Recently I made the decision to leave the hospital and try my hand at home care (in my case, home hospice), so I was eager to read ICU nurse Tilda Shalof's new book Bringing It Home: A Nurse Discovers Health Care Beyond the Hospital (McClelland and Stewart, 2014). I was hooked by the subtitle, because it spoke to my own ignorance about the great clinical work that occurs in nonhospital settings in Shalof's native Canada, the United States, and elsewhere. Home care nurses reading this may be rolling their eyes, but there is indeed a health care world outside acute care, and Shalof's book is a great guide through that world.
Shalof undertook her journey in 2012 at the invitation of Judith Shamian, then president of Canada's oldest home care service, the Victorian Order of Nurses (VON). She traveled all over Canada, shadowing VON nurses working in home care, hospices, adult day care centers, even street medicine programs, and writing about her experiences. Since these stories focus on patients and the care they need, rather than on specific health care policies or structures, it's likely they'll resonate with nurses anywhere.
Jackie, a nurse Shalof has to "listen fast" to because of her "lightning bolt mind," offers three essential precepts for understanding home care. "Here's the first thing you need to know," she says. "Home can be a mansion or a log cabin, a teepee, a yurt, under a bridge, or over a sewer or subway grating[horizontal ellipsis]. Second, everyone needs a home and wants to be at home. People do not want to be in hospitals or institutions. Third thing: nurses can't do it all. Nursing is not only about nurses." These think-outside-the-hospital principles can guide anyone considering a switch from hospital to home care nursing.
Other valuable lessons about the differences between home and hospital care emerge as Shalof makes her way across Canada. Repeatedly she finds that care provided in the home is truly patient centered, because it has to be. As Chelsea, another home care nurse, explains, in the patient's home the patient is in charge, not the nurse, a physician, or the health care system: "You have to always remember, you are a guest in their home. You have to tread lightly."
Using one of those nursing school words that can seem like a theoretical luxury in a hospital, Shalof writes, "Home care nursing feels more beneficent than hospital nursing." She has seen a level of kindness in the nurses providing home care that often seems missing among nurses and physicians working in acute care. And while care given in the home isn't necessarily better, it can be done more deliberately: more time can be taken to establish a human connection with patients.
Much of the lifesaving work done by ICU nurses would be impossible in a patient's home, so some of the hurried unkindness that can characterize intensive care is appropriate to the tasks at hand. But unlike many hospital nurses, the nurses Shalof shadowed seemed to feel they have control over their time. Even with several visits to make, they can stretch time for a patient in particular need, since the insistent pages and alarms of the hospital aren't constantly pulling them away.
Bringing It Home is a long book and worth the full read, but even a partial read will convey what Shalof finds wonderful in home care nursing. I suggest reading the first few chapters to follow her thought processes as she undertakes her exploration, and then skipping around. You'll find nurses giving chemo, helping patients cope with life-altering injuries, and managing central lines in nonhospital settings. Their stories are absorbing, and Shalof is a genial tour guide-keep reading until you find yourself in these pages.
Then again, you might not. Shalof returned to the ICU after finishing her tour. But she took away at least one valuable insight about the relationship between home care and hospital nursing. When her ICU colleagues asked where her loyalties had ended up, she realized that was the wrong question. The answer, she writes, "doesn't have to be this or that, either-or; it can be and." It's an intriguing and potentially revolutionary idea, though an old one: put patients in hospitals only when they really need to be there, and otherwise keep them happy in their homes, with nurses at the ready to care for them.