1. Barkley, Peggy Sue BSN, RN-BC, COS-C, HCS-D

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For the past 26 years, my heart has been in home healthcare nursing in rural southern Michigan. Home care nursing is holistic nursing at its best, where we can be caring, patient advocates. There are significant advantages to caring for patients and their families in their homes. The home setting is intimate, a more natural place where cultural beliefs and practices are visible. The nursing process is applied, but some of the processes are a little different or broader. For example, you not only assess the patient, but you assess their living environment.


At 8 a.m., my workday starts with gathering supplies and getting my computer ready for the day. Usually my schedule is set, but there are often changes in my day as it unfolds. Flexibility is a key factor. Every day, I get into my car thinking my day is laid out and my schedule is "good to go," but it never goes that way. You need a good sense of humor, an open mind, and the ability to be flexible to be a home healthcare nurse. While I am driving, I may be thinking of how I am going to jury rig an IV pole out of coat hanger on a curtain rod. Sometimes I use my travel time to the next home visit to clear my mind, and plan for the next visit. My travel distance and time can vary. I may encounter farm equipment, horse-drawn buggies, or less than desirable road condition, which slow my travel down.


There will be routine assessment visits, and a variety of skilled care visits including admissions and discharges on my schedule. When patients arrive home from the hospital, they have a lot of paperwork, bottles of pills, and instructions. Patients today are discharged home with a greater need for high acuity care. Many times I have been welcomed at the door by a frantic caregiver who is trying to figure out "what the doctor wrote" or "which medication bottle is for what." They may have heard what the doctors and nurses said, but for a variety of reasons, it does not always make sense when they get home. Someone needs to follow up, and that is where the home care nurse becomes an important part of the healthcare team.


A large percentage of patients I visit are older. Older patients tend to have vision, hearing, and memory deficits. Many times they will not tell me they cannot see the medication bottle label or did not hear what I said to them. Some patients need to be monitored more closely. For example, a forgetful patient with diabetes or a patient with a questionable caregiver may require more frequent home visits and additional disciplines involved with their care. In these cases, I will obtain a doctor's order to have a medical social worker make a home visit for an assessment of the care situation and needs. Often these problems are detected on the first home visit or two, but sometimes later in their episode of home care. Physical and occupational therapists and home healthcare aides are part of the home healthcare team, and patients may require care from the entire team depending on their care needs. As a home healthcare nurse, I act as a liaison between the housebound patient and their physician. The patient receives medical care in the comfort of their home without numerous follow-up visits to an office or clinic. I am the doctor's "ears and eyes."


Typically, I spend about an hour at a patient's home. Visit time depends on how much patient education needs to be done, if there are treatments to be performed, or if I encounter barriers to care. Barriers to care may be a language barrier, no caregiver in the home, or an unsafe home situation. I spend time to ensure my patient's safety and that the patient knows who and how to call for help if needed. My goal is to be done with my home visits by late in the afternoon, but that does not happen often. Some days I drive 10 miles, or it may be 100 miles in a day. I make sure my car is reliable. I do not want to be stuck in the middle of "no where" or in the worst part of the neighborhood with car problems and not knowing what to do next. You need to have an emergency plan in place for when this happens, because it will happen!


When I finally get my visits done, it can be 3 or 4 p.m. The next task is completing my documentation and synchronizing my computer when I finished. How I have learned to multitask! In home healthcare nursing, time management and organizational skills are critical. If you don't have these skills, you will either be letting work go or be spending time getting it done past your scheduled 8-hour day. I try my best to get up every day with a positive attitude, smiling, and making the best of the day. It is the patients I meet that make it all worthwhile. I have found home healthcare nursing rewarding in so many ways and I welcome nurses to try the home care nursing career path. Although, I will warn you that it is not an easy job. Home healthcare nursing takes time to become comfortable and expert, and it's not for everyone. I like to work independently, spending more time with my patients and setting my own schedule.


Building rapport with my patients results in positive outcomes. I think of myself as a coach, not a dictator. On my first visit to the patient's home, I start this process. For example, I may ask the patient about children, hobbies, or other interest to put them at ease. I may only spend 2 or 3 minutes focused on them, but it can reap benefits and build rapport. I have found that I do not have to like the patient's model of the world, or agree with it, but I do have to at least understand and respect it. I keep my patients "in the loop." For example, I explain the "why" of change or delay in their care. I find my patient outcomes are much more positive when the patient feels involved in their care.


Home healthcare nursing is a fantastic avenue to deliver healthcare, keeping patients healthy and independent as possible in their own homes. In my years of home healthcare nursing experience, home healthcare nurses go beyond meeting the patient's basic needs. Home healthcare is about quality of life where choice is a key component. As a home healthcare nurse, I do not look to drive my patient's decisions, but to provide education and support so they can make informed decisions. Again, I want to say that I thoroughly enjoy home healthcare nursing. I love the rural setting. Every day is different. I do have to admit, sometimes you have to be creative and innovative to get the job accomplished! Home healthcare nursing is holistic nursing at its best. At the end of my day, I have made a difference in someone's life (and my own). Home healthcare is a challenging and rewarding nursing career.