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Recently a patient filed a lawsuit against her home health nurse for emotional distress, but the suit might have been avoided if the nurse and patient had collaborated at the beginning of the relationship to define the purpose and goals of the visits.


The patient had quadruple bypass surgery and was discharged from the hospital 6 days later. Soon after, she again was admitted to the hospital with Staphylococcus and Escherichia coli infections. Three weeks later, she was discharged to home with a peripherally inserted central catheter (PICC) to deliver medicine, nutrition, and fluids.


The authorization for home health was limited to providing care only until the patient could show independence with self-care and disease management. On the first visit, the nurse began showing the patient how to clean the PICC tube and care for herself. The patient responded by insisting the provision of care was the nurse's job and that she should not be required to take care of herself. The conflict was established because the patient did not share the nurse's goal for teaching.


The patient understood that once she learned how to care for herself, the nurse would not return. She said if the nurse stopped visiting, she might get her infection back and die. So she refused to learn self-care.


The nurse did her best to encourage the patient to learn to provide at least some care for herself. The patient interpreted the nurse's communication as "overly polite in the way that people who really have no regard for you can be."


The nurse explained to the patient that she could lose her insurance coverage if she did not cooperate. The patient did not take that well. She sued the nurse, her supervisor, and the home health agency for intentional infliction of emotional distress. Her case was so weak, she apparently could not get a lawyer to represent her. The trial judge dismissed the lawsuit. The patient appealed, and the Court of Appeals agreed with the trial court and let the dismissal stand.


Mutually Determine Goals of Patient Education

In this case example, the nurse's goal was to help the patient become independent, and the patient's goal was to be cared for. Until the two goals are aligned, teaching was bound to fail.


Assessment before teaching may feel like an extra step, but it really can save time. The information you gain helps you individualize teaching to the learner, so it is more efficient and effective. If you don't assess first, you may waste valuable teaching time by teaching the wrong thing, teaching the wrong way, or missing an opportunity to develop a collaborative relationship with the learner.


When Frustrated, Return to Assessment

Even if you do an assessment, there is a chance you missed something. How do you know this? You feel frustration. The nurse in this case probably felt frustrated by the patient's unwillingness to learn. She responded by trying to convince the patient it was in her best interest to learn self-care skills by politely encouraging her and then by pointing out her insurance company would not pay for nursing care. The patient did not take this well and sued.


Instead, let frustration be your cue to ask more questions. Why does this patient want to be cared for? What is she really afraid of? Being alone? Getting sick and not able to get help? Or dying? Who are her supports? Does she believe she is not capable of learning how to care for herself? Why isn't this patient motivated to return to independence?


If the patient's main concern was being alone, arranging for friends, family, or clergy to visit may be helpful. If the patient did not believe she could care for herself safely, the nurse should have found out why. How is her vision? Can she read? Does she have memory problems? A better assessment could help identify how best to frame the nursing response.


Gentle teaching and trust development can help the nurse identify why the patient is refusing to learn. Reassure the patient that he or she will not be discharged until therapy is completed. Make sure the patient understands that visits will continue to monitor intravenous or line care, and that the agency or organization is always available for troubleshooting and problem solving. This will help improve the patient's comfort level and create a more collaborative, cooperative relationship between the patient and nurse.


Better team communication also may have helped to avoid this situation. The home care intake and liaison staff should inform referral sources specifically how patients are expected to participate in their care (such as frequency of dressing changes, or administration of IV antibiotics).



The nurse was not wrong to encourage the patient to care for herself or to inform the patient her insurance coverage did not pay for nursing care. The courts agreed it was consistent with the care plan and that an average person would not consider it offensive and dismissed the lawsuit. But the relationship between the patient and nurse was permanently damaged, and the trust the patient has in the healthcare system probably was damaged as well.


The key to efficient and effective patient education is to involve the learner in the process and individualize teaching to the learner's needs at this point in time. Listen to the learner's responses and adjust interventions accordingly. Pay attention to your frustration and recognize it means your actions are meeting with resistance. Use frustration as a cue that you need to reassess and perhaps modify your plan accordingly. It may not be easy, but it is rewarding to turn things around and help patients accept illness and integrate the implications of recovery into their lifestyles.




London, F. (1999). No time to teach? A nurse's guide to patient and family education. Philadelphia: Lippincott Williams & Wilkins.


Nurse's self-care instructions were not 'emotional distress.' (2005). Elder Law Issues, 12 (36). Available at:


Patient education: Nurses are sued for talking down to patient; case dismissed. (2005). Available at:

CMS Announces 2.8% Increase in Medicare Home Health Payment Rates


Centers for Medicare & Medicaid Services (CMS) Administrator Mark B. McClellan, MD, PhD, announced a 2.8% increase in Medicare payment rates to home health agencies for calendar year 2006. The increase will bring an estimated extra $370 million in payments to home health agencies next year.


Medicare pays home health agencies through a prospective payment system, which pays at higher rates to care for those beneficiaries with greater needs. Payment rates are based on relevant data from patient assessments conducted by clinicians as already required for all Medicare-participating home health agencies.