Gaining experience/knowledge in HH

[sunnysideRN]

I've been doing home health for just over a year and for the most part it's been very satisfying. Prior to this I worked as a nurse supervisor in post-acute rehab for a couple years so the pace of home health was a much needed break. The hours work well for my family ( I have three young kids). The charting is extremely tedious. I try to do as much of it as I can in the home or in my car right after the visit. Oasis assessments I tend to do at night after my kids are in bed. I've become very disciplined in performing the charting the same day as my visit and this helps prevent me from getting buried in it. I have a pretty stable caseload and avoid a lot of missed visits by keeping track of all their appointments in a calendar and using that to shape my day. The driving is really pleasant in my area.

What's bothering me is my own lack of knowledge of the medications, pathophysiology and sometimes inability to draw a lab, trouble shoot an alarming PCA pump, fix a leaky wound vac, know how to treat a stubborn pressure ulcer, access a port a cath and there's no one there to help.... I know these things come with time and being a supervisor in a SNF really didn't provide a rich nursing experience (to say the least!), but still I'm bothered that I'm not able to give more to my patients. The office is able to provide support to an extent. I do call other nurses but at the end of the day, it very much feels all on me.

I had one today who was just readmitted to the hospital after I did her SOC yesterday for side effects from a new medication. In retrospect, it should have been obvious but I missed it. I have one very challenging, hospice appropriate s/p CVA patient who has every diagnosis known to man and his son gets frustrated when I can't give him lengthy explanations to all his numerous questions. He told the MSW that he's unhappy with me because I don't "know enough." I guess he just said what I was already feeling sensitive about.

Typically, when I need to know more on a subject I just pick up a book or research on the web. I'd love to watch some Khan academy lectures on body systems as a refresher (nursing school was a decade ago for me), but there is literally no time. I'm either working, sleeping or caring for kids. I'm exhausted and feel like I have nothing more to give. I told my husband today that I'd like go work for Trader Joe's or sell shoes or anything!

Sorry for the long monologue... I needed somewhere to vent. Especially after the "She doesn't know enough" comment. I guess the most challenging aspect of HH is being a jack of all trades. Much easier to specialize. Support/advice welcome!

[DallasRN]

I greatly empathize with you. I've been a RN longer than most of you have been alive. My primary experience in years gone by was in some high level and complex ICU/trauma units, ER's with a short stint on Med-Surg (those are some hard working people!!). Personally, I think I'm a darned good nurse. However, working in those areas I never had to deal with wound vacs. I'm not well-versed in wound assessments/treatments. Those are things I'm having to learn now and part of what I like about home health - the new challenges.

As for the family member saying you don't know enough. True. You are not a walking encyclopedia of nursing knowledge and good luck to him on finding that person. We nurses tend to try to set ourselves up as "specialists" of sorts when in reality most of us are "generalists" and especially in the HH arena. Jack of all trades, as you said. And you know what, 99.9% of the time that is the perfect thing for HH.

We are in the home for a very short period of time. We can't address and/or undo years of bad habits, bad health. We can only do our best for the 45 minutes a week we are there. And yes, just like in the hospital or SNF, you will occasionally "miss" something in the flurry of activity. Your're fine. Hang in there and know that you will always do your best.

[sunnysideRN]

Thank you for your feedback and perspective. You are absolutely right about setting ourselves up as specialists when we're very much generalists. It'd be impossible to be experts in everything we encounter: wound care, cancer pain, palliative care, nutrition, diabetes educator, cardiology, pharmacology.... That reminds me of another thing I was recently asked in the home. The pts family member asked me to read a copy of their EKG strip. I literally have not done that since nursing school. Maybe it's the demographic I serve because I do feel like I get put on the spot quite often and am expected to be a little doctor. Thank you, thank you for the reminder that we won't be able to fix it all in 45 minutes once a week (or even daily for 9 weeks).

[Daisy4RN]

I concur with the other poster that of course you cannot know everything and should not feel bad about that. You can and should use whatever resources are available and fill in the rest with educational Youtube videos, internet ed etc. Also the wound vac , PCA pump companies etc should provide their own ed materials, maybe you can call them directly if unable to troubleshoot and they can walk you through it, i have done that before. Also, be careful what you are telling pts becuase they do ask many questions and some should be referred to the MD, you can try to call while in the home to have questions answered, i have done that also but it is usually hard to get the MD on the phone. You will pick up tips yourself and figure those things out (troubleshooting etc), it will get easier with time. Sounds like you are doing OK and probably premature to make the jump to TJ's lol. Best wishes!

[caliotter3]

Explore with your agency the possibility of having specialist reps (wound vac supplier) come to your agency to give in services for field nurses. One of my agencies did this with resp therapists or DME spec who gave vent training to our agency nurses. They focused on the down and dirty and trouble shooting in the home. Most worthwhile on the job training I ever got in healthcare.

[sunnysideRN]

Thanks Daisy4RN!

Sometimes I get suckered into thinking I should have all the answers when they really should be going to their MD's. I like calling the MD in the home, then the patient can see my effort to help them. Even if it's just leaving a message with the medical assistant.

[sunnysideRN]

Thanks Caliotter3!

That's a great idea. I'll ask my supervisor about getting some reps in after our case conference meetings once a month. I was just pondering the fact that we have all these inservices on Oasis and billing but literally nothing on improving patient care.