Real Nursing

[KateRN1]

I was having a discussion with another manager today and it dawned on me that a lot of home health care nurses don't think of what they're doing as "real nursing." They behave in ways that are far less professional and act outside of their scope of practice in home care in ways that they would never consider in an inpatient work environment.

A couple of examples: A nurse who doesn't measure wounds or document the appearance of the wounds because she didn't realize that it needed to be done. A nurse who sees the patient for a PT/INR and realizes that it's a day early, so she waits until the following day to tell the clinical manager. A nurse who wants the clinical manager to call the physician's office to report an abnormal assessment. A nurse who arbitrarily tells a patient to hold or double blood pressure medication without calling the doc or the office--and then doesn't document it but mentions it in passing to the manager.

In what hospital or inpatient facility would a nurse make independent decisions on administering medications or performing lab tests or ask another nurse to call an abnormal assessment or not document wounds? Why then do they think that this is appropriate for a professional nurse in home care? Just because we are caring for patients in their homes, it doesn't mean that we should behave any less professionally or not follow standard nursing practices.

Is this a peculiarity to our area or do you see this elsewhere?

[emilysmom,RN]

No sometimes I think I am writing too much. I write just about everything that happened. My manager has not said anything but I am trying to just write the facts and not elaborate. I sometimes second guess myself weather or not if I should have called a BP in or not. Sometimes I call a change in wt and the nurse at the MD offices says and meaning why else am I calling. But I document everytime I call a MD. We measure and document weekly wounds. No way would I tell a pt to hold or take a med without checking. I even check on OTC like Immonium before I tell them to take it. Maybe that is why it is 10pm and I am still charting. LOL

[KateRN1]

And I got to stewing over this little tidbit, too--I see so many nurses who accept a position as DON with no home care experience. I see it in real life, I see nurses come to this forum who clearly have no concept of home care or the rules and regulations that can come back to bite them in the orifice. Why do they accept a position as a director of a specialty area when they have no experience in that specialty? Would they accept a DON position in a surgical ICU without any surgical experience--or worse yet, a year out of school? And who are these owners who offer it to them? My best guess is that they want someone who doesn't know the rules and will do whatever they're told; or maybe they don't want to pay the salary that an experience home care leader would require. And then the DON gets blamed when the company doesn't do well and the reality is that s/he should never have been there to begin with. I think I'm getting fed up with home care again. Maybe I need a sabbatical.

[AMN74]

KateRN1, I agree with you. Often times at the home care agency that I work for, we have very educated managers with lots of letters behind their names but they have NO clue what it is like to be out in the field. They have spent years educating themselves with book smarts, but never been a real home care nurse. They can spew out CMS guidelines, but they don't know how to apply them to real life situations. They can't understand why I can not see 9 patients per day after having a morning meeting from 8:30-10 AM, and the patients I see are 40 miles away from the office. They have complicated our charting requirements so bad that passing a CMS audit is going to be difficult. Yes, we have requirements to photo document wounds q 14 days, with measurements at least weekly. That goes on the wound addendum form, Or if the patient has an IV there is a special addendum with multiple places to check off and document specifically what you did and if the patient verbalized understanding you have to write that in, if they need more education you have to state why..Then we have to check mark each box in the guidelines (our nursing care plans) to say specifically what you did for that guideline and if patient verbalizes understanding. Just checking the goal as met does not mean that the patient verbalized understanding. And when the patient is on multiple guidelines, copd/pneumonia/pain/Safety-fall risk/and probably diabetes too, it is more than 50 little boxes I am supposed to check and document in, then comes the meds with each med you have to document what you taught, if the patient verbalized understanding, and I seldom see a home health patient with less than 15 meds... That's all before you get to the actual visit note to spend more time documenting on each system/function etc. If there is an oasis that accompanies that visit...orders to be added...doctors or other disciplines to be called...watch out they all go in other boxes/forms with the added required documentation. And while these managers are very educated, business savy employees, they don't have a clue as to what I do. I have been in home care for 18 years and I am beginning to send out resumes and look for something else. This job has become too much. Since the summer they have really beaten me down with the demands and cutbacks, now suddenly all these boxes and forms have to be checked and documented in in 5 visits or less. Oh I didn't even mention all the extra hoops that have to be jumped through for managed care patients and begging for visits to have enough time to teach so they are safe to live at home, and the extra documentation that accompanies managing the managed care patient. I have always been a nurse that did a very thorough job documenting, trying to paint a picture for each visit, and making sure my patients understand, I'm a home health nurse because I want to make a difference in people's lives and I want to help them understand their disease and how to manage it.. but it's not possible anymore to accomplish these goals given the demands. The required documentation is rediculous.

I'm hearing from you that you have managers that have never done home health... Yeah, me too, they have lots of education, ie, RN, BSN, MA. That may mean you have enough letters behind your name to be business savy, but if you don't actually know what your staff is doing, or how to do the actual job yourself... it's easy to sit behind a cubicle desk and make up all these rediculous rules and mandate that staff follow them. I used to be able to see 8-10 patients per day, and get all my charting done, now the required 6 patients per day for full time productivity takes 10-12 hours per day to accomplish.

And lastly (trying to end my rant) we have scores of meetings about how to improve HHCHAPs scores. They say you need to put your laptop down and really listen to the patient, make them feel as if they are the only thing that matters on your visit. Give them eye contact and interact with them answer all their questions, use these key phrases to make them score you better on surveys....so what? I'm to do a thorough visit, not pick up my laptop and begin checking and documenting in the 50+ boxes that are in the guidelines, and not document about meds while I talk about them....but finish my documentation before 9am the next morning and make it accurate? OH man it's becoming toooooooooo MUUUUUCCCHHHH! I admit I am burnt out, and I know I need to find a new job.

[RN1263]

AMN74,

If I didn't know better I'd think we worked at the same company! More and more work is added to a visit that same visit 2 yrs ago would have taken "x" amount of time and now it takes that amount and a half, but that doesn't get added into the productivity.

Now that lap tops are in the field (with cameras to boot) the field nurse is expected to due more and more of "office" work that use to be done by office staff or was just easier on paper. Example- Now we have to order patients supplies online in the home...but first we have to get "on-line" which could take 10 minutes just doing that, then log in to supply link, put in patients ID #, then figure out the dollar amount they have left or get pre-approval from administrator, ect, ect....And that's just ONE example.

Also, one minute I'm told to do the Oasis in the home to increase productivity, then the next minute they want the patient to feel like the most important thing even if no computer charting gets done in the home trying to increase patient satisfaction scores- talk about mixed signals! I call them on it every time also and they try to side step what they just said, then talk in circles, cuz they know it's different from what they said the week prior.

Home care has changed in the 4 1/2 yrs I've been in this field....and it's not for the better. I use to think home care was the best kept secret in nursing....not anymore. Now it's the best way to have a nervous breakdown!

[AMN74]

I know the feeling RN1263, I am really burnt out and I am actively searching out new jobs. I've been with the same company for 14 years and I find I am being paid LESS to do more. I just can't take all the mandated documentation, and if you don't get it right someone in qa/qi or an outcomes manager is on your tail to get it fixed pronto, so that's more after hours work trying to clean up what you didn't get right in the first time. I just don't get the unrealistic expectations of the field staff. I told my manager that I wanted her to come out with me and do my job for just ONE day and let her see how it feels, she said that they were short staffed in the office and that there was no way she could leave her desk to come out in the field for a day. I have been refusing every extra patient thrown at me after productivity, I used to always be a team player and help out... I don't have the time to do it anymore.....I see the writing on the wall for me...after 20 years of home care experience it's time for me to go find a new job. And I'm looking high and low....something will pop up that will allow me to utilize my 25 years of nursing experience and have a better life....after the big cutbacks and managed care changes that happened at my company everything went to HECK for the field staff. I will soon be bowing out and looking forward to someplace new and something new. I love nursing, I actually love doing the patient care and education, but I am hating what they have made impossible to do at my job. Stick a fork in me....I think I'm done...no, I'm char burnt at this point....

[jmn126]

We encounter allmthe same things you mentioned here. It is extremely frustrating and when it is brought to the nurses' attention they of course dont like it, and then more crap starts... Everyday i try and every day i feel beat up. Been doing HH for 25 yrs so i know the ropes and can not stand these lazy orifice nurses

I was having a discussion with another manager today and it dawned on me that a lot of home health care nurses don't think of what they're doing as "real nursing." They behave in ways that are far less professional and act outside of their scope of practice in home care in ways that they would never consider in an inpatient work environment.A couple of examples: A nurse who doesn't measure wounds or document the appearance of the wounds because she didn't realize that it needed to be done. A nurse who sees the patient for a PT/INR and realizes that it's a day early, so she waits until the following day to tell the clinical manager. A nurse who wants the clinical manager to call the physician's office to report an abnormal assessment. A nurse who arbitrarily tells a patient to hold or double blood pressure medication without calling the doc or the office--and then doesn't document it but mentions it in passing to the manager.In what hospital or inpatient facility would a nurse make independent decisions on administering medications or performing lab tests or ask another nurse to call an abnormal assessment or not document wounds? Why then do they think that this is appropriate for a professional nurse in home care? Just because we are caring for patients in their homes, it doesn't mean that we should behave any less professionally or not follow standard nursing practices.Is this a peculiarity to our area or do you see this elsewhere?

[pinkfluffybunny]

I think that CM are put in a tough position also. They are nurses but also managing a business. So they have a lot of people to answer to. I imagine that it is a hatd place to be trying to balance all aspects of managing pt care and making money. That combined with finding competent nurses. HH is filled with a lot of nut jobs. Family and nurses, I am not one yet but, some days I feel like its coming.

[paddler]

I have often thought of HH as "Real World Nursing". Basically because the environment is not controlled by the nurse or a facility, and the nurse must teach and implement care in... the real world, simply put.

[Isabelle49]

I have often thought of HH as "Real World Nursing". Basically because the environment is not controlled by the nurse or a facility, and the nurse must teach and implement care in... the real world, simply put.

Some do that and some don't and there's the number that claim to see their patients but don't!