nurses who have certifications in myriad specialty areas to meet the needs of patients.


4. Supplies and equipment

Early in my career there were limited sterilized and disposable supplies. I was responsible for cleaning, wrapping, and sterilizing supplies and equipment such as dressings, catheters, syringes, and needles (including sharpening the needles). There was a small autoclave in the office that was used to sterilize supplies.


There was a sewing group that made small unsterile dressing and under pads (today's incontinence pads) using folded sheets of newspaper and covered with white cotton material. These supplies were stored at a local business where the nurses could pick up the amount needed for patients.


Lessons From the Past

I have my own history of nursing and home healthcare. I also have taken the opportunity to remember and appreciate my roots and the history of home healthcare through visits and books. Visits to Henry Street Settlement ( where Lillian Wald is credited with founding public health nursing (Harris, 2009), the Lower East Side Tenement Museum ( area where Ms. Wald and her colleagues met the health needs of the residents-and the Museum of Nursing History, Inc. (, where evidence of visiting nurse service is preserved (Box 1 and 2) are valuable resources.

Box 1 - Click to enlarge in new windowBox 1. COPY FROM SCOTTISSUE AD IN DECEMBER 4, 1944, LIFE MAGAZINE
Box 2 - Click to enlarge in new windowBox 2. ADDITIONAL RESOURCES

Theodore Roosevelt said: "Do what you can, with what you have, where you are" (Fenchuk, 1998, p. 64). These words summarize my experiences as a community/home healthcare nurse during my early years. I did what I could using my nursing knowledge and skills, with the supplies and equipment that were available, regardless of the circumstances in the homes.


Although I experienced many changes during my career, I believe the care I provided as a staff nurse in the 1960-1970s was quality care. This is confirmed by the letters from patients and families to the VNA that are included in my "memory books." The agency attained Medicare certification and national accreditation. Although my practice may be considered primitive when compared with the ANA's Scope and Standards of Practice: Nursing (2010) and Home Health Nursing: Scope and Standards of Practice (2007) in 2012, my commitment to professional nursing and quality patient care resulted in positive patient outcomes. I achieved personal and professional satisfaction, and the lifetime honor of membership in what I consider a rewarding and respected profession.


What are your experiences with home care over the years? Please write about them and send them to Tina Marrelli, Editor of HHN, at I look forward to reading them!




American Nurses Association. (2007). Home health nursing: Scope and standards of practice. Silver Spring, MD: Author.


American Nurses Association. (2010). Nursing scope and standards of practice. (2nd ed.). Silver Spring, MD: Author.


Fenchuk, G. (1998). Timeless wisdom: A treasure of universal truths. Midlothian, VA: Cake Eaters.


Harris, M. D. (1997). Home care: Before Medicare regulations and now. Home Healthcare Nurse, 15, 896. [Context Link]


Harris, M. D. (2009). Remembering Lillian Wald: Remembering our roots. Home Healthcare Nurse, 27, 67-68. [Context Link]


Life Magazine. (1944, December 4). ScotTissue advertisement.


Maternity Center Association (now Childbirth Connection) (September 1963). How to make a knitted uterus for teaching. BRIEFS.


Old York Road Public Health Nursing Center. (n.d). Policy and procedure manual. Jenkintown, PA: Author.


Old York Road Public Health Nursing Center. (n.d.). A guide to making antepartum visits. Jenkintown, PA: Author.


Visiting Nurse Association of Eastern Montgomery County. (1963). Nursing procedure manual. Abington, PA: Author.


Visiting Nurse Association of Eastern Montgomery County. (1973). Maternal & child health manual. Abington, PA: Author. [Context Link]


Visiting Nurse Association of Eastern Montgomery County. (1977). Nursing procedure manual (2nd ed.). Abington, PA: Author.