Assisting Patients in Their Homes

Reflecting on my nursing career, I often ponder how it might have unfolded had I not relocated overseas shortly after my first child was born. Despite being on maternity leave, one of the most challenging aspects of supporting my then-husband's aviation aspirations was leaving a job that was both humbling and gratifying—nursing within the community.

With six years of experience across various hospital departments, I felt well-prepared to transition into a more autonomous community nursing role. The prospect of visiting patients in their homes was far more appealing than the chaotic environment I had grown accustomed to in acute care settings.

Having my own desk and not having to compete for patient files seemed almost too good to be true. While initially daunting to be out on my own, I soon embraced the responsibility of making critical decisions regarding patient care and recognizing when something was amiss.

A network of supportive, experienced nurses was invaluable; they were always just a call away. Many had years of experience and were familiar with our long-term patients, often grappling with chronic health issues.

We organized our workload geographically, using a dot-sticker system to track time spent with each patient. Each dot represented 15 minutes of care; for example, four dots indicated hygiene assistance. Providing personal care at home was often tricky, given that facilities were not always ideal.

Typically, a productive day consisted of managing around 20 dots. Preparing my supply bag for visits was essential, as I needed to ensure that each patient's care plan was current—returning to the office mid-day was rarely practical. I often had to make do with what I brought.

By 9:30 AM, I was usually out on the road, aiming to return by 1:30 PM for lunch, unless I had eaten while traveling. Once back, I would write progress notes, update care plans, and organize charts for future visits. With travel time included, the days flew by!

Initially, I served as a floater, rotating between different areas. I enjoyed this aspect of the role as it allowed me to meet many chronic patients and explore various neighborhoods in South Auckland, home to many of New Zealand's indigenous Maori and Pacific Island communities.

Understanding and respecting their cultural practices was crucial for building trust. While I had grown accustomed to offering to remove my shoes when visiting friends in Montreal, it was not common practice for the average Kiwi.

I quickly learned to bring a second pair of indoor shoes; otherwise, I would have to go barefoot or wear socks—often not the cleanest option in some homes!

Most of my clients were elderly individuals battling chronic illnesses like diabetes, heart disease, and respiratory conditions such as emphysema. Others were on our roster after returning home from surgery or following a new diagnosis.

My visits served to ensure patients were following prescribed treatments and understood their conditions, including limitations and potential complications.

Common treatments included: - Wound care, especially for diabetic ulcers - Urinary catheter reinsertion - Blood sugar monitoring - Care for ileostomies, colostomies, and urostomies - Hygiene assistance - Palliative care and pain management for patients wishing to remain at home during end-of-life stages - Health education regarding symptom management and dietary needs related to diabetes, asthma, and heart disease

Regardless of the purpose of my visit, it also provided a chance for patients and their caregivers—if present—to voice concerns, ask questions, and demonstrate their ability to manage care at home. I could assess their home environment and look for signs that indicated things were not going well.

While community nursing aims to respect patients' wishes to remain at home, I had an obligation to intervene if safety was a concern.

Throughout my three years of community nursing, I encountered some of the kindest individuals and witnessed some heartbreaking situations. For some, I was the only person they interacted with or had physical contact with. At times, it was challenging to keep to my schedule because they enjoyed chatting.

I became familiar with my patients and their routines. One day, I was alarmed when an elderly client did not answer the door. After checking around the house, I found no signs of life. Since she rarely left home, it felt unusual. Before cell phones, I went on to my next appointment and tried calling her—no response.

I decided to return and knock more forcefully, but still got no reply.

Feeling uneasy, I consulted my supervisor, who suggested I call the police to gain entry. We discovered her lying by the toilet, barely breathing. It was unclear how long she had been there.

She was taken to the hospital, where she passed away a few hours later.

I also visited several children, including newly diagnosed asthmatics needing aerosol treatments to manage symptoms. Witnessing a child in respiratory distress can be frightening for parents, so much of my time was dedicated to teaching them how to administer medications effectively and recognize dangerous symptoms.

Together with the physician, I developed an action plan for parents to reference when their child exhibited concerning symptoms. Timeliness is crucial during respiratory distress, and the plan had to be straightforward for those alarming midnight episodes.

A few children required monthly intramuscular injections for rheumatic fever treatment. Unfortunately, the Indigenous Maori and Pacific Island communities faced a higher risk for this condition due to overcrowded living situations.

Rheumatic fever typically begins with a sore throat but can lead to severe heart valve damage if not treated promptly. Children diagnosed with this condition need ten years of intramuscular antibiotics and regular follow-ups to prevent recurring strep throat infections.

This aspect of my job was the hardest; the children dreaded the painful injections. The medication's viscosity necessitated a larger needle, making the process even more daunting. Regardless of whether I visited them at home or school, they were never happy to see me, and I often felt like the mean nurse inflicting pain!

The most challenging case I encountered was a young man diagnosed with Acquired Immunodeficiency Syndrome (AIDS). Glenn was in the final stages of his illness, and his sister, Rose, was his primary caregiver at home.

I visited Glenn three times weekly. He was bedridden and severely malnourished, suffering from a significant pressure wound on his right hip that required irrigation and packing thrice a week. His confusion, a result of the disease, often led to inappropriate behavior towards visiting nurses.

Rose took care of his basic needs but needed emotional support. She had a tough exterior and a short temper, which made some colleagues hesitant to visit.

I was fortunate to cultivate a meaningful relationship with both Glenn and Rose. I didn't judge Glenn's choice to smoke cigarettes and marijuana, understanding that these provided him with some semblance of enjoyment. Though concerning that he had burns from his cigarettes due to confusion, Rose recognized the importance of supervising him during those moments.

I monitored Glenn's condition and collaborated with his doctor and the Community AIDS Resource Team for wound and pain management. Although I was not present when he passed away, it comforted me to know he spent his final days at home with Rose by his side.

Most of my clients were friendly and grateful for the home care service, and I was fortunate never to feel threatened or unsafe. There were a couple of occasions when I chose not to enter a home due to an aggressive dog; such situations justified declining care. Clients were warned that they needed to secure their pets to continue receiving services.

With the advent of cell phones, communication has improved significantly. Back in 1995, they were just emerging. The office phone was bulky and unwieldy, and we often had to borrow patients' landlines—an impractical solution that would now breach privacy laws.

Patients play a vital role in their care, similar to the hospital environment. Research shows that those who inquire, stay informed, and adhere to medical advice tend to have better outcomes.

For instance, if a nurse visits to review a week's worth of blood sugar readings and the patient hasn’t taken any readings, it wastes both their time. If a patient decides to stop taking their medications due to side effects without consulting their doctor for alternatives, it can have serious implications since abruptly stopping some medications can be dangerous.

Here are some useful tips for ensuring effective collaboration with a visiting nurse if their services are needed: - Ensure you are home and provide the correct address. Inform the nurse of any special access or parking instructions during their call to confirm the visit. - If your doorbell is out of order, listen for knocking. I have often left without knowing someone was home, only to return to messages asking why I didn’t visit. - Keep pets, including dogs and curious cats, in another room while the nurse is present. - Arrival times can vary due to traffic and prior patient needs, so don’t be upset if the nurse is late or early. - Don’t take offense if the nurse declines a cup of tea; it’s not personal; they have other patients to see. - Follow any specific instructions given for treatments. - If you have questions about your care, don’t hesitate to ask.

The role of visiting nurses has expanded to include administering intravenous medications and conducting evening visits, while healthcare aides handle hygiene care, which was a significant shift I had to adapt to when transitioning from nursing in New Zealand to Canada.

I would have loved to return to community nursing in Montreal, but the weather was a significant drawback: it can be cold and snowy for six months.

Getting to the office is challenging enough, not to mention navigating the streets or searching for parking. The endless shoe changes for different environments are another deterrent.

I’ll leave that role to the more resilient souls and stick to my teaching responsibilities!