Why Nursing Home Care Is No Easy Task - Research Paper Example

Home Care Home Care is an arena where quality, skillful, compassionate, holistic, and ethical nursing care is realized. In the face of limited resources and continuing increase of people requiring long-term care, home care offers a viable alternative (Bone et al., 2010). It delivers health and social services right into clients’ home (Woodward et al., 2004). Home care removes nurses from the locus of the hospital, it places them right into the turf of the client – their home. The shift in the location of care alters the context of nursing care and as such, it posits a challenge to nursing in general and to nurses like me in particular (Woodward et al., 2004). I have held constantly that nursing is an encounter of care my experiences in home care have further deconstructed my notion of nursing as encounter of care. In this paper, I will touch upon my experiences when I, together with my preceptor, visited two home care clients of Alberta Health Services. In this regard, I will present two scenarios wherein I will expound on the nursing competencies as espoused in CARNA by sharing the health visits we had with the clients. Then, I will also show how the theory of evidence-based knowledge and theory of quality care nursing with phenomenology augments the minimal discourse on instruments to measure quality of home care (Robinson et al., 1999). Finally, I will conclude the paper with my reflection and its summary. Enabling Institution: Alberta Health Services-Home Care Alberta health Services (AHS) is the largest health care provider in Canada. AHS diverse health care services, employing highly qualified health care providers. Also, AHS view health care services as no one size fits all. Instead, they acknowledge the significance of divergence as it affects the needs and health concerns of their patients. AHS turned diversity into an enabling ethos, thus, it has established the care arena that is responsive, holistic and client-centered. However, in the midst of the condition of diversity, AHS holds a stable pillar - CARNA competencies. AHS strongly advocates knowledge-based and ethical nursing care practice in all the services they offer. As such, undertaking my home care services with AHS afforded me a chance to take a re-look in what I now know as a nurse and how I can further strengthen it while improving on aspects of the nursing practice where I may falter – a readiness for change. Scenario 1 Enlarge Prostate – Comorbidities The client is suffering from enlargement of the prostate. He lives at home with his wife. The patient has a Foley catheter inserted. Concurrently, the client is also suffering from other comorbidities. He is oxygen dependent with end-stage emphysema. Continuous assessment of the client is essential. As such, home care services have been continuously accessed. During the last visit, assessment of the patient’s leaking catheter was performed. The primary healthcare provider of the client is his wife, who is also living with him. Although the wife of the client is also already advanced in age, she is still capable of doing daily activities with ease. It is observed that there is a continued deterioration in the condition of the client. Nonetheless, the patient continues to manifest the capacity in performing minor tasks with minimum assistance. Nursing Approach: CARNA Competencies A Beacon In this section, I would like to focus on four important facets, nurse relation, and the home as an arena of care, knowledge-based and ethical practice. Nurse Relation. Before going to the client’s house, my preceptor and I first discussed the case. Although our immediate concern is his leaking catheter, we touched upon his comorbidities. We agreed that while the goal is to assess his overall health and give him the most appropriate nursing care that best respond to his condition, we have to do it in a knowledgeable and sensitive manner. This is for me a fundamental step for knowledge-based practice. Nursing relation is not only with the clients, but also with colleagues. The Home. Upon arriving at his house, my preceptor greeted the client and his wife as a friend. My preceptor introduced me to the couple and with congeniality; they welcomed me to their home. There was hesitation and apprehension on my part regarding home as an arena for care. Being used to the traditional hospital set-up, the home is unsettling. The intimacy afforded by the home prods nursing care to a different level (Dowling, 2008) – the level of intimate care. In the hospital, one can still hide from the cloak of authority, but in the home I met and attended the patient with asymmetrical relation between the nurse and the patient downplayed. Instead, what was highlighted was the meeting of people with a common goal. Knowledge-based practice. We attended the leaking catheter of the client with diligence and skill. There is no compromise in the technical skills. However, I have noticed that home care increases the demand for relational holistic care. Technical skills is a fundamental, given fact expected by the clients. But being able to relate and connect with them in their emotional, psychological, social, and spiritual pain changes the dynamics of care. I consciously undertook the teaching of the patient and the wife regarding the handling of the symptoms; pain, fatigue, sleep disorder. Likewise, both of them have informed of the various illness trajectories that he may experience. This is done to increase their knowledge and awareness the disease. In addition, bladder retraining is also included on the agenda. This is meant to assist the client in understanding the significance Kegel exercise, and on how to do it. As we were discussing with the, we are listening intently to their observations, doubts, questions, health concerns, values and other important elements their view of the disease. My preceptor and I saw this crucial in the care plan for it is through integrative discussion with the client that holistic assessment and care can be provided. In addition, I have made myself available to the wife. I listened to her stories, anxieties, fear and struggles and on how she is coping with the illness of her husband (Charalambolous et al., 2008). In this way, both the client and his wife are being valued (Dowling, 2008) while trust is established (de Reave, 2002), and caring relationship is set up in a nurturing environment (Bertero, 1999). Ethical Practice. Through active listening to the clients’ concerns, by including them in the care plan via inclusive and integrative discussions, by assisting them in opening venues on how they can have better life despite the illness and by respecting their dignity and rights in each home care encounter the nursing practice is transformed into an ethical one (Friedman, Bowden and Jones, 2003). These concrete actions that my preceptor and I have taken are actions aimed in establishing authentically being there with the patient and his wife at the time they are vulnerated by the experience of illness (Van der Zalm and Bergum, 2000). Scenario 2: The Wound One of the clients that we visited suffers from a buttock wound. The patient had a history of stroke. The wound was a pressure ulcer. Pressure ulcers are wounds resulting from prolonged sitting or lying in bed due to immobility (www.cawc.net). Pressure causes the blood flow to be reduced in certain areas of the body (www.cawc.net). It also leads to skin breakdown, aggravating the ulcer. During the visits, the pain and the shame of the patients due to the buttock wound were distinctly observable. At the onset, the immediate care plan were (1) frequent change of dressing and (2) offloading of the affected area by a constant change of position. During that time, the patient was very recluse and sensitive because of the impact of the wound to her body and more significantly, to her soul. Nursing Approach: The Wounded Patient and The Healing Hands Barr (1999) developed a critical pathway in dealing with wound management. It suggested that knowing the etymology of the disease should be the first stage in establishing a critical pathway for wound management. Then, the stringent laying down of the administrative duties of the wound care nurse follows. Fulfilling the administrative duties is essential but my preceptor has shown me that living-nursing care is, by far, more fundamental, since, it is right at the heart of nursing. CARNA Competencies in Action. In this scenario, my preceptor has shown me not only nursing care in theory, but also nursing care in action. The reality of CARNA competencies as it is practiced in wound care nursing raises a strong argument against the claim there is not enough the evidence-based instruments that measures the quality of home care nursing (Baich, Wilson and Cummings, 2010). My preceptor showed me what is dedication in nursing care service. We went to the client’s house. One remarkable thing that I saw and learned from her was her genuine and felt compassionate care. With expertise and highly technical skills, my preceptor attended the wound. I assisted her during this session. There was never a moment when you will see a trace of disgust or inhibition in tending the wound. She was there. I felt (and I also knew that the client saw and felt it as well) that my preceptor was ‘lovingly caring’ the patient while cleaning the wound. The strokes of her hands were firm but gentle. She was constantly engaging the patient and her family while we were cleaning and dressing the wound. She touches the hand or taps the shoulder of the patient with such gentleness and care. After tending the wound, we talked with the patient and the family. We discussed with them the next step of the care plan. We talked about not only the physical wound but the deeper wound – the felt shame, fear and destroyed body image that goes with the physical wound. At this point, intuitively I know we were entering into the dimension of home care that transforms it into life enabling arena of care. My preceptor was very sensitive in her choice of words, in her actions. She was very careful in lifting the humanity of the patient and her family. There was no condescension, but only compassionate care. Observing from my preceptor genuine nursing care in action, I found myself engaging with the patient and her family in such a way that the repulsion towards the wound was zero-in on the wound. The patient and her family are wounded; they do not bear the wound. It was eureka moment. The dedication and expertise of the nurses in working on wound management is the norm (Baker, 2001; Grande, 2008). This means accepting that as each patient is unique, what is common between him and her is the physiological and psychological impact of the wound (Arnold and Weir, 1994). This demands not only technical skills in taking care of the wound but the ability to communicate compassion, sensitivity in context, integrative and inclusive care and holistic care. I strongly believe, that as a nurse, these competencies require not only knowledge in nursing but also a combination of knowledge from other fields like philosophy, social sciences and spirituality. AS the wound not only affects the body, but it also afflicts the soul (Arnold and Weir, 1994), I have done research on how nursing care touches the wound in the soul that is caused by the wound in the body. I have found out that minimal studies have touched upon this subject matter. Sharing this with other wound care nurses, we have entered in to a discussion and consensus that wound care nursing should not only be seen from the perspective of its cost-benefits, but the holistic care it provides create a paradigm for compassionate and authentic nursing care. Taking this discourse a little further, we are planning to continue in exchanging these narratives and draw from it not only the strength in continuing our service to people whose physical wounds have cut them out from the public, but also to share something with the nursing community about it. Ethical Practice. It was not only the technical and relational skills that have transformed nursing care into ethical practice. The unceasing respect for the personhood of the client and her family has become an occasion where nursing transcends the health science as it enters into life affirming and flourishing endeavors. However, it is not only respect for the patient that is essential. I have learned deeper respect for my preceptor and other colleagues and nursing as an Institution. The technical skills and knowledge that we strive for, the holistic knowledge that we integrate in our service and the central role of compassionate care in nursing practice truly changes it into an ethical one. Nursing Theory In this section, I will combine McGill model of Nursing and theory of quality nursing care with the phenomenology of hermeneutics. McGill Model of Nursing informs us that nursing is not only about health, but it is about the person, the environment, the family and cultural beliefs/values all dynamically working together to establish notions of health (Gottlieb and Rowat, 1987). It transforms the role of nursing from not just one of the health care providers but the health care provider that seeks holistic health as it creates the condition for positive health-life changes. Meanwhile, the theory of quality nursing care with the phenomenology of hermeneutics accounts for the person (Charambolous et al., 2009). This theory accounts for caring as an affirmation of the patient’s and the family’s humanity (Davis, 2005). Drawing from Paul Ricoeur, it emphasizes not just the disease but also the established care relation that transpires in home care (Hunt, 1991;Ricouer, 1981). Each home care visits becomes an occasion and an encounter for care (Ricouer, 1998). The patient is valued as a person whose care needs can be responded not just by the nurse but also by everybody in the family. This is also observed in terms of wound management, nursing practice on the ground affirms and attests to the reality of the theory of quality nursing care with the phenomenology of hermeneutics. Nurses, equipped with the expertise, compassionate heart and willingness to take an enabling leadership, authentically transforming home care into an encounter with care (Morse, 1991). Nurses working in wound management goes beyond knowing the body (Ricouer, 1991). Accounting for the context and uniqueness of their individual patients and their carers, they see and understand that the physical wound goes beyond the body. Healing the wound while mending the broken image of the body enables nurses to respond genuinely to the challenge of quality care nursing – holistic quality care that touches the human in us (Charambolous et al., 2008; 2009). Combining the two theories helped me in understanding the what, why, and how of nursing care. What is nursing care? Nursing care is holistic health care that creates the condition for transforming nursing care into life flourishing care. Why nursing care? Because it is engaging and affirmative. How? Nursing care is always in context. Lessons Learned Home care nursing demands authentic nursing care. As a nurse, I believe that I have to undertake enabling leadership via harnessing skills, knowledge, compassion, sensitivity and heart in the practice. It is in this way that I can empower the patient, the family and myself in the process of nursing. This is no easy task. The challenge is gargantuan. However, the collegiality among my peers and the congeniality experienced in home care make it worth aiming for. Conclusion As shown in the two scenarios, nursing home care is no easy tasks. It demands authentic presence of the nurse in the actual context of the clients. It transforms nursing care into intimate, personalize and compassionate care. This is challenge as we try to strike the balance technical knowledge and skills, therapeutic care with intimate, personalize and compassionate care. Again, this is not easy, but it is not impossible. I have seen and experienced it with my preceptors, with nursing home care and with AHS. References Arnold, N., & Weir, D. (1994). 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