Implementing Home Health Standards in Clinical Practice Reprinted from the Handbook of Home Health Care Administration. In 1986, the American Nurses Association (ANA) published the first Standards of Home Health Practice. Revised in 1992 and expanded in 1999 to become Home Health Nursing: Scope and Standards of Practice, it was revised in 2008 and again in 2014. In the 2014 edition, there are 6 standards of home healthcare nursing practice and 10 standards of professional performance for home healthcare nursing. The focus of this article is to describe the home healthcare standards and to provide guidance for implementation in clinical practice. It is strongly encouraged that home healthcare administrators, educators, and staff obtain a copy of the standards and fully read this essential home healthcare resource.
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Home Healthcare Nursing Defined and Described The workgroup for the home healthcare scope and standards developed an updated definition of home healthcare nursing. The following definition was affirmed during the review process, which allowed the opportunity for public comment: Home health nursing is a specialty area of practice that promotes optimal health and well-being for patients, their families and caregivers within their homes and communities. Home health nurses use a holistic approach aimed at empowering patients, families, and caregivers to achieve their highest levels of physical, functional, spiritual, and psychosocial health. Home health nurses provide nursing services to patients of all ages and cultures and at all stages of health and illness, including end of life. (American Nurses Association [ANA], 2014, p. 5)
Lisa A. Gorski, MS, APRN, BC, CRNI
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standards that are applicable to home healthcare. Notably, the Infusion Nurses Society (2011) revises and publishes the Infusion Nursing Standards of Practice, which address all settings across the continuum of care.
Standards of Home Healthcare Nursing Practice The term standard is defined as an authoritative statement defined and promoted by the profession by which quality of practice, service, or education can be evaluated (ANA, 2010, p. 146). The ANA (2014) identifies the six steps of the nursing process as the “Standards of Practice for Home Health Nursing.” These standards are “authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty are expected to perform competently”(ANA, 2010, p. 31). The ANA emphasizes the importance of recognizing that the nursing process is more than the separate or singular actions of assessment, diagnosis, outcome identification, planning, implementation, and evaluation, but is a nonlinear process with a constant “back and forth” between and among the steps. For example, although outcomes may be identified based on evaluation, these outcomes may be modified to reflect assessment of the patient’s current condition or progress. Both the professional registered nurse and the advanced or specialized nurse are expected to follow the nursing process, which provides a framework for working with the patient and
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One of the challenges, and attractions, for nurses in home healthcare practice is the broad scope of practice. Unlike nurses who may work in a specific practice area defined by patient condition (e.g., cardiac care, cancer care) or age group, home healthcare nurses care for patients with a wide variety of diagnoses and for patients across the life span. Home healthcare nurses must have a high level of expertise in assessment, clinical decision making, and clinical practice (ANA, 2014). They fulfill many roles in day-to-day practice, not only providing and coordinating care, but also educating and counseling patients, families, and other healthcare providers; acting as a patient advocate; and supervising home healthcare personnel (e.g., licensed practical nurses, nursing assistants). Another unique aspect of home healthcare nursing is that home healthcare nurses assume a significant degree of responsibility in financially managing the cost of care and must have knowledge related to the reimbursement systems for home healthcare. Some home healthcare nurses may work with specific patient populations within the home care organization such as geriatrics, patients with diabetes, or neonatal care. Home healthcare nurses should be aware that the ANA publishes numerous standards of practice documents for specialty areas of practice, often in conjunction with specialty nursing organizations. Table 1 lists some of the ANA specialty standards documents that may be of interest to home healthcare nurses. Other specialty nursing organizations also publish
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family. Each standard includes specific competencies for both the home healthcare registered nurse and the advanced practice registered nurse (APRN) or the graduate-level–prepared nurse in home healthcare. The APRN holds a master’s or doctoral degree in nursing. APRNs build on the practice of the generalist nurse by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and significant role autonomy. With healthcare reform and an ever-growing focus on community care, there is great need as well as increasing opportunities for APRNs in home healthcare (ANA, 2014, p. 13). An APRN typically works with more complex patients, focuses on promotion of evidence-based practice, and works not only at the direct patient care level, but also at the home healthcare organization level and broader healthcare system level. Clinical nurse specialists and nurse practitioners are the advanced practice roles most frequently seen in home healthcare practice. Graduate-level–prepared nurses working in home healthcare, other than APRNs, may include those with master’s or doctoral-level education in areas such as business or healthcare administration, education, research, informatics, or quality improvement and most often serve in administrative and organizational leadership positions (ANA, 2014). A description of each home healthcare nursing practice standard is provided. Note that for the purpose of this article, the focus is on the standards as applied to the generalist nurse in home healthcare practice. Each standard includes specific competencies that are reflective
of compliance with the standard. Some, but not all, of the competencies under each standard are discussed with clinical examples to demonstrate their application. Standard 1: Assessment
“The home health registered nurse collects comprehensive data pertinent to the patient’s health and/or the situation” (ANA, 2014, p. 44). The measurement criteria under this standard state that the nurse collects comprehensive data, which includes physical, functional, nutrition, psychosocial, emotional, cognitive, sexual, cultural, agerelated, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process. In agencies certified by the Centers for Medicare and Medicaid Services, the Outcome and Assessment Information Set (OASIS) items are embedded into assessment forms. OASIS items are intended as data collection items, specifically for use with adult, nonobstetric patients to evaluate outcomes of care over time. Although some OASIS items address assessment of specific areas such as functional ability and number and level of wounds, it is important that home healthcare nurses realize that OASIS items do not comprise a comprehensive assessment. Further assessment is required to describe the patient’s condition. For example, OASIS surgical wound assessment requires that the nurse code a wound as fully granulating, early/partial granulation, or not healing. Beyond the OASIS item, further documentation to describe the wound will include presence/ type of any drainage, peri-wound skin condition, and presence of staples or sutures.
Table 1. Selected Specialty Standards of Practice From the American Nurses Association Addiction nursing
Nursing professional development
Cardiovascular nursing
Palliative nursing
Faith community nursing
Pediatric nursing
Gerontology nursing
Public health nursing
Holistic nursing
Psychiatric–mental health nursing
Intellectual and developmental disabilities nursing
Rheumatology nursing
Neonatal nursing
Transplant nursing
Neuroscience nursing Source: Data from Nursesbooks.org. (2013). Standards. Retrieved from http://www.nursesbooks.org/Main-Menu/Standards.aspx. ANA Standards may be purchased at www.nursingworld.com. Infusion Nursing Standards of Practice may be purchased at www.ins1.org.
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Another competency under assessment addresses the need to involve the family, other caregivers, and other healthcare providers in data collection. Family members or other caregivers are frequently involved in the patient’s care, such as providing medication or meal assistance. For example, if a family member is providing meal preparation, assessment should include the family member’s level of knowledge and understanding of any prescribed dietary limitations. Specific self-care management skills are also assessed. The home healthcare nurse should never make assumptions about a patient’s ability based on self-report. Further assessment and investigation are frequently necessary. Consider the case of Mr. Smith who has diabetes and has been repeatedly hospitalized for hyperglycemic episodes. All aspects of diabetic management should be assessed, from diet to ability to draw up the insulin dose correctly to administration technique. Consider that Mr. Smith may well have been independent and accurate with insulin administration for years but perhaps there are recent visual changes that have affected accuracy in drawing up his insulin or perhaps Mr. Smith is experiencing some cognitive changes that impact his memory. Such factors may influence his self-care abilities and result in his recent hospitalizations. Assessment of potential patient barriers to managing their healthcare is a vitally important aspect of home healthcare nursing. The standards specifically address the need to identify deficits and barriers to the patient effectively performing self-care management skills and behaviors. Consider also the case of Mrs. Coleman, a patient with multiple diagnoses including asthma, heart failure, diabetes, Parkinson disease, and arthritis who takes many medications to manage her conditions. She has been in and out of the hospital several times over the last few months, primarily for exacerbations of asthma. The first day after she returns from the hospital, you admit Mrs. Coleman to your home healthcare agency and perform a physical assessment. Her lungs are currently clear, and all vital signs are within normal limits when compared to baseline information from the hospital. Although she is weak after returning home, overall she feels better and has an adequate appetite and good fluid intake. There are no obvious problems in relation to the physical assessment. One of the competencies under “assessment” states that the home healthcare nurse “synthe-
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sizes available data, information and knowledge relevant to the patient’s situation to identify patterns and variances” (ANA, 2014, p. 45). The home healthcare nurse’s competence in the ability to scrutinize, evaluate, and analyze assessment details is critically important in home healthcare nursing in order to achieve the best outcomes for patients. An overarching goal, and a publicly reported outcome for home healthcare agencies, is to reduce unplanned hospitalizations. So it must be asked, why is Mrs. Coleman in the hospital so often? Assessment must address potential contributory factors. Questions the home healthcare nurse must ask include: • Are there environmental causes to her respiratory exacerbations? Considerations might include exposure to irritants in the home or infection control issues. Questioning Mrs. Coleman about the circumstances leading to her symptoms may provide clues. Obtaining and reviewing hospital data related to the admissions or discussion about rehospitalization issues with her physician may also prove helpful. • Are there issues with her taking prescribed medications? Taking the time to review her medications, you find disorganization and multiple bottles of old and new prescriptions mixed together. You also find that there are financial issues making it difficult for Mrs. Coleman to always order and pay for her refilled medications on time. • Mrs. Coleman takes inhaled medications to manage her asthma. Does Mrs. Coleman use her prescribed inhalers correctly? Research has shown that many patients do not use their inhalers correctly (e.g., Bryant et al., 2013). Clearly, if the inhaled medication is not reaching her lungs, this is another likely contributing factor in Mrs. Coleman’s asthma exacerbations. Thorough and comprehensive assessment is essential in developing an individualized plan of care. Assessment data are documented in the medical record. Standard 2: Diagnosis
This standard states that “the home health registered nurse analyzes the assessment data to determine the diagnoses, needs, or issues” (ANA, 2014, p. 46). The ANA uses the term diagnosis as
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a standard of professional practice, stating that registered nurses use both nursing and medical diagnoses “depending upon the educational and clinical preparation and legal authority of the nurse” (ANA, 2010, p. 64). The nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Without “naming” the nursing diagnoses, it is difficult to establish a sound plan to address them! Competencies under the diagnosis standard address the need for reviewing and validating the nursing diagnoses with the patient, family, and other healthcare providers and the directive to use standardized classification systems and clinical decision support tools, when available, in identifying diagnoses (ANA, 2014). Another important competency emphasizes that both actual and potential risks to the patient’s health and safety are identified. For example, the primary diagnosis of a patient relates to the presence of a wound requiring ongoing treatment. However, the patient has a history of heart failure and a history of several hospitalizations for dehydration. Although the assessment data indicate the patient is currently clinically stable in terms of vital signs and he reports good fluid intake, the potential problems of fluid volume excess and deficit are identified. When potential problems are named and listed, this will ensure ongoing assessment not only of wound healing, but also of his nutritional intake and signs of heart failure exacerbation. Examples of accepted terminology include the standardized client problem list from the Omaha System or the accepted nursing diagnoses defined by NANDA International (NANDA-I). Nursing diagnoses or problems are validated with the patient, family, and other healthcare providers. For example, in the case of Mr. Smith, the assessment reveals that he is not drawing up his insulin accurately, he has had a history of hyperglycemic episodes resulting in repeated hospitalizations, and there are deficits in his knowledge of diabetic diet management. In discussing the home care plan with Mr. Smith, he agrees that he needs help in these areas. Omaha System problems would include Nutrition (signs and symptoms of hyperglycemia and does not follow recommended nutrition plan) and Medication regimen (signs and symptoms including evidence of adverse reaction of hyperglycemia) (Martin, 2005). If using NANDA-I nursing diagnoses, they could include ineffective
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self-health management and risk for unstable glucose level (Ackley & Ladwig, 2011). When diagnoses are validated with patients and family members, they, as well as the home healthcare nurse, should be able to verbalize the purpose of the home care visits and what healthcare issues they are working on with their home healthcare nurse. Standard 3: Outcomes Identification
The home healthcare nurse identifies expected outcomes for a plan individualized to the patient, the family, other caregivers, and the caregiving situation (ANA, 2014, p. 47). It is important to state that expected outcomes are not decided on by the home healthcare nurse alone; rather, this is a collaborative process involving the patient and family and other healthcare team members. Goals should be “SMART,” that is, specific, measurable, achievable, relevant, and time-defined (ANA, 2014). Patient values, ethical considerations, the home care environment, and cultural considerations are all incorporated into identifying expected outcomes. Examples of some measurable outcomes developed in conjunction with the patients in the preceding examples might include: • Mr. Smith will demonstrate accuracy in drawing up his insulin dose. Target date: Within 3 days after start of care. • Mrs. Coleman will demonstrate good technique in administering her inhaled medications. Target date: Within 2 days after start of care. • Mrs. Coleman will state three signs/symptoms of asthma exacerbation to report to the home healthcare nurse/physician. Target date: Within 3 days after start of care. Standard 4: Planning
The home healthcare nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes (ANA, 2014, p. 49). Measurement criteria described in this standard include developing an individualized plan adapted to the patient’s unique needs and preferences; providing for a smooth transition to home care and to discharge from home care; defining the plan within boundaries of current rules and regulations and standards; and integrating best practices, research, and evidence-based practice guidelines into the plan (ANA, 2014). When planning care, it is important to consider the etiology of patient
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To address medication adherence, the home healthcare nurse plans to provide patient education about each medication as specifically listed on the pathway. But planning must also consider the patient’s situation.
problems and nursing diagnoses identified upon assessment. Consider a patient who has dyspnea with activities. In developing a plan for reducing dyspnea, the plan and interventions will be quite different for a patient who has dyspnea due to chronic lung disease versus a patient without any lung disease but who has been deconditioned after a protracted hospitalization prior to home care. Many agencies have standardized clinical pathways for planning and implementing care for patients with heart failure. Such pathways are based on current evidence addressing medication adherence, dietary restrictions, activity and exercise, and patient/caregiver self-monitoring of daily weights and symptoms. To address medication adherence, the home healthcare nurse plans to provide patient education about each medication as specifically listed on the pathway. But planning must also consider the patient’s situation. Assessment has revealed not only lack of knowledge about medications, but also organizational issues and financial limitations—as cited in the case of Mrs. Coleman—and this patient desires help in managing her medications. The nurse must consider alternative strategies, not listed on the standardized pathway, in the plan for providing home care. For example, the nurse contacts the physician for an additional order for medical social work for financial issues and planning and adds interventions that address organizing and simplifying medication management to the pathway. Standard 5: Implementation
The home healthcare registered nurse implements the individualized patient plan of care (ANA, 2014, p. 51). This standard includes four areas: coordination of care, health teaching and health promotion, consultation (APRN only), and prescriptive authority and treatment (APRN only). It is expected that the home healthcare nurse implements the plan in a safe and timely manner, that evidence-based interventions and treatments are utilized, that the plan is coordinated with all members of the healthcare team, and that all
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appropriate resources are utilized. The patient educator role is especially important in home healthcare nursing. Nurses must partner with the patient and family, not only in increasing knowledge and ability, but also in increasing motivation and confidence in the ability to change. Teaching strategies should include use of simple language, motivational interviewing and coaching techniques, and use of strategies such as teach-back and return demonstrations (ANA, 2014). Getting back to the cases of Mr. Smith and Mrs. Coleman, both patients had potential medication management issues that could be contributing factors in disease exacerbation. Insulin administration and inhaled medication technique are assessed and addressed in the plan of care. When prioritizing safe and timely implementation of interventions, these are interventions that are best done during the initial home visits to optimize symptom management and reduce risk of hyperglycemia and asthma symptom exacerbation. In the case of Mr. Smith, the plan and interventions are modified. Additional interventions are developed when his technique in drawing up his insulin is evaluated and the nurse finds that his eyesight limits his ability. Although his actual administration technique is good, the home healthcare nurse and Mr. Smith determine that he could benefit from an aid to compensate for his visual impairment, such as a syringe magnifier, or perhaps an insulin pen would work. Because it will take a day or two to obtain the aid, the nurse draws up his insulin for administration over the next 2 days, until the next planned home visit, to ensure that he will get his correct dose of insulin. If Mr. Smith had an available and willing caregiver, the nurse would likely have modified the plan to involve the caregiver in this aspect of care. Implementation of evidence-based interventions is emphasized. Consider the case of Mrs. Brown who requires 7 days of intravenous (IV) antibiotics at home to treat an infection. Mrs. Brown will require a peripheral IV (PIV) catheter for her antibiotics. All patients with invasive devices, including all types of IV catheters, are
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fusions. Implementation of this plan requires that the evidence-based infection prevention precautions are also taught to the patient. Standard 6: Evaluation
If diagnoses and expected outcomes are no longer appropriate or if planned interventions are not working, the overall plan of care is revised.
at risk for infection; complications of PIV catheters also include phlebitis, infiltration, and nerve damage. What evidence-based interventions reduce the risk for such complications? The Infusion Nursing Standards of Practice (Infusion Nurses Society, 2011) include the following evidence-based guidelines: • Proper hand hygiene • Appropriate site selection; for example, avoiding areas of flexion (phlebitis/infiltration risk), lateral/ventral surface of wrist (nerve damage risk), and lower extremities (infection risk) • Attention to skin antisepsis and aseptic technique during PIV placement • Maintenance of aseptic technique during infusion administration • Attention to needleless connector disinfection prior to connecting infusions to the patient’s catheter • Assessment and removal of PIV with signs of any complications The nurse’s assessment of Mrs. Brown reveals no functional limitations, and she is willing to learn how to administer her own IV antibiotic in-
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The last standard of home healthcare nursing practice states that the home healthcare nurse evaluates progress toward attainment of outcomes (ANA, 2014, p. 58). Evaluation is an ongoing process. Mrs. Brown is doing very well administering her IV antibiotics. She is very careful about washing her hands before each IV antibiotic infusion, consistently maintains aseptic technique during the procedure, and has tolerated her infusions well without any side effects. There is no need to modify the plan. However, if diagnoses and expected outcomes are no longer appropriate or if planned interventions are not working, the overall plan of care is revised. Looking at the case of Mr. Smith yet one more time, a review of his technique in preparing his insulin revealed that his visual limitations affected his ability to draw up his insulin accurately. The intervention of a magnifier has worked well for him. He is now able to draw up his insulin accurately and consistently, and he is very pleased with this outcome. Mr. Smith’s fasting blood glucose (BG) levels are currently good. However, for years, he has only checked his fasting BG levels and has not been agreeable to checking his BG more often. An order for a hemoglobin A1c (HbA1c) is obtained to evaluate his long-term glucose control, an evidencebased recommendation for monitoring patients with diabetes. His HbA1c results come back at 8.5%, higher than the generally recommended level of under 7% (American Diabetes Association, 2013). Good glycemic control is essential to reducing the risks of long-term diabetic complications. The meaning and implications of his elevated HbA1c level are discussed with Mr. Smith. He is agreeable, based on these results, to reevaluating his plan for BG monitoring. He will check his BG level before dinner and at bedtime, instead of his fasting levels, for at least 2 weeks; a consistent pattern of BG elevation in the afternoon is found. In consulting the patient’s physician, dietary intake is to be reevaluated before possibly making changes in Mr. Smith’s long-acting insulin. The home healthcare nurse is meeting the standard of evaluation by consistently evaluating Mr. Smith against established
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expected outcomes, he has been included in the process, and the nurse has revised the plan and implementation strategies.
Standards of Professional Performance The Standards of Professional Performance describe competent levels of behavior in the professional nursing role (ANA, 2010, p. 10). Beyond directly caring for patients and applying the Standards of Practice for Home Health Nursing in their day-to-day clinical setting, all registered nurses are also expected to engage in professional activities related to their role. Each of the professional performance roles is briefly described. Standard 7: Ethics
The home healthcare nurse practices ethically (ANA, 2014, p. 60). The classic and essential reference for nurses is the Code of Ethics for Nurses with Interpretive Statements, which was recently updated and released (ANA, 2015). A discussion reflecting on the nine provisions of the Code of Ethics related to home healthcare is provided within the document (ANA, 2014). Some examples of ethical issues faced by home healthcare nurses include: • The patient who wants to remain in his or her home despite safety issues • Dealing with end-of-life issues when patients and family members have different views • Neglectful or abusive caregivers • Ensuring patient privacy when patients are dependent on others in meeting their needs • Limited home visits under insurance plans when patients clearly require more home visits to remain safe • Services needed beyond the agency’s ability to provide them The protection of patient dignity, autonomy, rights, and confidentiality must be ensured. Home healthcare is different from any other setting in that the nurse is the “outsider,” with the patient and family “allowing” the nurse to provide care. The home healthcare nurse must be a patient advocate, informing patients about risks, benefits, and outcomes of the healthcare regimens. When dealing with insurance payers requiring authorization for home visits, the home healthcare nurse must clearly articulate information about the patient’s problems, the planned interventions, lack
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of progress toward expected outcomes, and what it will take to improve the patient outcome. Most home healthcare agencies have internal or external resources to deal with ethical issues, such as formal ethics committees. The home healthcare nurse must have knowledge of these resources and refer to and participate in ethical decision making as appropriate. Standard 8: Education
The home healthcare nurse attains knowledge and competency that reflects current nursing practice (ANA, 2014, p. 62). As mentioned in the introduction of this article, a big challenge in home healthcare nursing is the broad scope of practice. For example, the new home healthcare nurse may come from a surgical floor setting, with good experience and knowledge about wound healing and postoperative complications; however, the nurse may have limited understanding or experience in the management of the patient with heart failure, chronic obstructive lung disease, or diabetes. Alternatively, longtime home healthcare nurses may fall into the belief of doing things as they always have done them and may not be up to date on the latest evidence-based practice guidelines. Learning is a lifelong process for all nursing professionals. The competencies under this standard include a commitment to lifelong learning, the acquisition of evidence-based knowledge and skills, and maintaining professional records providing evidence of competence and lifelong learning (ANA, 2014). Attending as many educational opportunities as possible that are offered through the home healthcare agency is one way to stay current. But in this rapidly changing and evolving world of healthcare, the home healthcare nurse must also identify his or her own personal learning needs and seek knowledge to improve clinical practice. Subscribing to and regularly reading professional journals (e.g., Home Healthcare Now) is one way to stay current. There are increasing numbers of Internet Web sites and Web-based educational sessions allowing the nurse to obtain needed education in a convenient and cost-effective (often free) manner. The professional home healthcare nurse must seek the learning experiences needed to maintain competence. It is also a professional responsibility to share educational findings and experiences with coworkers (ANA, 2014).
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Standard 9: Evidence-Based Practice and Research
As discussed in the Standards of Practice for Home Health Nursing, the importance of implementing evidence-based practices is emphasized. Research is required to provide the evidence on which interventions are based and home healthcare programs are structured. Safe, efficient, and cost-effective care practices must be identified to ensure the best patient outcomes. The home healthcare nurse meets this standard by using evidence to guide practice, identifying clinical problems or questions for research, and conducting research or participating in data collection or other research activities. Consider the patient with an indwelling urinary catheter who is having increasing problems with bladder spasms. The nurse previously assigned to this patient had been placing larger catheters. The newly assigned nurse questions this practice, reviewing pertinent literature and consulting with the agency APRN, and finds placement of larger catheters actually can cause urethral damage and more spasms. Further study of agency practices may be warranted such as conducting clinical record reviews. Opportunities for education and development of clinical procedural guidelines for catheter selection and insertion are identified, also meeting the standards of quality of practice, education, collegiality, and collaboration. Standard 10: Quality of Practice
The home healthcare nurse contributes to quality nursing practice (ANA, 2014, p. 65). There are many ways in which the home healthcare nurse demonstrates this standard. Seeking opportunities to participate in quality improvement activities, such as reviewing medical records for quality indicators, is one way many home healthcare nurses evaluate quality in relation to documentation, quality of care, and compliance with home care regulations and reimbursement guidelines. Application of the nursing process as described in the previous standards of practice demonstrates quality. Standard 11: Communication
The home healthcare registered nurse communicates effectively in a variety of formats in all areas of practice (ANA, 2014, p. 67). Good communication skills are essential in all levels of
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Research is required to provide the evidence on which interventions are based and home healthcare programs are structured. Safe, efficient, and cost-effective care practices must be identified to ensure the best patient outcomes. nursing practice, whether dealing with patients, families, coworkers, or other healthcare providers. Unlike other healthcare settings, where nurses often have the opportunity to directly talk to other physicians and other healthcare providers, home care communication is primarily via telephone or written methods. Home care nurses must seek continuous improvement of their communication, as well as conflict resolution, skills (ANA, 2014). Additional competencies within this standard include the use of motivational interviewing and health coaching and the importance of assessing the language and literacy needs of patients in learning how to best communicate. Standard 12: Leadership
The home healthcare nurse demonstrates leadership in the professional practice setting and the profession (ANA, 2014, p. 68). The nurse demonstrates adherence to this standard in many ways, as previously addressed through adhering to all of the professional practice standards—by commitment to lifelong learning, acting as a preceptor to those new to home healthcare, and treating colleagues with respect, trust, and dignity (ANA, 2014). Active participation in organizational committees and teams and participation in professional organizations and other community activities, such as political or fundraising events, are additional ways to demonstrate leadership. Standard 13: Collaboration
The home healthcare nurse collaborates with patients, families, caregivers, interprofessional healthcare teams, and others in the conduct of nursing practice (ANA, 2014, p. 70). Collaboration is essential for the home healthcare nurse. In the earlier clinical examples, the importance
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Standard 16: Environmental Health
of collaboration with the patient, family, and other healthcare providers is emphasized as patient problems are identified and the care planning process is initiated. Home healthcare nurses most often serve as the case manager, overseeing the plan of care and working with physicians and other disciplines, perhaps physical therapy and medical social workers. Other organizations may be involved as well, such as the home infusion pharmacy that prepares and delivers all needed infusion therapy medications and supplies. Ongoing communication and collaboration with all others involved in the patient’s care are essential to ensure positive outcomes of care.
The home healthcare registered nurse practices in an environmentally safe and healthy manner (ANA, 2014, p. 75). This is a new standard and highly pertinent to home healthcare nursing. It is important that nurses understand issues affecting the environment. The competencies under this standard address advocating for safe disposal of products used in patient care and promoting an environment that reduces environmental health risks for patients, families, and home healthcare staff. An example would be use of dedicated equipment or supplies in the presence of multidrug-resistant organism infections.
Standard 14: Professional Practice Evaluation
Conclusion
This standard dictates that home healthcare nurses evaluate their own practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations (ANA, 2014, p. 72). Measurement criteria under this standard include self-evaluation to identify strengths and areas for improvement, incorporating feedback from peers, and taking action to achieve goals to improve practice.
In this article, the ANA Standards of Home Health Nursing Practice and Standards for Professional Performance for Home Health Nursing have been briefly summarized. Examples of how the standards can be implemented in day-to-day clinical practice were shared; however, there is much more detailed information available in the source document. To reiterate, every home healthcare agency should have an accessible copy of the standards (ANA, 2014), and all home healthcare nurses should be oriented to the standards. The standards are intended for and should be used in evaluating the individual home healthcare nurse’s delivery of nursing care and professional performance.
Standard 15: Resource Utilization
The home healthcare nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible (ANA, 2014, p. 73). When working in the home healthcare setting, the nurse must be especially aware of resources and services in the community that may meet patient needs during the episode of home healthcare or after discharge. For example, the patient may need and desire longterm help with bathing, transportation, or meals. These things are not typically covered by insurers, but there may be programs to assist the patient and the family. The home healthcare nurse must constantly assess for the patient’s needs and help the patient and family to identify and secure the services needed. The home healthcare nurse should advocate for cost-effective use of technology. For example, implementation of telemonitoring systems may decrease the number of nursing visits (saving a precious resource) while still allowing frequent assessment of vital signs and the ability to intervene for changes in condition such as increasing weight or blood pressure in the patient with heart failure.
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DOI:10.1097/NHH.0000000000000349
REFERENCES Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (9th ed.). St. Louis, MO: Mosby Elsevier. American Diabetes Association. (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(1 Suppl.), S11-S66. American Nurses Association. (2010). Scope and Standards of Practice. Washington, DC: Nursebooks.org. American Nurses Association. (2014). Home Health Nursing: Scope and Standards of Practice (2nd ed.). Washington, DC: Nursebooks.org. American Nurses Association. (2015). Code of Ethics for Nurses With Interpretive Statements. Washington, DC: Nursebooks.org. Bryant, L., Bang, C., Chew, C., Baik, S. H., & Wiseman, D. (2013). Adequacy of inhaler technique used by people with asthma or chronic obstructive pulmonary disease. Journal of Primary Health Care, 5(3), 191-198. Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1 Suppl.), S1-S110. Martin, K. S. (2005). The Omaha System: A Key to Practice, Documentation, and Information Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.
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Home Healthcare Nursing Defined and Described The workgroup for the home healthcare scope and standards developed an updated definition of home healthcare nursing. The following definition was affirmed during the review process, which allowed the opportunity for public comment: Home health nursing is a specialty area of practice that promotes optimal health and well-being for patients, their families and caregivers within their homes and communities. Home health nurses use a holistic approach aimed at empowering patients, families, and caregivers to achieve their highest levels of physical, functional, spiritual, and psychosocial health. Home health nurses provide nursing services to patients of all ages and cultures and at all stages of health and illness, including end of life. (American Nurses Association [ANA], 2014, p. 5)
Lisa A. Gorski, MS, APRN, BC, CRNI
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standards that are applicable to home healthcare. Notably, the Infusion Nurses Society (2011) revises and publishes the Infusion Nursing Standards of Practice, which address all settings across the continuum of care.
Standards of Home Healthcare Nursing Practice The term standard is defined as an authoritative statement defined and promoted by the profession by which quality of practice, service, or education can be evaluated (ANA, 2010, p. 146). The ANA (2014) identifies the six steps of the nursing process as the “Standards of Practice for Home Health Nursing.” These standards are “authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty are expected to perform competently”(ANA, 2010, p. 31). The ANA emphasizes the importance of recognizing that the nursing process is more than the separate or singular actions of assessment, diagnosis, outcome identification, planning, implementation, and evaluation, but is a nonlinear process with a constant “back and forth” between and among the steps. For example, although outcomes may be identified based on evaluation, these outcomes may be modified to reflect assessment of the patient’s current condition or progress. Both the professional registered nurse and the advanced or specialized nurse are expected to follow the nursing process, which provides a framework for working with the patient and
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One of the challenges, and attractions, for nurses in home healthcare practice is the broad scope of practice. Unlike nurses who may work in a specific practice area defined by patient condition (e.g., cardiac care, cancer care) or age group, home healthcare nurses care for patients with a wide variety of diagnoses and for patients across the life span. Home healthcare nurses must have a high level of expertise in assessment, clinical decision making, and clinical practice (ANA, 2014). They fulfill many roles in day-to-day practice, not only providing and coordinating care, but also educating and counseling patients, families, and other healthcare providers; acting as a patient advocate; and supervising home healthcare personnel (e.g., licensed practical nurses, nursing assistants). Another unique aspect of home healthcare nursing is that home healthcare nurses assume a significant degree of responsibility in financially managing the cost of care and must have knowledge related to the reimbursement systems for home healthcare. Some home healthcare nurses may work with specific patient populations within the home care organization such as geriatrics, patients with diabetes, or neonatal care. Home healthcare nurses should be aware that the ANA publishes numerous standards of practice documents for specialty areas of practice, often in conjunction with specialty nursing organizations. Table 1 lists some of the ANA specialty standards documents that may be of interest to home healthcare nurses. Other specialty nursing organizations also publish
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family. Each standard includes specific competencies for both the home healthcare registered nurse and the advanced practice registered nurse (APRN) or the graduate-level–prepared nurse in home healthcare. The APRN holds a master’s or doctoral degree in nursing. APRNs build on the practice of the generalist nurse by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and significant role autonomy. With healthcare reform and an ever-growing focus on community care, there is great need as well as increasing opportunities for APRNs in home healthcare (ANA, 2014, p. 13). An APRN typically works with more complex patients, focuses on promotion of evidence-based practice, and works not only at the direct patient care level, but also at the home healthcare organization level and broader healthcare system level. Clinical nurse specialists and nurse practitioners are the advanced practice roles most frequently seen in home healthcare practice. Graduate-level–prepared nurses working in home healthcare, other than APRNs, may include those with master’s or doctoral-level education in areas such as business or healthcare administration, education, research, informatics, or quality improvement and most often serve in administrative and organizational leadership positions (ANA, 2014). A description of each home healthcare nursing practice standard is provided. Note that for the purpose of this article, the focus is on the standards as applied to the generalist nurse in home healthcare practice. Each standard includes specific competencies that are reflective
of compliance with the standard. Some, but not all, of the competencies under each standard are discussed with clinical examples to demonstrate their application. Standard 1: Assessment
“The home health registered nurse collects comprehensive data pertinent to the patient’s health and/or the situation” (ANA, 2014, p. 44). The measurement criteria under this standard state that the nurse collects comprehensive data, which includes physical, functional, nutrition, psychosocial, emotional, cognitive, sexual, cultural, agerelated, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process. In agencies certified by the Centers for Medicare and Medicaid Services, the Outcome and Assessment Information Set (OASIS) items are embedded into assessment forms. OASIS items are intended as data collection items, specifically for use with adult, nonobstetric patients to evaluate outcomes of care over time. Although some OASIS items address assessment of specific areas such as functional ability and number and level of wounds, it is important that home healthcare nurses realize that OASIS items do not comprise a comprehensive assessment. Further assessment is required to describe the patient’s condition. For example, OASIS surgical wound assessment requires that the nurse code a wound as fully granulating, early/partial granulation, or not healing. Beyond the OASIS item, further documentation to describe the wound will include presence/ type of any drainage, peri-wound skin condition, and presence of staples or sutures.
Table 1. Selected Specialty Standards of Practice From the American Nurses Association Addiction nursing
Nursing professional development
Cardiovascular nursing
Palliative nursing
Faith community nursing
Pediatric nursing
Gerontology nursing
Public health nursing
Holistic nursing
Psychiatric–mental health nursing
Intellectual and developmental disabilities nursing
Rheumatology nursing
Neonatal nursing
Transplant nursing
Neuroscience nursing Source: Data from Nursesbooks.org. (2013). Standards. Retrieved from http://www.nursesbooks.org/Main-Menu/Standards.aspx. ANA Standards may be purchased at www.nursingworld.com. Infusion Nursing Standards of Practice may be purchased at www.ins1.org.
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Another competency under assessment addresses the need to involve the family, other caregivers, and other healthcare providers in data collection. Family members or other caregivers are frequently involved in the patient’s care, such as providing medication or meal assistance. For example, if a family member is providing meal preparation, assessment should include the family member’s level of knowledge and understanding of any prescribed dietary limitations. Specific self-care management skills are also assessed. The home healthcare nurse should never make assumptions about a patient’s ability based on self-report. Further assessment and investigation are frequently necessary. Consider the case of Mr. Smith who has diabetes and has been repeatedly hospitalized for hyperglycemic episodes. All aspects of diabetic management should be assessed, from diet to ability to draw up the insulin dose correctly to administration technique. Consider that Mr. Smith may well have been independent and accurate with insulin administration for years but perhaps there are recent visual changes that have affected accuracy in drawing up his insulin or perhaps Mr. Smith is experiencing some cognitive changes that impact his memory. Such factors may influence his self-care abilities and result in his recent hospitalizations. Assessment of potential patient barriers to managing their healthcare is a vitally important aspect of home healthcare nursing. The standards specifically address the need to identify deficits and barriers to the patient effectively performing self-care management skills and behaviors. Consider also the case of Mrs. Coleman, a patient with multiple diagnoses including asthma, heart failure, diabetes, Parkinson disease, and arthritis who takes many medications to manage her conditions. She has been in and out of the hospital several times over the last few months, primarily for exacerbations of asthma. The first day after she returns from the hospital, you admit Mrs. Coleman to your home healthcare agency and perform a physical assessment. Her lungs are currently clear, and all vital signs are within normal limits when compared to baseline information from the hospital. Although she is weak after returning home, overall she feels better and has an adequate appetite and good fluid intake. There are no obvious problems in relation to the physical assessment. One of the competencies under “assessment” states that the home healthcare nurse “synthe-
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sizes available data, information and knowledge relevant to the patient’s situation to identify patterns and variances” (ANA, 2014, p. 45). The home healthcare nurse’s competence in the ability to scrutinize, evaluate, and analyze assessment details is critically important in home healthcare nursing in order to achieve the best outcomes for patients. An overarching goal, and a publicly reported outcome for home healthcare agencies, is to reduce unplanned hospitalizations. So it must be asked, why is Mrs. Coleman in the hospital so often? Assessment must address potential contributory factors. Questions the home healthcare nurse must ask include: • Are there environmental causes to her respiratory exacerbations? Considerations might include exposure to irritants in the home or infection control issues. Questioning Mrs. Coleman about the circumstances leading to her symptoms may provide clues. Obtaining and reviewing hospital data related to the admissions or discussion about rehospitalization issues with her physician may also prove helpful. • Are there issues with her taking prescribed medications? Taking the time to review her medications, you find disorganization and multiple bottles of old and new prescriptions mixed together. You also find that there are financial issues making it difficult for Mrs. Coleman to always order and pay for her refilled medications on time. • Mrs. Coleman takes inhaled medications to manage her asthma. Does Mrs. Coleman use her prescribed inhalers correctly? Research has shown that many patients do not use their inhalers correctly (e.g., Bryant et al., 2013). Clearly, if the inhaled medication is not reaching her lungs, this is another likely contributing factor in Mrs. Coleman’s asthma exacerbations. Thorough and comprehensive assessment is essential in developing an individualized plan of care. Assessment data are documented in the medical record. Standard 2: Diagnosis
This standard states that “the home health registered nurse analyzes the assessment data to determine the diagnoses, needs, or issues” (ANA, 2014, p. 46). The ANA uses the term diagnosis as
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a standard of professional practice, stating that registered nurses use both nursing and medical diagnoses “depending upon the educational and clinical preparation and legal authority of the nurse” (ANA, 2010, p. 64). The nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Without “naming” the nursing diagnoses, it is difficult to establish a sound plan to address them! Competencies under the diagnosis standard address the need for reviewing and validating the nursing diagnoses with the patient, family, and other healthcare providers and the directive to use standardized classification systems and clinical decision support tools, when available, in identifying diagnoses (ANA, 2014). Another important competency emphasizes that both actual and potential risks to the patient’s health and safety are identified. For example, the primary diagnosis of a patient relates to the presence of a wound requiring ongoing treatment. However, the patient has a history of heart failure and a history of several hospitalizations for dehydration. Although the assessment data indicate the patient is currently clinically stable in terms of vital signs and he reports good fluid intake, the potential problems of fluid volume excess and deficit are identified. When potential problems are named and listed, this will ensure ongoing assessment not only of wound healing, but also of his nutritional intake and signs of heart failure exacerbation. Examples of accepted terminology include the standardized client problem list from the Omaha System or the accepted nursing diagnoses defined by NANDA International (NANDA-I). Nursing diagnoses or problems are validated with the patient, family, and other healthcare providers. For example, in the case of Mr. Smith, the assessment reveals that he is not drawing up his insulin accurately, he has had a history of hyperglycemic episodes resulting in repeated hospitalizations, and there are deficits in his knowledge of diabetic diet management. In discussing the home care plan with Mr. Smith, he agrees that he needs help in these areas. Omaha System problems would include Nutrition (signs and symptoms of hyperglycemia and does not follow recommended nutrition plan) and Medication regimen (signs and symptoms including evidence of adverse reaction of hyperglycemia) (Martin, 2005). If using NANDA-I nursing diagnoses, they could include ineffective
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self-health management and risk for unstable glucose level (Ackley & Ladwig, 2011). When diagnoses are validated with patients and family members, they, as well as the home healthcare nurse, should be able to verbalize the purpose of the home care visits and what healthcare issues they are working on with their home healthcare nurse. Standard 3: Outcomes Identification
The home healthcare nurse identifies expected outcomes for a plan individualized to the patient, the family, other caregivers, and the caregiving situation (ANA, 2014, p. 47). It is important to state that expected outcomes are not decided on by the home healthcare nurse alone; rather, this is a collaborative process involving the patient and family and other healthcare team members. Goals should be “SMART,” that is, specific, measurable, achievable, relevant, and time-defined (ANA, 2014). Patient values, ethical considerations, the home care environment, and cultural considerations are all incorporated into identifying expected outcomes. Examples of some measurable outcomes developed in conjunction with the patients in the preceding examples might include: • Mr. Smith will demonstrate accuracy in drawing up his insulin dose. Target date: Within 3 days after start of care. • Mrs. Coleman will demonstrate good technique in administering her inhaled medications. Target date: Within 2 days after start of care. • Mrs. Coleman will state three signs/symptoms of asthma exacerbation to report to the home healthcare nurse/physician. Target date: Within 3 days after start of care. Standard 4: Planning
The home healthcare nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes (ANA, 2014, p. 49). Measurement criteria described in this standard include developing an individualized plan adapted to the patient’s unique needs and preferences; providing for a smooth transition to home care and to discharge from home care; defining the plan within boundaries of current rules and regulations and standards; and integrating best practices, research, and evidence-based practice guidelines into the plan (ANA, 2014). When planning care, it is important to consider the etiology of patient
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To address medication adherence, the home healthcare nurse plans to provide patient education about each medication as specifically listed on the pathway. But planning must also consider the patient’s situation.
problems and nursing diagnoses identified upon assessment. Consider a patient who has dyspnea with activities. In developing a plan for reducing dyspnea, the plan and interventions will be quite different for a patient who has dyspnea due to chronic lung disease versus a patient without any lung disease but who has been deconditioned after a protracted hospitalization prior to home care. Many agencies have standardized clinical pathways for planning and implementing care for patients with heart failure. Such pathways are based on current evidence addressing medication adherence, dietary restrictions, activity and exercise, and patient/caregiver self-monitoring of daily weights and symptoms. To address medication adherence, the home healthcare nurse plans to provide patient education about each medication as specifically listed on the pathway. But planning must also consider the patient’s situation. Assessment has revealed not only lack of knowledge about medications, but also organizational issues and financial limitations—as cited in the case of Mrs. Coleman—and this patient desires help in managing her medications. The nurse must consider alternative strategies, not listed on the standardized pathway, in the plan for providing home care. For example, the nurse contacts the physician for an additional order for medical social work for financial issues and planning and adds interventions that address organizing and simplifying medication management to the pathway. Standard 5: Implementation
The home healthcare registered nurse implements the individualized patient plan of care (ANA, 2014, p. 51). This standard includes four areas: coordination of care, health teaching and health promotion, consultation (APRN only), and prescriptive authority and treatment (APRN only). It is expected that the home healthcare nurse implements the plan in a safe and timely manner, that evidence-based interventions and treatments are utilized, that the plan is coordinated with all members of the healthcare team, and that all
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appropriate resources are utilized. The patient educator role is especially important in home healthcare nursing. Nurses must partner with the patient and family, not only in increasing knowledge and ability, but also in increasing motivation and confidence in the ability to change. Teaching strategies should include use of simple language, motivational interviewing and coaching techniques, and use of strategies such as teach-back and return demonstrations (ANA, 2014). Getting back to the cases of Mr. Smith and Mrs. Coleman, both patients had potential medication management issues that could be contributing factors in disease exacerbation. Insulin administration and inhaled medication technique are assessed and addressed in the plan of care. When prioritizing safe and timely implementation of interventions, these are interventions that are best done during the initial home visits to optimize symptom management and reduce risk of hyperglycemia and asthma symptom exacerbation. In the case of Mr. Smith, the plan and interventions are modified. Additional interventions are developed when his technique in drawing up his insulin is evaluated and the nurse finds that his eyesight limits his ability. Although his actual administration technique is good, the home healthcare nurse and Mr. Smith determine that he could benefit from an aid to compensate for his visual impairment, such as a syringe magnifier, or perhaps an insulin pen would work. Because it will take a day or two to obtain the aid, the nurse draws up his insulin for administration over the next 2 days, until the next planned home visit, to ensure that he will get his correct dose of insulin. If Mr. Smith had an available and willing caregiver, the nurse would likely have modified the plan to involve the caregiver in this aspect of care. Implementation of evidence-based interventions is emphasized. Consider the case of Mrs. Brown who requires 7 days of intravenous (IV) antibiotics at home to treat an infection. Mrs. Brown will require a peripheral IV (PIV) catheter for her antibiotics. All patients with invasive devices, including all types of IV catheters, are
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fusions. Implementation of this plan requires that the evidence-based infection prevention precautions are also taught to the patient. Standard 6: Evaluation
If diagnoses and expected outcomes are no longer appropriate or if planned interventions are not working, the overall plan of care is revised.
at risk for infection; complications of PIV catheters also include phlebitis, infiltration, and nerve damage. What evidence-based interventions reduce the risk for such complications? The Infusion Nursing Standards of Practice (Infusion Nurses Society, 2011) include the following evidence-based guidelines: • Proper hand hygiene • Appropriate site selection; for example, avoiding areas of flexion (phlebitis/infiltration risk), lateral/ventral surface of wrist (nerve damage risk), and lower extremities (infection risk) • Attention to skin antisepsis and aseptic technique during PIV placement • Maintenance of aseptic technique during infusion administration • Attention to needleless connector disinfection prior to connecting infusions to the patient’s catheter • Assessment and removal of PIV with signs of any complications The nurse’s assessment of Mrs. Brown reveals no functional limitations, and she is willing to learn how to administer her own IV antibiotic in-
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The last standard of home healthcare nursing practice states that the home healthcare nurse evaluates progress toward attainment of outcomes (ANA, 2014, p. 58). Evaluation is an ongoing process. Mrs. Brown is doing very well administering her IV antibiotics. She is very careful about washing her hands before each IV antibiotic infusion, consistently maintains aseptic technique during the procedure, and has tolerated her infusions well without any side effects. There is no need to modify the plan. However, if diagnoses and expected outcomes are no longer appropriate or if planned interventions are not working, the overall plan of care is revised. Looking at the case of Mr. Smith yet one more time, a review of his technique in preparing his insulin revealed that his visual limitations affected his ability to draw up his insulin accurately. The intervention of a magnifier has worked well for him. He is now able to draw up his insulin accurately and consistently, and he is very pleased with this outcome. Mr. Smith’s fasting blood glucose (BG) levels are currently good. However, for years, he has only checked his fasting BG levels and has not been agreeable to checking his BG more often. An order for a hemoglobin A1c (HbA1c) is obtained to evaluate his long-term glucose control, an evidencebased recommendation for monitoring patients with diabetes. His HbA1c results come back at 8.5%, higher than the generally recommended level of under 7% (American Diabetes Association, 2013). Good glycemic control is essential to reducing the risks of long-term diabetic complications. The meaning and implications of his elevated HbA1c level are discussed with Mr. Smith. He is agreeable, based on these results, to reevaluating his plan for BG monitoring. He will check his BG level before dinner and at bedtime, instead of his fasting levels, for at least 2 weeks; a consistent pattern of BG elevation in the afternoon is found. In consulting the patient’s physician, dietary intake is to be reevaluated before possibly making changes in Mr. Smith’s long-acting insulin. The home healthcare nurse is meeting the standard of evaluation by consistently evaluating Mr. Smith against established
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expected outcomes, he has been included in the process, and the nurse has revised the plan and implementation strategies.
Standards of Professional Performance The Standards of Professional Performance describe competent levels of behavior in the professional nursing role (ANA, 2010, p. 10). Beyond directly caring for patients and applying the Standards of Practice for Home Health Nursing in their day-to-day clinical setting, all registered nurses are also expected to engage in professional activities related to their role. Each of the professional performance roles is briefly described. Standard 7: Ethics
The home healthcare nurse practices ethically (ANA, 2014, p. 60). The classic and essential reference for nurses is the Code of Ethics for Nurses with Interpretive Statements, which was recently updated and released (ANA, 2015). A discussion reflecting on the nine provisions of the Code of Ethics related to home healthcare is provided within the document (ANA, 2014). Some examples of ethical issues faced by home healthcare nurses include: • The patient who wants to remain in his or her home despite safety issues • Dealing with end-of-life issues when patients and family members have different views • Neglectful or abusive caregivers • Ensuring patient privacy when patients are dependent on others in meeting their needs • Limited home visits under insurance plans when patients clearly require more home visits to remain safe • Services needed beyond the agency’s ability to provide them The protection of patient dignity, autonomy, rights, and confidentiality must be ensured. Home healthcare is different from any other setting in that the nurse is the “outsider,” with the patient and family “allowing” the nurse to provide care. The home healthcare nurse must be a patient advocate, informing patients about risks, benefits, and outcomes of the healthcare regimens. When dealing with insurance payers requiring authorization for home visits, the home healthcare nurse must clearly articulate information about the patient’s problems, the planned interventions, lack
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of progress toward expected outcomes, and what it will take to improve the patient outcome. Most home healthcare agencies have internal or external resources to deal with ethical issues, such as formal ethics committees. The home healthcare nurse must have knowledge of these resources and refer to and participate in ethical decision making as appropriate. Standard 8: Education
The home healthcare nurse attains knowledge and competency that reflects current nursing practice (ANA, 2014, p. 62). As mentioned in the introduction of this article, a big challenge in home healthcare nursing is the broad scope of practice. For example, the new home healthcare nurse may come from a surgical floor setting, with good experience and knowledge about wound healing and postoperative complications; however, the nurse may have limited understanding or experience in the management of the patient with heart failure, chronic obstructive lung disease, or diabetes. Alternatively, longtime home healthcare nurses may fall into the belief of doing things as they always have done them and may not be up to date on the latest evidence-based practice guidelines. Learning is a lifelong process for all nursing professionals. The competencies under this standard include a commitment to lifelong learning, the acquisition of evidence-based knowledge and skills, and maintaining professional records providing evidence of competence and lifelong learning (ANA, 2014). Attending as many educational opportunities as possible that are offered through the home healthcare agency is one way to stay current. But in this rapidly changing and evolving world of healthcare, the home healthcare nurse must also identify his or her own personal learning needs and seek knowledge to improve clinical practice. Subscribing to and regularly reading professional journals (e.g., Home Healthcare Now) is one way to stay current. There are increasing numbers of Internet Web sites and Web-based educational sessions allowing the nurse to obtain needed education in a convenient and cost-effective (often free) manner. The professional home healthcare nurse must seek the learning experiences needed to maintain competence. It is also a professional responsibility to share educational findings and experiences with coworkers (ANA, 2014).
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Standard 9: Evidence-Based Practice and Research
As discussed in the Standards of Practice for Home Health Nursing, the importance of implementing evidence-based practices is emphasized. Research is required to provide the evidence on which interventions are based and home healthcare programs are structured. Safe, efficient, and cost-effective care practices must be identified to ensure the best patient outcomes. The home healthcare nurse meets this standard by using evidence to guide practice, identifying clinical problems or questions for research, and conducting research or participating in data collection or other research activities. Consider the patient with an indwelling urinary catheter who is having increasing problems with bladder spasms. The nurse previously assigned to this patient had been placing larger catheters. The newly assigned nurse questions this practice, reviewing pertinent literature and consulting with the agency APRN, and finds placement of larger catheters actually can cause urethral damage and more spasms. Further study of agency practices may be warranted such as conducting clinical record reviews. Opportunities for education and development of clinical procedural guidelines for catheter selection and insertion are identified, also meeting the standards of quality of practice, education, collegiality, and collaboration. Standard 10: Quality of Practice
The home healthcare nurse contributes to quality nursing practice (ANA, 2014, p. 65). There are many ways in which the home healthcare nurse demonstrates this standard. Seeking opportunities to participate in quality improvement activities, such as reviewing medical records for quality indicators, is one way many home healthcare nurses evaluate quality in relation to documentation, quality of care, and compliance with home care regulations and reimbursement guidelines. Application of the nursing process as described in the previous standards of practice demonstrates quality. Standard 11: Communication
The home healthcare registered nurse communicates effectively in a variety of formats in all areas of practice (ANA, 2014, p. 67). Good communication skills are essential in all levels of
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Research is required to provide the evidence on which interventions are based and home healthcare programs are structured. Safe, efficient, and cost-effective care practices must be identified to ensure the best patient outcomes. nursing practice, whether dealing with patients, families, coworkers, or other healthcare providers. Unlike other healthcare settings, where nurses often have the opportunity to directly talk to other physicians and other healthcare providers, home care communication is primarily via telephone or written methods. Home care nurses must seek continuous improvement of their communication, as well as conflict resolution, skills (ANA, 2014). Additional competencies within this standard include the use of motivational interviewing and health coaching and the importance of assessing the language and literacy needs of patients in learning how to best communicate. Standard 12: Leadership
The home healthcare nurse demonstrates leadership in the professional practice setting and the profession (ANA, 2014, p. 68). The nurse demonstrates adherence to this standard in many ways, as previously addressed through adhering to all of the professional practice standards—by commitment to lifelong learning, acting as a preceptor to those new to home healthcare, and treating colleagues with respect, trust, and dignity (ANA, 2014). Active participation in organizational committees and teams and participation in professional organizations and other community activities, such as political or fundraising events, are additional ways to demonstrate leadership. Standard 13: Collaboration
The home healthcare nurse collaborates with patients, families, caregivers, interprofessional healthcare teams, and others in the conduct of nursing practice (ANA, 2014, p. 70). Collaboration is essential for the home healthcare nurse. In the earlier clinical examples, the importance
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Standard 16: Environmental Health
of collaboration with the patient, family, and other healthcare providers is emphasized as patient problems are identified and the care planning process is initiated. Home healthcare nurses most often serve as the case manager, overseeing the plan of care and working with physicians and other disciplines, perhaps physical therapy and medical social workers. Other organizations may be involved as well, such as the home infusion pharmacy that prepares and delivers all needed infusion therapy medications and supplies. Ongoing communication and collaboration with all others involved in the patient’s care are essential to ensure positive outcomes of care.
The home healthcare registered nurse practices in an environmentally safe and healthy manner (ANA, 2014, p. 75). This is a new standard and highly pertinent to home healthcare nursing. It is important that nurses understand issues affecting the environment. The competencies under this standard address advocating for safe disposal of products used in patient care and promoting an environment that reduces environmental health risks for patients, families, and home healthcare staff. An example would be use of dedicated equipment or supplies in the presence of multidrug-resistant organism infections.
Standard 14: Professional Practice Evaluation
Conclusion
This standard dictates that home healthcare nurses evaluate their own practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations (ANA, 2014, p. 72). Measurement criteria under this standard include self-evaluation to identify strengths and areas for improvement, incorporating feedback from peers, and taking action to achieve goals to improve practice.
In this article, the ANA Standards of Home Health Nursing Practice and Standards for Professional Performance for Home Health Nursing have been briefly summarized. Examples of how the standards can be implemented in day-to-day clinical practice were shared; however, there is much more detailed information available in the source document. To reiterate, every home healthcare agency should have an accessible copy of the standards (ANA, 2014), and all home healthcare nurses should be oriented to the standards. The standards are intended for and should be used in evaluating the individual home healthcare nurse’s delivery of nursing care and professional performance.
Standard 15: Resource Utilization
The home healthcare nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible (ANA, 2014, p. 73). When working in the home healthcare setting, the nurse must be especially aware of resources and services in the community that may meet patient needs during the episode of home healthcare or after discharge. For example, the patient may need and desire longterm help with bathing, transportation, or meals. These things are not typically covered by insurers, but there may be programs to assist the patient and the family. The home healthcare nurse must constantly assess for the patient’s needs and help the patient and family to identify and secure the services needed. The home healthcare nurse should advocate for cost-effective use of technology. For example, implementation of telemonitoring systems may decrease the number of nursing visits (saving a precious resource) while still allowing frequent assessment of vital signs and the ability to intervene for changes in condition such as increasing weight or blood pressure in the patient with heart failure.
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DOI:10.1097/NHH.0000000000000349
REFERENCES Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (9th ed.). St. Louis, MO: Mosby Elsevier. American Diabetes Association. (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(1 Suppl.), S11-S66. American Nurses Association. (2010). Scope and Standards of Practice. Washington, DC: Nursebooks.org. American Nurses Association. (2014). Home Health Nursing: Scope and Standards of Practice (2nd ed.). Washington, DC: Nursebooks.org. American Nurses Association. (2015). Code of Ethics for Nurses With Interpretive Statements. Washington, DC: Nursebooks.org. Bryant, L., Bang, C., Chew, C., Baik, S. H., & Wiseman, D. (2013). Adequacy of inhaler technique used by people with asthma or chronic obstructive pulmonary disease. Journal of Primary Health Care, 5(3), 191-198. Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1 Suppl.), S1-S110. Martin, K. S. (2005). The Omaha System: A Key to Practice, Documentation, and Information Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.
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