Article Content

The Growth of a Professional Nursing Specialty

As one of the alumnae of editors for Home Healthcare Nurse celebrating the profession I have known and loved since the 1970s, this column has been an interesting walk down memory lane. And a dusty one!!


We began with Medicare in 1965. In the early days our journal was published by Hospital Publications Incorporated. No surprise, since the public recognized hospitals as the key providers of medical care and nursing services. Basically, the nursing service was thought of as an extension of the medical service, meant to shorten the more expensive cost of a hospital stay. Thus, the definition and intent was spelled out by calling us a "skilled service." That artifact began the ongoing discussion of what was skilled (needed by persons being discharged before their medical condition was stabilized) and what was "chronic" service (those services that everyone needs at home, to remain there-ie, grocery shopping, meal preparations; driving to a medical practitioner for follow up on disease or operative status; assistance with bathing; and other personal health, home, and hygiene needs).


What followed has been a marathon of regulations and debates to limit the cost of reimbursable "skilled" service through such artificial means as establishing the "100 annual skilled visit" rule and the meaning of "homebound," ending in the continuing debate between how to describe "short-term intermittent services" and "comprehensive in-home service," which enabled people to remain in their homes over a long period of time. Since nursing care is the dominant component of service needed in home care, the profession was caught up on the middle of all this turmoil; experiencing, creating, describing, and birthing a growing home healthcare nursing profession and industry.


Birth of an Industry

As the specialty of home healthcare was developing, a professional debate sprang up among "public health nurses," "visiting nurses," "proprietary home healthcare agency nurses," and "community health" organizations about who this home healthcare nurse was. Questions were raised about what educational and clinical criteria should be expected in this "nurse"; what personal and clinical skills are expected and how can the skills and knowledge base of nurses working in all venues of community services be incorporated into this practice field.


I can remember one great midnight debate among public health, home health, and visiting nurses who were trying to write a resolution at an American Public Health Association convention being held in Annapolis, about how to name this emerging breed of nurse. We finally compromised, at an early morning hour, by naming this nursing role a community healthcare nurse. As you know, that term didn't really take root; however, I still slip into that language sometimes lately, as I see more and more being asked of nurses who work in clients' homes and communities!!


Suddenly the country and the profession were faced with the need to increase the numbers of nurses who were


* Able to meet Medicare requirements for interpreting and providing "skilled" nursing and medical services


* Knowledgeable-able to apply professional nursing techniques, observations, education and interpretive skills, while in the home setting; and teach many of these to the client or family member


* Adept at interviewing and educating clients and their families or caregivers about self-care, reinforcing habits of living that promote wellness and/or how to recognize and handle illness


* Aware of community resources that care for long-term needs of persons once "skilled" services were no longer necessary or considered reimbursable by the Medicare gatekeepers


* Culturally competent and able to understand and interpret healthcare concepts to a fast-growing, multiethnic society


* Lifetime learners, able to apply concepts of Quality Control and assurance and the use of clinical record guidelines such as the "Problem Oriented Record System" while documenting a 487/487 to the satisfaction of auditors; not to mention today's telemetric systems!!



Consumer/Client Satisfaction

To this day, the public does not quite understand the differences between Medicare coverage for home healthcare and "long-term care." And although the greater numbers of the "Boomer" population seem to be getting it, there are great numbers of seniors who still believe that Medicare will cover their long-term care at home or in a "skilled nursing facility!!" Thus, we see more and more of the debate about a universal healthcare system, what it will include, and how the public-private partnership in healthcare will pay for it.


During those 10 years as editor of Home Healthcare Nurse, we faced the need to remedy the absence of a complete Healthcare Insurance benefit. We aimed at the provision of eminently readable, seemingly clinically simplistic articles, giving case examples and information that practicing home healthcare nurses could use to augment their caregiving. Our efforts were aimed at augmenting the continuing need for education of the public, by the nurse, about resources that could be helpful, and to fill in the service vacuum often caused by federal interpretations of reimbursable care. We also attempted to provide a review of new and/or changed regulations that would make it necessary to modify nursing practice programs and to better understand the benefits and drawbacks of the Medicare health insurance program.


It was so gratifying to receive nursing "war" stories, along with original poetry that was so beautiful and inspiring. The one I remember vividly came from a home healthcare nurse in Alabama whose diabetic client would not allow the nurse in the house to change dressings for leg ulcers. Instead, he agreed to let her perform the dressing by placing his wounded leg out the side window of the house. To me, this nurse was a brave example of the skill, talent, and spirit of the home heathcare nurse. Is it any wonder that a nationwide survey conducted by Peter D. Hart Research Associates, Inc. (1990) found that:


* 77% of the public says nurses play a constructive role in the healthcare system


* 95% of the public is impressed with nurses and sees them as very competent and caring practitioners


* 67% believe that an RN has either a 3-year diploma or a bachelor's degree


* 67% strongly favor more treatment at home instead of in the hospital or at a nursing home


* The public resoundingly approves (77% to 10%) the trend toward more use of RNs to provide basic healthcare services.



Memory Lane!!

This trip down "memory lane" has been quite fun, and I wish all readers the same one day. It's an amazing profession we're involved in, and the world has so much need for the skill and kindness we bring to it.


I leave you with a vignette from a nurse author, humorist, and realist:


"I grew up in the city-where directions were given in turns, left or right, distance in number of City blocks, and location by street name. When I moved to the country, I went to work for a rural Home Health Agency and found great difficulty in becoming accustomed to a quite different method of directions. Now the turns were North, South, East, or West; the distance was in tenths of a mile; and the streets became roads whose only names were-Paved, Blacktop, Gravel and Dirt!!" - -Marion Jakel Wilson




Peter D. Hart Research Associates, Inc. (1990). A nationwide survey of attitudes towards health care and nurses. Washington, DC. [Context Link]