The Nurse/Family Relationship

Developing a good working relationship with the client and the family is the bedrock of home healthcare nursing. This will be a two part blog, with this one covering general points of being in the home, and questions for the families of those who have received or are receiving services. The basics are as follows:

1. You are the healthcare professional, but the family, and they alone, are the experts on their loved one.
2. Ask if there are any particular household rules that the nurses need to observe. Simply showing an interest in their way of doing things is a relationship builder.
   
3. Unless you are on a stat case situation, there should be an orientation from your agency's clinical supervisor, a nurse already on the case, or a family member who has carried out the client's care. This affords the family, client, and you a chance to assess the comfort level of your being there. It also allows you, the nurse, to formulate questions regarding care, equipment use, etc. for your clinical supervisor or agency before reporting to work.
   
4. If the client can verbally interact, get feedback about specific likes or dislikes regarding care and routine.
5. Keep the work area clean and organized. In addition, immediately clean up any mess you make in the kitchen or work area. Ask where they would like you to eat your meals, if you can use the microwave, where to put your food in the refrigerator, which bathroom to use, etc.
6. Let the family offer the use of the TV! If they do not offer, chances are great that they do not intend to allow you to watch it. If the only TV is in the communal living area, never turn the channel or request to see a particular show if they are in the room. Unless they are going to bed or leaving the house, assume they are watching the show even if they leave the room. Ditto the remote. You are a visitor. No matter how comfortable you feel, you are at work!!!
7. Have plenty to entertain yourself during downtime (client is sleeping or with the family). Reading is good but can sometimes put you to sleep, which is a no, no. It is better to have multiple things to keep you stimulated. A Netflix subscription and DVD player are invaluable time fillers. Buying a laptop and a connect card (for an Internet connection) are worth their weight in gold.
   
8. Make the client your only priority. Aside from the physical and medical care, you must attend to mental, social, and emotional needs as well. Some of these needs will be apparent or expressed. Others may not be, so, stay vigilant using yours skills of observation.
9. Sometimes family members or the client will not express displeasure with something you are doing. Always be aware of what you are doing and their reactions (body language, distancing, facial expressions) to what you are doing---or not doing. Look and listen for cues about what distresses the family about nurses' behaviors.
   
10. Never, never, never smoke---not even outside, not even if they do---never. It is unprofessional and not healthy for the patient. The smell will remain in your clothing, and thereby offending others.
11. Bring your own food. You should never eat anything that has not been offered, and even then, use discernment.
    
12. You are sure to ruin the relationship, or worst, never allow it to develop if you are controlling. Again, this is their home, and they are the experts about what goes on there. Learn the art of offering a suggestion, and then letting the matter go.
    
13. Keep noise (TV, computer, DVD player, cell phone, movements around the house, etc.) or any type of disturbance to a minimum. If you must take a call, keep it to, absolutely, no more than 60 seconds. Put you phone on vibrate.
    

These tips will get you in the door and help to develop the relationship; however, once there, the ongoing nuances of developing and maintaining a good relationship is crucial. That will be the basis of next week's blog. In addition to the above pointers, I would like to invite parents, clients, and family members to respond to the following questions:

1. What was your overall experience having nurses in your home?
2. What annoyed you most about their behaviors?
3. What did you want to say but did not?
4. Do you feel your home was respected? If not, in what ways did they not show respect?
5. If you had to have nurses in your home again, what would you do to make it a different/better experience?
6. What pleases you most about your nurses?
7. What was the hardest adjustment for you and your family while having nurses in the home?
8. Were you pleased with the interactions between the nurses and other family members, including children?
9. What do you think every nurse should know (from the standpoint of the family) before coming into some one's home to work?
10. Are there any other comments you would like to share?

In the near future, I hope to turn this information into a guide for nurses and publish it, so, this is a chance for clients and families to have a significant impact in the future of home healthcare nursing.

Is HHC Nursing for You?

When I started nursing in 1974, home healthcare was far different than what it is today. Having a LPN or RN come into the home for six or more hours a day was a privilege that only those with an excellent insurance policy or the wealthy could afford. Anyone else had an occasional visit from the public health nurse or was taken care of by family members and friends. There were very few agencies and the Nurses' Registry to help you find clients. Documentation was basic and kept in the home. The only rules were those of basic nursing care and whatever the agency deemed necessary.

Today, Medicare, Medicaid, and Long-Term Care Insurance reimbursements are the driving forces for the many agencies in the business of home healthcare. Documentation is key, not only for reimbursements, but also in the many layered web for certification. The rules and regulations under which these agencies must abide are many, and their angst is passed along to the nurses in the home. Even with the pressures of multiple regulations, home healthcare (HHC) is a fast growing industry and is a highly gratifying nursing speciality.

What makes a good HHC nursing candidate? One of the most important things is the ability to be alone or without adult interaction for long periods of time. Even if you are working with a cognizant adult patient, he or she will frequently need to rest or be in the company of family and friends. Critical thinking skills and the ability to handle emergency situations alone are essentials. Most agencies require that a nurse has had at least one year of hospital experience before doing HHC. In the hospital setting you can get a feel for what speciality is most suited to your nursing style. In HHC you can choose from both high-tech and low level care pediatrics, geriatric care, terminally ill patients, long-term disability patients, and the list goes on. In any situation you must be team oriented. In a client's home you will work with two teams---the family team and medical/agency team. Always remember that you work for the agency, but you must build a rapport with the family. Almost as important as your nursing skills is your ability to communicate effectively and to be a diplomat extraordinaire. You will need to know how to set up and respect boundaries. Aside from the mandatory inservices your agency offers, you must have a willingness and a drive to learn as much as possible about the disease, disorder, or disability of your client. This is essential information to help you when communicating with the family, the doctor, and when conducting patient/family education.

When deciding on a speciality, remember that if you select pediatrics, you will need to like children in general if their are siblings in the home. Even though their care is not your responsibility, you will be dealing with their noise, curiosity, and sometimes their need for attention. Make sure this will not bother you.

Increasingly agencies are leaning to 12 hour shifts. Can you be in a home setting for that period of time and remain alert and productive? I will devote an entire future blog to the pros and cons of various shifts in HHC.

Finally, can you be secure and happy with agency work? Agency work offers flexibility and freedom, but if you work per diem or PRN you will not have the benefits of facility work. Many agencies also offer the benefits of facility work if you commit to certain guidelines in availability. Be aware that this greatly reduces your freedom and flexibility. Many offer health insurance at group rates and a 401K plan. More on all of this in a later blog.

Let me hear from you. I welcome your feedback and input, whether you are a nurse, agency, client, or family member. Next week I will talk about the basics of being in a client's home and rapport building.

Getting Started

Hello to home healthcare nurses and the families to whom their services are highly valued. This is a weekly blog for nurses in the dynamic field of home healthcare nursing who spend four to sixteen hours a day caring for a chronically or acutely ill person in the home setting. This blog is also for families who have nurses in your home for extended periods of time delivering nursing care. Since most of my experience is with pediatric HHC, most of my information will lean in that direction, however, much of the information will apply to any homecare situation.

The focus will be on social and household etiquette when working in some one's home as a caregiver, and how to navigate the world of home healthcare agencies. Clinical skills are a must in nursing, but when in the homes of people of varying cultures, races, religions, and attitudes for four or more hours a day, two to five days per week, it takes people savvy to be successful. I will also blog about the emotional impact of caring for terminally ill children, grieving the loss of a client, self-care, and boundary issues. As the blog evolves from your input, other issues will be addressed.

I invite feedback and useful information from families that have had or currently have nurses in the home. If there are things you would like to share with all nurses doing homecare, let this be your platform. I want each blog to be a springboard for discussion and sharing ideas. I look forward to the weekly experience of posting in the hope of making homecare a positive experience for the giver and the recipient.