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Home is where the care is

All through nursing school, Melissa Marrero, MSN, RN-BC, was sure she wanted to work in a hospital ICU until she accompanied a home health nurse in New York’s Chinatown as part of a clinical rotation in community nursing. “I was converted during my senior semester,” said Marrero, manager of college relations for Visiting Nurse Service of New York. “The mystery of what happens to your patients when you send them home­­ — you get to see that.”

Home health is one of the fastest growing industries in the country, according to Bureau of Labor Statistics, and is predicted to add nearly as many jobs as hospitals between 2010 and 2020. Home health workers care for about 4.5 million Medicare and Medicaid patients a year, according to the Centers for Medicare and Medicaid Services. Evidence shows nursing is an integral part of home health. A report from the University of Pennsylvania School of Nursing, published in October, showed home health agencies that provided strong support for their nurses, including adequate staffing, had better outcomes and were better able to keep patients out of the hospital. As healthcare reform rewards organizations for keeping patients out of the hospital and more people insist on care in their homes, demand for high-quality home health nursing will increase, and with it the need to expose more nursing students to home health, said Judy Didion PhD, RN, professor and dean of Lourdes University College of Nursing in Sylvania, Ohio. “We have to educate nurses to take care of patients in all settings,” she said.

Seeing is understanding

Exposing nursing students to home health — whether or not they decide to go into the field — shows them the services available to patients after a hospital discharge, home health nurses and clinical instructors said, and makes them think about obstacles patients might encounter in caring for themselves at home.

Marrero’s student experience inspired her to bypass hospital nursing and apply for a new graduate program at VNSNY, where she worked as a home health nurse. Through the college relations program, she organizes home health experiences for more than 600 students a year from nursing schools nationwide. “Going into a person’s home gives you an amazing perspective of the needs of a patient,” Marrero said. “We want everyone to see home healthcare.”

Most students in her home health rotations know very little about what home health nurses do, said Keli Wludyka, RN, a community health nurse case manager at Oakwood Home Care Services in Allen Park, Mich. They don’t understand the complexity of care home health patients often require, she said. “They don’t know how much teaching and education we actually do in the home.”

Like Marrero, Shawn Quinn, BSN, RN, had no intention of going into home health when he began his clinical rotation with Wludyka last year as a senior nursing student at University of Detroit Mercy. Now an ICU nurse, he doesn’t see himself working in home health anytime soon, though he wouldn’t rule it out for the future. But Quinn was surprised at how much he learned during a semester and how much he enjoyed interacting with the patients he cared for, both under Wludyka’s tutelage and later in the rotation, on his own. Twice a week for about 10 weeks, he visited patients in their homes. He saw people with diabetes, wounds and heart failure. Eventually he visited low-risk patients by himself, answering their questions, assessing what they knew about their care and teaching them to care for themselves.

There were a lot of distractions, he said — often from a television or other family members. But his patients seemed to enjoy telling him their stories and he liked listening to them, especially when they talked about their current health situations. One of his most memorable patients had an amputated leg as a result of diabetes, he said, and the patient told Quinn about walking on both legs just the year before. During Quinn’s rotation, the remaining leg had to be amputated. “It was frustrating and sad,” he said.

As a hospital nurse, he said, when he sees someone with a leg ulcer, he thinks about the consequences if the patient couldn’t take care of the wound properly after discharge. “If I hadn’t had home healthcare, it would be easy to overlook those kinds of things.”

Rotations pose challenges

Not all nurses get a chance to experience home health as students, or their experience may be negative, said researcher Olga F. Jarrín, PhD, RN, the lead author on the Penn report. When Jarrin informally surveyed colleagues, some told her they had no exposure to home health as nursing students, or they had negative experiences in one or two days of shadowing, such as being in a car with a preceptor who drove unsafely or encountering a blaring television in a patient’s home that drowned out any other sound.

Marrero said she has seen increased demand for home health placements in recent years, but setting up a home health rotation has different challenges than setting up a rotation in a hospital. Clinical instructors don’t accompany the students, so a good one-on-one student-preceptor relationship is important. Students need to have their own transportation to patients’ houses and training to follow standard safety precautions and adapt them to a home setting.

Several years ago, Lourdes decided to revamp its curriculum to introduce nursing students to community health earlier in their nursing education by having them work in senior centers, schools and integrated health clinics. But creating home health clinical rotations became more difficult because most first- and second-year students weren’t ready to go one on one with a preceptor, Didion said.

In her state, public health agencies with visiting nurses have given way to private agencies that often see more patients and provide complex care, she said. “It’s become so specialized that nurses are going in to do in the home what we used to do in hospitals.”

Because students couldn’t participate much, Lourdes no longer offers home health rotations for pre-licensure students, though Didion and her staff are looking at ways to offer all students a home health experience. “We don’t want to see it go away,” Didion said.


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By | 2014-11-10T00:00:00-05:00 November 10th, 2014|Categories: National|0 Comments

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