CONTENT
Chapter 1: Healy Nurses Home Care Work Rules
Chapter 2: Introduction to Working in Home Care
The Environment
The Relationships
Chapter 3: General Information for Nurses Working in Home Care
Adjustment to Home Care
The First Thirty (30) Minutes of Home Care
Chapter 4: Guiding Principles for Nurses in Home Care
The Parent/Guardian as Authority in the Home
Professional and Personal Support
Maintaining a Professional Relationship
Chapter 5: Specific Guidelines in the Home
Common Courtesy in Home Care
Value Judgement
Spiritual or Religious Beliefs
Transaction-by-Transaction Routine
Authority in the Home
Dependency
Documentation
Reporting Abuse or Neglect
Chapter 6: Specific Guidelines for Dealing with the Patient
Supporting the Parent/Guardian-Child Relationship
Communication with the Patient
Influencing the Patient
Chapter 7: Specific Guidelines Regarding the Relationship with Siblings
Transaction-by-Transaction Involvement
Sibling Interactions
Babysitting
Chapter 8: Specific Guidelines for Involvement with Parents/Guardians
Communication
Privacy and Confidentiality
Interactions Between Parents or Parents and Significant Others
Conclusion
Chapter 1: Healy Nurses Home Care Work Rules
Healy Nurse wants to encourage a safe and pleasant work atmosphere. This can only happen when everyone cooperates and commits to appropriate standards of behaviour.
The following is a list of behaviours that the company considers unacceptable. Any nurse found engaging in these behaviors will be subject to disciplinary actions including reprimand, warning, or dismissal:
- Failure to be at the patient’s home, ready to work, at the scheduled/regular starting time.
- Willfully damaging, destroying, or stealing property belonging to a patient or their family/friends.
- Fighting or engaging in disorderly conduct.
- Refusing or failing to carry out instructions of a nursing supervisor.
- Leaving your patient’s home/station (except for reasonable personal needs) without completing a patient’s treatment.
- Ignoring work duties or loafing during home care visits to patients.
- Going for home care duties under the influence of alcohol or any drug, or taking alcoholic beverages or drugs at a patient’s home.
- Using threatening or abusive language toward a patient, his/her family, and friends.
- Falsifying records including nursing notes/documentation.
- Smoking is contrary to established policy or violating any other fire protection regulation in a patient’s home/station.
- Willfully or habitually violating safety or health regulations.
- Failing to wear clothing conforming to standards set by the Healy Nurse.
- Being tardy or taking unexcused absences during a patient’s treatment.
- Not taking proper care of, neglecting, or abusing a patient’s medical equipment and tools.
- Using a patient’s medical tools and equipment in an unauthorized manner.
- Possessing firearms or weapons of any kind in a patient’s home or property.
Chapter 2: Introduction to Working in Home Care
Providing nursing care in a home differs from hospital-based nursing for several reasons. The following information describes some issues families and nurses experience while working together to provide home and community-based services to patients. This document is a guide/manual for how Healy Nurses should conduct themselves while discharging their home-care duties.
The Environment
Home care and hospital care are different because of the setting. The hospital is a primary setting for nurses and a secondary setting for families. The home is the primary setting for the family and a secondary setting for nurses. Under normal circumstances, nurses are the authority on nursing care in the hospital, and parents/guardians are the authority on their family life in the home. In the hospital, nurses rarely consult much with parents about what is done.
In the home, parents/guardians rarely consult with anyone about how they function or the decisions they make. Under normal circumstances, the hospital and the home are two distinct environments. However, in home care, two settings collide, creating a unique and sometimes difficult situation for nurses and parents/guardians.
Before taking a ward with an ailment home, parents/guardians should learn about the patient’s total care. When this is done, parents/guardians usually know more about the individual care of the patient than any professional coming to the home. The parents/guardians become the experts in the total day-to-day care of their wards at home. Parents/guardians are not used to being in charge of nursing care but are used to being the authority at home.
Nurses are not used to providing nursing care in homes but are used to being the authority on nursing care. Conflicts may arise once home care begins because the parents/guardians have a “home court” advantage and know more about the specific patient but do not have the overall knowledge base and experience of the nurse.
Home care nurses must also adjust to a work environment that’s drastically different from a hospital setting. Hospital management prescribes and enforces standards of care and a fairly contained space in a hospital. It also defined the lines of authority for determining care and for enforcing rules and regulations.
In the home, more of a family-professional partnership should exist, with the family taking the lead in determining the household “rules and routines.” Nurses should take a less directional role. In a home, there may be standards of care, but who, where, and when will not be as easily defined as in the hospital. The frequency and duration of visits and numbers of visitors are more relaxed and, therefore, less controlled than in the hospital. Nurses have less control over whom they expose the patient to. They are more at the mercy of the environment in the home setting than that of a hospital.
The family and nurses have a greater number of decisions about how to balance normal recuperative experiences with care needs. There is a proper sense of isolation from other professionals with whom to discuss treatment plans, progress, and problem-solving.
Similarly, the home is more relaxed than the hospital environment, with fewer backups or supports available to help. While it may be desirable to focus more intensely on one patient, there are also fewer challenges than offered by a hospital environment. Boredom and complacency may be a problem, as home care can become almost too casual. The professionalism required in the hospital may become diluted by the home environment.
The Relationships
Home care exposes nurses to the inner workings of family life, some of which may be distressing. Nurses may not agree with the treatment of family members and may feel uncomfortable with aspects of a family’s culture and/or lifestyle. In a hospital setting, nurses may have some exposure to the behavior of siblings and parents/guardians. But generally, this exposure is not as intense or extensive as when working in the home. In the home, nurses may become involved in family relationship issues during home care visitations.
These issues are technically unrelated to the patient’s care but are to the environment in which the care is being provided. Relationship issues may make it more difficult to maintain the professional relationship required by the job. Nurses’ primary focus is the medical care of the patient. Nurses, however, can expect to take part in any activities that relate to the patient, including physical care, daily care of the patient’s equipment and environment, and support of educational and recuperative programs.
Questions about other aspects of the patient’s life, within the context of the family, will arise for nurses, just as questions about nurses will arise for the family. Although the nurses are employed to care for one patient, they must establish relationships with other family members in the home and other healthcare professionals. The initial moments of the first visit are especially difficult as everyone adjusts to their roles and relationships with the multiple providers of care.
Healy Nurse provides the following information to help nurses establish and maintain a professional working relationship within a home environment. Healy Nurse designed the guidelines to help nurses prepare mentally for the experience of home care and avoid identified sources of stress. We recommend that parents/guardians, the Care Coordinator, and/or the hospital personnel meet with our nursing personnel who will be in the home after discharge to go over the guidelines. Healy Nurse’s supervisor needs to be involved in the discussions to assure that the parents/guardians are in line with the platform’s policies and procedures. And that they approve of the guidelines.
Chapter 3: General Information for Nurses Working in Home Care
Adjustment to Home Care
For nurses who have not worked in home care before, there will be a period of change no matter how well the experiences are thought through by all involved. It is an unfamiliar environment, and nurses must realize it will take time to adjust; there will never be clearly defined roles and responsibilities that exist in other environments. Learning to cope with the home setting will cause a willingness and ability to be flexible.
Family members will experience several emotionally charged issues over the course of the home care experience. They may react angrily toward nurses in inappropriate ways. Nurses do not have to submit to mental or verbal abuse. However, it is important to remember to be “objective” and not take irrational outbursts personally.
Experienced professionals do not feel threatened when a parent questions some action. Nurses should listen to the content and the meaning of questions or even outbursts. It is important to evaluate what else is going on in the home because even subtle changes may be the source of stress.
The First Thirty (30) Minutes of Home Care
The first thirty (30) minutes of home care are a time of acute anxiety for everyone, with the first hour being the most difficult. Parents/guardians are nervous about their own ability to care for the patients without the backup of the hospital staff and do not yet fully trust the home care nurses. Parents/guardians will be anxious about everything but especially about the “details” of the care of the patients. These family stressors may affect nurses simply because of being there.
It is also a time of anxiety for nurses who are new to home care and who are not sure of their ability or the parents’/guardians’ ability to handle emergencies. It is during this time that nurses should establish trust with parents/guardians. Nurses may establish inappropriate patterns of communication with parents/guardians because of their anxiety and parents’/guardians.
The first thirty minutes are also a time of high turnover of nurses who decide they do not wish to work in such an environment. However, it is important to understand that the home care situation will not always be so anxiety or tension-ridden. Parents/guardians and nurses will develop a routine with the patient, and anxiety will decrease markedly.
Chapter 4: Guiding Principles for Nurses in Home Care
Three guiding principles are important to assure that home care is the supportive service it is meant to be. The principles overlap and are interrelated but are separated into three main takeaways.
The Parent/Guardian as Authority in the Home
With many agencies, organizations, and health care professionals involved with the patient and family, it is easy to forget that the parents/guardians are the ultimate authority over the patient and his/her care. Everyone else is there as service providers and/or consultants. The parents/guardians are the ones who are and should be in control of the overall situation. Healy Nurse may deploy nurses, though funding for home care may come from another payor, the parents/guardians are still essentially the nurse’s employers.
Parents/guardians have the authority to both select and remove supervisors and individual nurses and to establish specific guidelines for treating the patient in their home. While the discharge of an individual nurse and/or Healy Nurse as a home care platform is not the recommended first response when dealing with problems in home care, the parents are the authority in their own homes and may make this decision.
Nurses must keep in mind that they are working for the family and not present in the home as a favour to the patient or family or out of altruistic concern. Working in home care is a contractual, business relationship. This relationship, therefore, requires respect for parental/guardian authority.
Efforts to enable parents/guardians to develop and maintain the central position of authority are essential. This does not mean that parents/guardians have to do everything themselves, but that they have the authority to oversee the entire home care situation and assign responsibility to the people.
Nurses should aim to gain the parents’/guardians’ trust as they complete their responsibilities. Parents/guardians must also feel that the nurses in the home will support their decisions and respect their ability and right to care for the patient. If nurses can develop a supportive, trusting, and mutually respectful relationship with parents/guardians, they can discuss and resolve difficulties and problems in a non-threatening manner for all involved.
Developing a relationship that is respectful of the parents’/guardian’s authority and the nurses’ skills and responsibilities is a dynamic process. It takes time and a conscientious, consistent commitment from the nurse, the Healy Nurse, and the parents/guardians.
Professional and Personal Support
It is of utmost importance for nurses to establish a personal and professional support network outside of the home where they work. This network will help them cope with the intensity and stress of home care. Working with one patient in one home has drawbacks. It can become boring, stressful, or all-consuming, especially for nurses who work for an extended time in the home.
Professional support will be available through the nursing supervisor, home care colleagues, and Healy Nurse. Regular supervision meetings, staff conferences, or even nursing support groups may help the individual nurse put their behavior or the unexpected behaviour of family members into perspective.
Personal or social support from one’s family and friends is also important. Nurses who try to have personal or social needs fulfilled in the patient’s environment are at risk of becoming too involved with the family. This can make it impossible to keep an appropriate professional relationship.
Maintaining a Professional Relationship
It is perfectly normal for families to try to incorporate the nurse into the family unit to decrease the stress of having an outsider in the home. They may do this consciously or unconsciously.
This pull is hard to resist because it feels like acceptance and a statement of affirmation to be considered a “family member.” While this may appeal to the nurse, this does not necessarily reflect the family’s statement regarding the nurse as a person. It is, instead, an attempt to decrease the family’s anxiety.
As professionals, nurses are responsible for maintaining an appropriate professional distance while supporting and respecting the family’s naturally established boundaries, even when the family attempts to include nurses as family members.
Some families have no boundaries, or boundaries that are so spread out they seem virtually nonexistent. These families will automatically view nurses as members of the family unit and expect nurses to function as full members of the family. In these circumstances, it is even more important for the nurses to help the family establish boundaries by identifying those areas where it is inappropriate for the nurses to be involved, even when invited. Examples include family arguments, decisions about family activities, or even lifestyle choices.
Becoming overly identified with the patient or family can be a problem for nurses and the family. Nurses need to remain objective to fulfill their role with maximum efficiency and effectiveness. This does not mean that the home care assignment is “just another job.” However, the assignment is, in fact, a job and should not become the nurse’s life.
Chapter 5: Specific Guidelines in the Home
The next sections will deal with more specific guidelines for nurses working in home care. We wrote the specific guidelines for all our nurses in home care. While some may seem obvious, we provide them as reminders that certain behaviours and actions may have an impact beyond the original intent.
Common Courtesy in Home Care
There may be many caregivers entering the home and the patient’s treatment area/room in particular. It is important to be sensitive to the fact that it is someone’s home and treat the furnishings with respect, e.g., wipe up spills on furniture and carpeting; notify the parents/guardians if something is broken; wipe feet before entering, and so forth. With so many additional people coming in and out of the home, there will be extra wear and tear on the furnishings.
Nurses must make efforts to minimize this as much as possible. It is not the nurse’s responsibility to do general housework. Nurses should help maintain a neat environment for the patient, e.g., replacing supplies and equipment in their proper places, making sure the patient puts other personal effects away after use, and so forth.
Value Judgments
Home care nurses may work with families whose basic social values and behaviour differ from their own. They should not identify these differences from the parents/guardians.
As long as the lifestyle and behaviours of the family do not risk harm to the patient or prevent the nurses from doing their job, how a family lives are their own choice. Most concerns in this area center on judgments regarding the discipline of the patient and/or siblings, housekeeping, and relationships.
Similarly, the financial affairs of the family, including how a family spends their funds, are not the nurse’s business. However, it may be difficult to work in an environment where values differ dramatically. If nurses find the differences too distressing, it may be necessary to consider not working with a particular family.
Spiritual or Religious Beliefs
Nurses should not express their spiritual or religious beliefs during home care. In addition, it is essential to avoid any attempt to influence the patient, siblings, or parents/guardians regarding spiritual or religious values that may differ from the family’s own beliefs. If the patient asks questions of a spiritual or religious nature, nurses should defer to the parents/guardians.
Transaction-by-Transaction Routine
Healy Nurse’s home care is 2-hour per transaction. However, customers can request more time (hourly) if the initial 2 hours is not enough.
Home care is a 24-hour a day, seven days a week job for the family and a 40-hours or less work week for nurses. Nurses should follow the family’s established routines as closely as possible. Asking the family how and when they would like to discuss non-emergency updates on the patient’s care will avoid the repetition of information.
Authority in the Home
Where there are acceptable options for care, nurses need to support the parents’/guardians’ authority. Unless they place the patient at risk of harm, the parents/guardians have a right to determine the care of their ward. When nurses feel that parents/guardians are making inappropriate decisions about the care, they should discuss it with the parent(s)/guardian(s) and the nursing supervisor. If this does not resolve the concern, the nursing supervisor, physician, and the case manager may help negotiate a resolution.
When a written plan of treatment includes a specific activity or routine, we expect nurses to follow written physician orders at all times. If parents/guardians wish to alter a plan of treatment that is part of the physician’s orders, it is up to the parents/guardians to negotiate with the physician. However, there will be many daily routines in the patient’s care that are not covered by written physician orders. The parents/guardians are the authority in determining general, non-prescriptive routines and procedures. We expect nurses to respect this authority as long as it does not compromise the care of the child.
Dependency
Parents/guardians depend on the nurses’ services to keep the patient at home. This can create a power differential to which nurses need to be sensitive. Parents/guardians do not want to antagonize nurses any more than nurses want to antagonize them. Systematic negotiation of differences of opinion, while everyone’s responsibility, should be a skill that the experienced nurse brings to the home environment. The primary goal is to foster independent family functioning while providing appropriate support as needed.
Documentation
There must be a standard procedure in the home for recording information about the care the patient receives. Other than the required charting and recording, it is not appropriate to document in the chart or other places any aspects of family life or family functioning that are not directly related to the medical care, status, or safety of the patient.
Reporting Abuse or Neglect
Child Abuse or Neglect: Sometimes it may be necessary to raise concerns about a parent’s/guardian’s or other caregiver’s ability or willingness to care for a patient. We mandate nurses to report to Healy Nurse and the Lagos State Office of Public Defendants (LSOPD) at (+234) 0708 060 1080.
Nurses are also responsible for reporting any acts of physical abuse, neglect, or sexual abuse to the Lagos State office of Public Defendants. Neglect, on the other hand, is less easy to determine, especially when the ailment is complex.
It is necessary to document a description of alleged neglectful behaviour, including dates and times. If the nurse is in the home to care for a patient, it is important to remember that it is difficult to make a case for the parent/guardian or another caregiver as neglectful, since the nurse handles the patient during that time. However, it can be considered neglect if, for example, the family caregiver taking over the care of the patient is intoxicated, fails to appear without notice, cannot provide the necessary care, or where the environment is unsafe or potentially life-threatening.
In reporting abuse or neglect, nurses are responsible for providing specific information that is pertinent to the allegation. It should be understood that a report is only an allegation of abuse or neglect. The designated agency for protective services (LSOPD), not the nurse, is responsible for investigating the report. While as much information as possible is important, nurses do not have to prove abuse or neglect, only to report it when they suspect that it is occurring.
With suspected abuse or neglect, it is also a professional responsibility for the reporting nurse to remain with the patient until the Healy Nurse’s nursing supervisor, protective services worker or the police arrive after a report is made. The nurse cannot legally remove the patient from the home without the parents’/guardians’ permission unless the patient requires emergency medical treatment. Only the police or designated protective service worker can legally take custody of a patient at risk and, in a nonmedical but protective emergency, the police should be called.
Chapter 6: Specific Guidelines for Dealing with the Patient
Supporting the Parent/Guardian-Child Relationship
Nurses need to be diligent about supporting and reinforcing the parent/guardian-patient relationship. They should not do anything to undermine that relationship. It is extremely easy to become attached to and feel protective of the patient. To usurp the parent/guardian relationship with the patient, however, is unethical behavior. This is not to say that it is inappropriate to view the patient as more than just a “patient.” What is inappropriate is to lose objectivity and to try and replace the parent/guardian in the patient’s life.
It is important to be conscious of how home care nurses refer to the patient. Statements such as “my patient” are common in the hospital, but they can be offensive to parents/guardians in the home situation. Similarly, when speaking of the family, a nurse should avoid using the word “we” as though the nurse is part of the family. Using “you” or “they” is more appropriate and less offensive.
Communication with the Patient
It is not appropriate to discuss any negative reflections about family members with the patient. Patients will look for support from nurses by speaking negatively about one or both parents/guardians when they feel they are being unfair. Nurses who support patients’ negative comments about their parents/guardians will be interfering in normal family functioning. While patients may be initially looking for support, they ultimately resent a non-family member making negative comments about the family.
Nurses should encourage patients to discuss their feelings with their parents/guardians. Even the most innocent of questions, e.g., “Why is my Husband doing that?” can be redirected with a simple “I don’t know. I think you should ask him.” to avoid falling into the trap of trying to interpret parental/guardian behavior to the patient.
Influencing the Patient
Patient especially children-patients under the care of an adult for an extended period, may adopt the traits of that person. This occurs naturally when children begin school and teachers influence them. Nurses need to be sensitive to the fact that the child-patient may reflect their personalities and personal habits. Therefore, it is important to remember to be circumspect in attitudes, conversations, and behaviors because the child-patient will adopt a variety of mannerisms and verbalizations that may or may not appear desirable to the family.
Chapter 7: Specific Guidelines Regarding the Relationship with Siblings
Transaction-by-Transaction Involvement
Siblings are an important part of family life. When there are other siblings in the family, nurses need to be sensitive to them, also. Some siblings may seem like more of a nuisance than a help, but it is not the right or responsibility of the nurses to “organize” the rest of the patients’ siblings. If siblings are interfering with the care of the patient, then this needs to be addressed directly with the parents/guardians and/or nursing supervisor.
It is also important to remember that siblings may resent all the attention that the patient receives including, the patient having his or her own friends visiting. Nurses can help foster positive family relationships by including the siblings in activities whenever appropriate, being patient in answering their questions, and showing a genuine interest in the siblings’ activities and feelings.
Sibling Interactions
It is important for siblings to spend time together. This may include play activities but also may include the normal disagreements and fighting that occur among brothers and sisters. Nurses should encourage and provide the opportunity for as much normal activity among siblings as possible and not be overly protective of the patient.
Especially for younger patients, sibling interaction is an important socializing experience. Even a good squabble promotes growth and development for all involved as long as it does not endanger the physical well-being of the patient.
Babysitting
Nurses are not expected to babysit siblings nor should they take responsibility to do so. This does not mean that nurses may not supervise the play of siblings with the younger patients. However, nurses should not be responsible for siblings when the parents/guardians are out of the home.
Chapter 8: Specific Guidelines for Involvement with Parents/Guardians
Communication
Good communication between parents and home care nurses is critical to the success of home care. Therefore, it is important to clarify with parents/guardians what information needs to be reported to them immediately and what information can wait. Methods and systems of communication need to be established and may entail written as well as verbal communication.
If there is a repeated breakdown in communication or an inability to resolve communication difficulties, the nursing supervisor may help the nurse problem-solve. It is inappropriate to call a consultant of any sort to come in to “fix” the family, but nurses working in the home may benefit from talking to others in order to determine an appropriate course of action.
Nurses should not call the doctor, (non) medical home care provider, or other agencies regarding the patient without discussing it with the parents/guardians first. Except in an emergency, when the parents/guardians are unavailable, all home care nurses should comply with this expectation.
Privacy and Confidentiality
Privacy is a major issue for parents/guardians who have other caregivers in their homes. They need to identify times when they do not wish to be disturbed, e.g., for the next hour during the visit, and so forth; places where they do not wish to be disturbed, e.g., in the bedroom or bathroom; and under what circumstances they do not wish to be disturbed, e.g., when on the phone, when visiting with friends.
Nurses are expected to respect the confidentiality of the family and not discuss the family members with anyone outside of the home except with specified health care professionals as it relates to the patient. Nurses should not provide information pertaining to the whereabouts of the parents/guardians when they are not home. Nurses should respect and protect the family’s privacy appropriately at all times whether in the home or talking with others outside of the home. Any breach of confidentiality by a nurse mandates immediate supervisory action.
Interactions Between Parents or Parents and Significant Others
All parents/guardians periodically get into arguments. Nurses are expected to avoid involvement in relationship disputes unless the patient or the nurse is placed at risk. If it seems as though parents/guardians are trying to involve the nurse in a dispute, it is the nurse’s responsibility to identify to them that this is inappropriate. At times this may be difficult because sympathy may well be with one parent/guardian over the other.
However, it is important for the parents/guardians to negotiate their own problems without the involvement of nurses. It is inappropriate for nurses to become romantically involved with a parent in the home where they are working, even if the relationship is with a single parent and is developed after visiting/work hours.
Conclusion
We believe that the Healy Nurse’s Guide/Manual for Home Healthcare in Nigeria will help us foster a safe work atmosphere. There are stresses for family members and nurses working in a home environment, but with conscientious effort, they can overcome most difficulties. When they establish good communication and understanding early in the home care visit/experience, the service can be supportive of the family and professionally gratifying for nurses.