1. Curry Narayan, Mary MSN, RN, HHCNS-BC

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Home healthcare nurse colleagues, I believe that over the past 15 years or so, we have been witnessing the demoralization and demise of professional home health nursing practice. This is a shocking statement, but before dismissing it, consider: In 2000, home healthcare nurses had a vibrant professional nursing organization, and an American Nurse Credentialing Center-supported certification. Now, we have neither of these.


A professional association and certification are "pillars of professional practice." The loss of these pillars has an adverse effect on home healthcare nurses and their patients. Patients are deprived of the kind of passionate commitment to excellence that a nursing specialty's association and certification inspire its nurses to achieve. Think of the Infusion Nurses Society or the Wound Ostomy Continence Nurses Society and their certification processes-and the difference they are making in enhancing the standard of care for their patients.


I can tell you the reason we lost these pillars of professional practice as I was personally involved in both of these endeavors when the bad news came that they were being terminated. Basically, it was a lack of interest: not enough nurses were seeking or maintaining their membership in the Home Healthcare Nurses Association (HHNA) to support an independent professional organization, and not enough nurses were seeking certification from the ANCC as Home Healthcare Nurses to maintain a psychometrically valid exam or financial viability. The HHNA is now an affiliate of the National Association for Home Care, where there is limited, if any, opportunity for interested nurses to have a voice in the direction of the association.


Why have home healthcare nurses not been interested in, and why do they not support, the very endeavors that were trying to support them? I suspect that, as a nursing specialty, home healthcare nurses have felt particularly powerless in the face of the economic and regulatory pressures that have buffeted their practices and their lives. Medicare and other payers of home healthcare services have demanded more care at less cost and economic realities do require belt-tightening. However, these pressures are squeezing home healthcare agencies and their nurses, leaving the nurses feeling burdened, battered, and bruised. Feeling demoralized and powerless, we, as a group, have succumbed to "helpless behaviors," losing interest in the structures that could have supported us in enhancing our professional practice. Let me provide some evidence for my suspicions.


* As Medicare increased its regulatory oversight, and ever-more drastic measures were instituted to decrease costs, nurses had little, if any, opportunity to provide input into those policies.


* Agencies gave visiting nurses limited opportunities for a voice, let alone an opportunity for shared governance, when changing processes to meet the tightening economic realities.


* Agencies report that the measures they have taken to address economic pressures are demanding more work from their nurses with less compensation and benefits (Jarrin et al., 2014).


* The widely adopted pay-per-visit payment structure, which rewards quantity of care versus quality of care, demoralizes nurses motivated by excellence.


* Although advanced education and certification result in better patient outcomes (Aiken et al., 2003), in general, due to economic pressures, home healthcare agencies do not incentivize or support them.


* Agency finances for nursing conferences and educational resources have dried up. And nurses who are getting paid less, and working longer hours to make their ends meet, are no longer willing or able to put their own money down for nursing conferences, association membership, certification applications, and journal subscriptions.



I am making a plea to my home healthcare nurse colleagues. Our specialty grew out of one of the most noble, innovative, altruistic endeavors in nursing history. Lillian Wald, and the Visiting Nurses Associations that emerged about a century ago, overcame apathy and adversity to meet the needs of community-based patients (Ruel, 2014). From my perspective, we have recently been in a death spiral away from that heritage. Yet, our patients need us to proactively rise up because home healthcare nursing is about to become more important than it has ever been (Institute of Medicine, 2011; Patient Protection and Affordable Care Act, 2010).


For our patients' sakes, home healthcare nurses have an ethical obligation to ascend from the death spiral we have recently experienced and to begin the arduous climb back up the spiral staircase toward excellence, despite its twists and turns, to enhance the professionalism of our practice. Somehow we need to recreate the structures needed to have a strong voice and a way to enhance excellence in home healthcare nursing knowledge and practice. We need to proactively address our professional concerns and our patients' needs, instead of merely reactively complying to CMS, payer, and agency concerns and pressures, even as we help them address the social and economic realities they face.


Although I have presented a rather depressing picture of home healthcare nursing, in truth, not all is gloom and doom, and perhaps we are already well on our way up that arduous spiral staircase to professional excellence. Two very encouraging home healthcare initiatives have recently surfaced. First is that the most recent edition of the Scope and Standards of Home Health Nursing Practice (ANA, 2014) was recently revised and republished, through the efforts of a Marilyn Harris, MSN, RN, NEA-BC, FAAN, and other home healthcare nursing advocates. This document offers a vision and pathway toward home healthcare nursing excellence. A second promising initiative is the formation of the International Home Care Nurses Organization ( through the efforts of Tina Marrelli, MS, RN, FAAN, and another group of dedicated nurses. The IHCNO is a relatively new, "loose" organization, really a network of nurses interested in advancing home healthcare nursing practice. They will be holding their 3rd Annual Conference this year July 8 through 10 in Chicago (


I am a great believer in "the power of a small group of committed citizens to change the world," or at least in the power of a group of highly committed nurses to enhance their specialty area of practice. If we put our minds together, if we think creatively and innovatively, we can recreate a vibrant and home healthcare nursing voice that advocates for, encourages, and inspires excellence in home healthcare nursing.




Aiken L. H., Clarke S. P., Cheung R. B., Sloane D. M., Silber J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290(12), 1617-1623. [Context Link]


Home Health Nursing: Scope and Standards of Practice 2nd edition. (2014). American Nurse Association: Silver Springs MD>. [Context Link]


Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press. [Context Link]


Jarrin O., Flynn L., Lake E. T., Aiken L. H. (2014). Home health agency work environments and hospitalizations. Med Care, 52(10), 877-883. [Context Link]


Patient Protection and Affordable Care Act. (2010). 42 U.S.C. [S] 18001. [Context Link]


Ruel S. R. (2014). Lillian Wald: A pioneer of home healthcare in the United States. Home Healthc Nurse, 32(10), 597-600. [Context Link]