The home and palliative care nurse panel discussion kicks off with an introduction of our panelist Elaine D. Stephens, Executive Vice President of the National Association for Home Care & Hospice, she’s also Former Chair of the Home Healthcare Nurses Association. Also joining us on the home healthcare nursing panel is Barbara Burgess, chief executive officer of Pathways Home Health, Hospice & Private Duty.
Nursing Notes Live is an audio extension of the national award-winning monthly e-newsletter, Nursing Notes – which offers the latest industry news, trends and updates in nursing. You can subscribe to the e-newsletter at www.discovernursing.com. Each month’s Nursing Notes issue, hosted by nurse Jamie Davis, is accompanied by a select few episodes of Nursing Notes Live, which expands on the content and provides you greater insights into the topics presented in the e-newsletter. You can listen to previous episodes and subscribe to the podcast on iTunes!
Jamie Davis: Hi, Barbara and Elaine, it’s great to have you both here on Nursing Notes Live and joining us on the show. We’re talking about home health care nursing this month. That’s an exciting topic with all the things going on with changes to healthcare and trying to keep people healthier at home. Before we get started with the meat of our discussion today, I thought I would ask each of you my traditional first question. And I guess we’ll start with you first, Barbara. Go ahead and let us know a little bit about why you wanted to become a nurse? What was it that drew you to this nursing profession?
Barbara Burgess: Well, I wanted to become a nurse early on. I can remember in my late teens. It’s really interesting. I don’t think I knew anyone personally that was a nurse, but I started out volunteering as a young teenager in a hospital. As some of you may remember as a candy striper. That gave me a feeling for that helping profession. We were allowed to go up onto the units and do certain things with the nurses. I was just very excited about it and thought it was something I was drawn to. So my desire started really quite early.
Elaine Stephens: I can’t believe this but – this is Elaine Stephens – but I also started as a candy striper, as a volunteer in a hospital. At that time, they did let us go up on the floors and actually do some really meaningful work with the patients. It was so exciting. So the idea that I could do this and impact directly and positively on the lives of others, and combine not just delivering care but teaching. That was a really important thing to me, the teaching people. That was very exciting. So I was very exciting about nursing and going into nursing and, very clear, this is what I wanted to do from the outset.
Jamie: Elaine, why don’t you continue and tell us a little bit about your path in nursing, your educational path and your career path, that brought you into the specialty of home healthcare?
Elaine: Well, my nursing degree comes from Boston College and they provided me an outstanding base in nursing education. They divided nursing education into primary, secondary and tertiary interventions and then all the specialties within that. They also included teaching courses and leadership, change leadership, ethics, communication, values. I believe that made a huge difference in terms of my nursing education and then the excitement that I had about going into nursing. I then went on to work fulltime. And while I was working – I didn’t work very long in a hospital before. I wanted to go into community health and work for VNA. While I’m doing that, I attended BU Medical School and my concentration there was Health Systems in their School of Public Health. That included courses in legal, social and economic issues and issues that impact the health system. So I had both things I thought in my tool box – the clinical things and the clinical experience and also a lot of that information in health on and learning leadership and change theory. From there, I was a staff nurse, a nurse educator and a nurse manager in a home care. Then I went on to be the Director of Planning as I graduated from Graduate School for a very large home care and then became a President and CEO for over 23 years of a large home care attached to a multihospital system. I find myself here at the National Association for Home Care and Hospice, where I have been involved for all of my career in home health. Being able to bring it all together and help other homecare providers and especially nurses in their love of home care and hospice.
Jamie: Barbara, how about you?
Barbara: Well, it’s interesting. Beyond the candy striper years, as I got a little bit older, I kind of fell in love with the idea of the Peace Corps. For those of you that remember when that was – during Pres. Kennedy’s time and there was so much about the Peace Corps. It was at that time such a positive ambition. So I remember writing for their literature and looking through it and finding out – and I was very disappointed with this because I wanted to go right then, so I was just getting out of high school, I wanted to go right then finding out that, no, they don’t really need 18-year-olds with no skills in the Peace Corps. So I began to see what kinds of occupations they were looking for, what kinds of skills sets and I saw nursing. So that was my second draw towards nursing. It just seemed to fit. Because I was just so anxious to get going I actually chose to go into an Associate Degree program, which is where I started out in a two-year program, because I thought I can get these skills in a couple of years and be on my way to the Peace Corps to some wonderful country to – I was very idealistic as you can imagine. But as time went on, I began to understand more about having nursing as a career and got a lot of good mentorship, the Peace Corps sort of went to the background. I went on after that degree to get my Bachelor’s degree in Nursing, which was a wonderful step forward and very quickly after – and working during this time in acute care. And then I went on to get my Master’s at UCSF in San Francisco in Community Health and Administration. So I kept that community health focus while I did that. So I worked in acute care for about 10 years before and got some great experience, which I think is really good for new graduates to start out within an acute care setting because there’s so much mentorship and support available. But I was very anxious to get out into the community for a lot of reasons. One of them was the economy of the practice. The 10 years in acute care was wonderful, wouldn’t trade it for anything, great preparation. But I very much wanted to work more autonomously and in the community and home health was perfect. Home Health also began as the years went by to include hospice and some other kinds of programs but they were all in the community. So that was sort of my trajectory. In home health, of course, I was a home health nurse and a hospice nurse and eventually a manager. Until now, I’m the CEO of Pathway Home Health and Hospice, which is a large community-based hospice in the San Francisco Bay area in northern California.
Jamie: Excellent. It’s interesting when you think about home health care and I actually began my medical healthcare career as a paramedic and an EMT before that. So I was very actively working a lot of times with nurses in the home healthcare arena with patients that were receiving care at home and needed to be transported to the hospital or just be seen by someone. I see that so much has changed recently. There was so much of the focus on reform and change. It seems to me that a lot of – there’s a lot of refocusing on the importance of home healthcare. Barbara, what are your thoughts about that?
Barbara: Absolutely. I think that this focus on – we’ve been saying for years, those of us in the community had been saying for years that, in some sense, this is where it’s at. In other words, that’s where you meet the patient and their family where they live all-year round. So if you have a patient who’s unfortunately in the hospital for a few days in a year, they get very good care, but for the 350-some days that they’re at home, if you can intervene at their place where they live and where the environment is impacting them and you can see that and assess that and hopefully influence the patient and the family towards some different kinds of interventions, it’s just very powerful. So I think we’ve been saying for – we in the community have known just instinctively, especially if you’ve worked in different settings like acute care and then you go and work in the community and you are looking at the world through very different optics. You’re looking at patients and families through very different optics. It’s very powerful. The impact you can have on families when you meet them where they are, that is, in their home, is powerful for a nurse. It’s an experience I wouldn’t want any nurse to miss. Every year that goes by, especially since the Affordable Care Act went into effect a few years ago, that is becoming more and more the truth. It is kind of funny, in a way, we feel we’ve been discovered. Now we’ve been around for 100 years or more working in the Visiting Nurse Association in the community but in a kind of a funny way we feel after the Affordable Care Act was passed that we’ve been “discovered”. I find that personally here that, all of a sudden, relationships that were “transactional”. What I mean by that is you would get a referral from a doctor or a hospital, I call that “transactional”, and that’s how we function for a long time and we were appreciated, but it was at a transactional level. That has really transitioned to a strategic level. I’m now very involved in the health systems around us, be it Stanford or some of the other community hospitals in this particular area. I’m now very involved with them strategically. So it’s gone some sort of a tactical perspective to a strategic level. So we’ve been discovered, which is wonderful, who it’s wonderful for really is the patient, because they’re going to end up reaping the benefits of the attention. Everybody in healthcare now is giving in a very patient-centric way. But definitely…
Elaine: …have been discovered, that’s for sure. That’s so exciting, Barbara, that you would say that. The other thing that we’ve been discovered for is our ability to keep people home and our ability to get them home quicker and keep them home and this whole need for the health care system to avoid institutionalization and hospitalization has really opened up the window for us to step through and make a difference. I’m sure Barbara will agree that this new focus on chronic disease management. We’ve always been focused on chronic disease management but now it’s being taken very seriously on what we can do and it’s actually been formalized. The ability for us to impact care transitions as home care nurses is being taken seriously and formalized. We’re working very hard and being very successful at that. We were always patient-navigators in home care. We help patients and families to figure out where to go and what to do and how to do it. That’s being taken seriously now, and that role again is being formalized. Our role in accordance with medical home, that’s been formalized too. Patients are going home from orthopedic surgeries the same day and who’s there? The home care nurse and the therapist and altogether the team. These are things that we said we could do and, in some cases, we were, but now they are being taken seriously. As Barbara said, it’s because of the Accountable Care Act for sure.
Barbara: Absolutely. The healthcare system has always been siloed and it’s becoming much less so. It’s a really exciting time to be a nurse and it’s a really exciting time for people to get into nursing. The healthcare system has been siloed. You had all of your different sites of care and they all did it as a job and wanted to do the best for the patient, but it was very siloed. For instance, your hospital or even your home health agency or your hospice or your clinic and you would take the best care you could of patients and felt good about it and the patients would feel good about your particular care, but the patient was very much, at times, could be lost in that system as they went from one site of care to the other. Although the system, the healthcare system had all the parts, say, that are needed, and each part might function very well, the patient could easily get lost in that as they try by themselves to transition from one to the other. So now the exciting thing now is that we’ve been charged – especially home health – we’ve been charged with carrying out that transition formally and we’re getting credit for it. As we said, we’ve done it for years, but now we’re really – if there’s really a focus on transitioning patients from setting to setting, transitioning handoffs and nursing is central in that. All of the other disciplines have extremely important roles, but nursing, as you’ll see, is front and center in being responsible for those transitions for the patients. And this is really a very exciting time.
Jamie: It certainly is and it seems to me like it’s a return to the basics, because for hundreds of years people came to nurses – may be thousands of years people came to the nurses in their community and asked for assistance. It seems like we’re going back to the basics of the nurse and the patient really being the central hub of that initial communication and that ongoing communication to bring them all the care pieces together, to break up those silos.
Elaine: Absolutely, the role of nurses has always been to be the person that works between the social worker, the physician, the other members of the – the paramedic – to help to make sure that all of those things, the outcomes – what happens to this patient is understood by the patient and communicated between the various people so that the right things can happen. That is definitely not only true today, but it’s the goal of the home care nurse in many cases is to accomplish that objective as we’ve been talking about care transitions. So home care nurses today have to make sure that they have great communication skills. That they can comfortably talk with patients and families as well as members of the team. And that team of people is growing because we’re finding that in order to keep people at home, it takes more than just the basics. It takes a lot of social interventions to keep them comfortably at home. I think that it is very important for nurses going into homecare today to know that the great communication skills are the basis for the practice that they are about to enter.
Jamie: It’s interesting you go that direction because my next question is what does it take to be a good home care nurse? Elaine, I’ll ask you that first.
Elaine: I talked about communication skills with people and that’s certainly one thing. Courage. When you’re a home care nurse or a hospice nurse, yes, Barbara, isn’t it true? You never know what you’re going to walk into. You just never know. So you have to be of the personality that is comfortable with what you – not knowing exactly what you’re going to greet every day. Now you don’t in the hospital, but it’s very different when you’re walking into people’s home. It’s their territory and you don’t know. But that’s also what makes it exciting. You have to be able to work independently, but at the same time, know how to utilize the key that’s available to you wisely. So there are people – you have your cell phone, you have your equipment, you have access to people who can help you right there in the home, but it’s different. Because you are there independently first making decisions, looking at things, assessing and then coming up with a plan of care to recommend with the physician and the family. So you have to be comfortable with working independently. I think you also have to have comfort with technology to be a great home care nurse today, because we are using so much of it from the EMR that we use, medical records to TeleHealth to complex wound care. We do a lot of complex wound care in the home. There are all sorts of new technologies, which can enable us to do that more effectively and efficiently. So you have to be comfortable that this technology available and that you will be able to and comfortable with helping your patient use it and using it yourself. Then we get into some of these newer things like wearable technology. But in any case, those are things that I think that are important – the good communication skills, courage, working independently and the comfort with technology and, most importantly, that you are compassionate.
Barbara: Yes, you just said everything that I was thinking. Caring. I think the nurses begin to realize that when they walk into the door, that family and that patient are very vulnerable. They’re afraid. They have fear. They’re very vulnerable in many ways. And when you walk into that door, they can feel the caring that you bring in with you. And that’s what they need. Yes, they need the technical excellence, absolutely, but they also need a caring spirit that walks in that door that takes an extra few minutes to put their arm around someone’s shoulder. Believe me that make all the difference in the world. I think also the only thing that I would add is in today’s world, with the metrics that we have, so I’m thinking of new nurses coming in and what they ought to be thinking about. Thankfully, we’ve got a lot of ability to measure. So nurses will want to be measured on their quality. We have patient outcomes. We have ways of doing that now, as well as, and just as important, patient experience and efficiency. So as a nurse working day to day, there are metrics that can help you to see how you’re doing on, how are your patients feeling about you, how your patients measure the experience that you provided for them. If you’re a case manager, what’s the experience that your team provided to the patient? What were the quality outcomes? Were you efficient? All of those things are going to come into play? Well, they’ve always been in play, but now we can measure them. The other thing I would say for a new nurse coming in is look for people that do well in those areas. I meant for mentors. You may have your official mentor when you come in and that personal will be very helpful for you, but keep your eyes open for those around you, those nurses around you that seemed to just do very well in the basics. Seemed to be caring people, seemed to do very well with patient experience, metrics and quality and efficiency and sort of hang around with them if you can, especially in your first year or two.
Elaine: And they’re so welcoming. Nurses in home care, it’s been my experience that they’re so welcoming to want to welcome that new nurse and make her feel or him feel comfortable and do everything they can to let them know that they’ll be supportive if they call or if they want to make a joint visit. Home care nurses and hospice nurses, in my experience, has been welcoming new nurses and wanting to do everything they can to involve them. I think engaging in their national association, the nurses associations, is so important. So that they can feel the comfort and feel the knowledge and experience of other nurses who have been there and also to advocate for the things that nurses need from our Congress. That’s so important for nurses, new nurses in homecare, to engage so that they can learn how they can become a part of that, so that they can direct and steer their future instead of having it done for them.
Jamie: I think that’s a great way to put that and it’s important for us all as nurses to be very activist in our outlook to advocate for our patients at that national level as well. And being part of a national organization for your specialty is so important. I completely agree with that. As we wrap up here, we’re getting down towards the end, I think I’ll just close with maybe each of you coming up with a brief comment about – and we’ll start with you, Barbara, what is your hope for the future of home healthcare nursing?
Barbara: Well, my hope is that we can expand very easily, do a great job in the home health that we know today, but expand well into transitions and well into what I’ll call “high-risk care management”, which is outside what we traditionally call “home health” right now. But I think that these segments will slowly disappear and what we’ll do in what we now call “home health” will be much more patient-centric and we’ll have to do with taking care of patients in their homes, in assisted-living facilities and, very importantly, in all of the transitions they have to make. The other thing I would like to say before we end is, for those thinking about nursing, is we really need to increase our diversity in nursing. As our country’s diversity, especially myself being out here in northern California, we really need more men in nursing and we need significantly more diversity, ethnic diversity in nursing. When I say “we need that”, really who needs it is for patients, when families need it.
Elaine: Absolutely. They need nurses from all cultures to be able to help patients to understand and to get better. By 2018, the employment for home health nurses, they predict, that’s going to grow by 33%. And what my hope is that we’ll have engaged professionals who are out in our communities doing a primary work of healthcare. That’ll be home care and hospice and those engaged professionals who love what they do, because most of the home care and hospice nurses that I know at the very base of it, at the very bottom of it, they love what they do. Now we have to engage them to help them to be able to talk about that and share that and engage other professionals to come join us in this home care and hospice journey.
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Make sure you check out the entire February 2015 issue of Nursing Notes where we look at what it’s like to be a home healthcare nurse. You can read the entire issue www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I sit down with our Get to Know nurse Greg Burns of HomeHealth Visiting Nurses of Southern Maine. He is focused on pediatrics and parent education for infants who are able to leave the hospital, but deal with developmental obstacles. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.