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528938
research-article2014
HHCXXX10.1177/1084822314528938Home Health Care Management & PracticeSaunders
Original Article
Home Health Care Nurses’ Perceptions of
Heart Failure Home Health Care
Home Health Care Management & Practice
2014, Vol. 26(4) 217­–222
© 2014 SAGE Publications
Reprints and permissions:
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DOI: 10.1177/1084822314528938
hhc.sagepub.com
Mitzi M. Saunders, PhD, RN, ACNS-BC1
Abstract
High-quality nursing care in the home setting is one approach to improving outcomes in patients with heart failure (HF). This
study describes home health care nursing care of patients with HF from the perspectives of home health care nurses (HHNs).
Using an emergent, qualitative design, 14 HHNs were interviewed and six major themes emerged: (1) HF care is unique, (2)
HF patients’ needs exceed imposed limitations, (3) listening to HF patients is key, (4) HF education is critical, (5) eyes and
ears of physicians, and (6) high reward/high commitment. Overall, HHNs felt that patients with HF have nursing care needs
that exceed imposed limitations on HHN services. HHNs need time to educate patients and family caregivers about HF.
Keywords
heart failure, home care, nursing, qualitative inquiry, listening, patient education
Introduction
An estimated 5.1 million Americans have heart failure (HF)
with figures expected to reach 7 million patients by 2030.1
One of every two patients with HF dies within 5 years of the
diagnosis and 1 million HF-related hospitalizations occur
each year.1 HF is the most common diagnosis of Medicare
recipients supporting the need for interventions that will
achieve optimal outcomes.2 Home health care may be the
most viable and least costly of interventions to meet the
needs of patients with HF.3 Home health care nursing is one
important aspect of care rendered to patients with HF in the
home setting. Thus, knowing home health care nurses’
(HHNs) perspectives of what is involved in HF home health
care nursing may be an important step to improving outcomes in patients with HF.4
The HHN is regarded by some as the most important provider of care in the home setting.2,5 Home health care nursing
has been associated with fewer patient emergency room visits, reduced hospital readmission rates,6 and increased levels
of health-related quality of life in patients with HF.7 Patients
regard HHNs as knowledgeable, competent, and caring.2
Family caregivers of patients with HF have found the support and care rendered by HHNs crucial to their care experience and the one whom patients listen to and trust.8
Interestingly, very few studies have reported HHNs’ perceptions about their experience. In one study, HHNs
described their role with patients and family caregivers
immediately following a hospitalization.9 HHNs expressed
difficulties in finding and translating the discharge plans and
felt the family caregivers to be ill equipped in the caregiver
role. In another study, the establishment of trust between
HHNs and patients was the most critical factor in the nurse–
patient relationship.10 By actively listening to patients,
researchers established the evolution of a trusting and working relationship between HHNs and patients. However,
HHNs need sufficient time with patients and families to
develop working relationships. Pairing HHNs and patients
together, over time and without time constraints, was associated with earlier recognition of changes in patient status.10 In
another report, HHNs felt empowered and valued in their
abilities in helping patients and caregivers achieve optimal
care outcomes.11 These HHNs also found listening to be a
critical skill of HHN practice, as well as patient education,
achieving desired levels of patient comfort, and patient
advocacy.11
HHNs’ viewpoints specific to home health care nursing
of patients with HF are unknown. Knowing that gaps in care
may contribute to the readmissions of 20% of all Medicare
recipients, and often among patients with HF, calls for
immediate action.12-14 HHNs are in an optimal position to
articulate the needs of patients with HF.4,8 Communicating
HHNs’ perspectives about HF home health care nursing
may improve the care experience and HF patient outcomes.
The purpose of this qualitative study was to describe home
health care nursing of patients with HF from the perspectives of HHNs.
1
University of Detroit Mercy, MI, USA
Corresponding Author:
Mitzi M. Saunders, College of Health Professions, University of Detroit
Mercy, 4001 W. McNichols Road, Detroit, MI 48221-3038, USA.
Email: saundemm@udmercy.edu
218
Home Health Care Management & Practice 26(4)
Table 1. Home Health Care Nurse Participants’ Characteristics
(N = 14).
Variables
Age (years)
30-39
40-49
50-59
>60
Gender
Female
Ethnicity
White
Biracial
Marital status
Single
Married
Divorced
Nursing education
Associate’s degree
Bachelor’s degree
Master’s degree
Employment status
Part-time
Full-time
Time in home care (years)
M (SD)
n (%)
52 (10.7)
2 (14)
5 (36)
4 (29)
3 (21)
14 (100)
13 (93)
1 (7)
3 (21)
3 (21)
8 (58)
5 (36)
7 (50)
2 (14)
4 (29)
10 (71)
13 (7.7)
Methods
Design and Sample
This study used a qualitative, emergent design. An emergent design allowed inquiry from the researcher’s viewpoint as the study was being conducted.15 This study was
approved by an institutional review board. HHNs had a
minimum of 6 months in home health care nursing and in
providing care to patients with a primary diagnosis of HF.
Exclusion criterion of HHNs was not being in active practice at the time of the study. Following email notifications
of the study to home health care agencies in Michigan, New
York, and Missouri, 10 HHNs volunteered by email correspondence. Using the snowball technique, 4 HHNs recommended 4 other HHNs as good informants. The researcher
contacted the additional 4 HHNs by email and all agreed to
participate. This expanded the sample to include 14 HHNs
across seven home health care agencies. Sample characteristics are given in Table 1.
Data Collection and Analysis
Interviews were private, conducted by telephone for 10
HHNs due to geographical distance from the researcher, and
face-to-face with four HHNs. Each interview ranged between
45 and 60 minutes and was audio-recorded. HHNs received
a cash incentive of US$40.00. Data were collected from June
2012 to January 2012.
Interviews began with the collection of demographic
information. The researcher then used an interview guide to
promote consistency in asking the same questions and in the
same order with each HHN (see Table 2). HHNs received the
interview guide in advance of their scheduled interview.
Following each interview, the researcher noted the interview setting, events or interruptions that occurred during the
interview, and patterns that emerged as the study progressed.
Patterns enabled the researcher to ask additional probing
questions to gain clarity of emerging themes and to observe
for informational redundancy.
When informational redundancy was observed, audiotapes were transcribed verbatim and transcriptions were confirmed with the audiotapes. A line-by-line method of analysis
was used to code, categorize, analyze data, and identify main
themes.16 A second reader with expertise in qualitative
research confirmed the themes with 90% consistency. Strict
confidentiality of HHN information and data was maintained
throughout the study.
Results
Data were collected from 14 female HHNs ranging in home
health care nursing experience from 3 to 32 years (M = 3, SD
= 7.7). The HHNs’ ages ranged from 38 to 78 years (M = 52,
SD = 10.7). The majority were Caucasian (93%), divorced
(58%), employed full-time (71%), and had a bachelorette
degree or higher in nursing (64%). All HHNs were working
in agencies that used telehealth technology in some capacity.
All HHNs had a caseload of patients with HF but were seeing
a variety of other patient types in the areas of oncology,
orthopedics, pulmonary, diabetes, and wound care. None of
the agencies were HF specific.
Six themes emerged from the data: (1) HF care is unique,
(2) HF patients’ needs exceed imposed limitations, (3) listening to HF patients is key, (4) HF education is critical, (5)
eyes and ears of physicians, and (6) high reward/high commitment. Each theme will be discussed with supportive testimonies from the HHNs.
HF Care Is Unique
HHNs regarded patients with HF to have greater care needs
than other patient types. HF patients were referred to as “a
more brittle population” or being “touchy.” In comparison
with cancer patients, one HHN stated, “Even with the chemo,
you have this many treatments and then you have time off.
With HF, it is constant.” Another HHN compared HF patients
with orthopedic patients, “You know they (orthopedic
patients) are going to progress to the next level, but HF is
complex, it’s progressive and at some point, hospice.”
HF care was more time-consuming than nursing care of
other patients. “A lot of nurses shy away (from taking a HF
patient). You have a lot more work with the HF patient.
There are just more questions and more follow up . . . they
219
Saunders
Table 2. Interview Guide.
(1) Please describe one or more of the most rewarding and possibly touching/emotional experience(s) you have had in working with a
HF family?
(2) Please describe a time when you faced adversity in patient care and specific to the HF patient/family caregiver?
(3) In what ways do you attempt to make the HF patient’s environment one that supports healing? How does the HF family caregiver
fit into your work in creating a restorative environment at home?
(4) Do you feel the current system allows you to care for the HF patients and their family caregiver physically, emotionally, and
spiritually? (Why or why not)
(5) Does the care you provide for HF patients and the family caregiver change from one family to the next? (Please explain)
(6) How important is health education for HF patients and their family caregivers?
(7) Do you feel you have adequate authority in determining nursing practice for HF patients and their family caregivers? Are there
obstacles or barriers?
(8) Are you comfortable in confronting others (physicians, etc.) when you feel an order is not in the best interest of the HF patient
and/or family caregiver? (Examples of why or why not)
(9) How would you define “excellent home-based HF family care?” Is your description different from how you practice today?
(10) How do you take care of your own personal needs (physically, emotionally, and spiritually)?
(11) Is there anything I should have asked you that I did not?
Note. HF = heart failure.
might have 3-4 different doctors.” In addition, HF care meant
higher numbers of medications to review. “A patient may
have 20 (medications) and it’s real important to go through
them all . . . they might be taking the same pill twice but it
has a different name.”
HHNs felt that patients with HF and their family caregivers had greater emotional needs. Depressive symptoms, as
described by one HHN, were as common as “every 9 out of
10 HF patients.” Family caregivers of patients with HF were
described as “overwhelmed” and in need of “lots of emotional support.” When describing the needs of the HF family
in general, one HHN stated, “If the family had the support of
a HHN, then so fewer patients would be placed in nursing
homes.”
Regardless of high care needs and the extra time needed
to deliver HF care, HHNs reported personal gain and satisfaction. As one HHN stated, “With HF, you spend more
time, you develop a closer relationship, and they think of you
as a family member . . . the patients love you, but the family
caregivers depend on you more.”
HF Patients’ Needs Exceed Imposed Limitations
HHNs agreed that rules and regulations that imposed limits
on their services were a major problem. HHNs claimed that
they needed more visits and more time for follow-up telephone calls. One HHN commented, “Two years ago we had
unlimited visits for 8 to 9 weeks. Now, we have five visits in
3 weeks.” Another HHN stated, “You want to call them but
you know it won’t be simple and a simple question can have
you on the phone for the next 20 minutes.” HHNs voiced a
mismatch in care in that patient needs were rising and time
to spend with patients was shrinking. One HHN stated, “The
hospitals are sending them home quicker and sicker with
higher needs. It is a challenge.” HHNs conveyed seeing
more instability in patients with HF and reported how “you
can see them one day and hear they are back in the hospital
the next.”
HHNs advocated for telehealth technology for homebound HF patients to monitor them between HHN visits.
Most HHNs felt that a higher usage of telehealth technology
would prevent hospital readmissions, “Through telehealth,
we caught it (patient symptoms) early.” The assessment
information gleaned through telehealth technology for HF
patients might lead to interventions that prevent serious complications from occurring. HHNs agreed that in the absence
of telehealth, the current system of care was reactive rather
than proactive. Overall, HHNs felt existing time constraints
for home health care nursing visits and telephone calls and a
lack of telehealth technology to be the root causes of why
patients with HF were rehospitalized.
Listening to HF Patients Is Key
Although HHNs felt they were in a hurry when seeing
patients with HF, taking the necessary time to listen to
patients was highly valued and practiced. One HHN
described it this way, “If I had one thing to tell nurses, it is to
listen to the patients and do so very carefully.” HHNs
described the skill of listening as being more important and
more common in their work in home health care than their
previous nursing roles in acute care settings. Listening was
the vehicle for building trust and a working relationship with
HF patients and families. The phrase “being on the patient’s
turf” was used by several HHNs to suggest how the setting of
care heightened the need for active listening. One HHN
stated, “The major thing for me in finding an environment
that supports healing is one of trust. I think when patients are
listened to, they begin to trust. When they trust you, they
listen too, and follow through.”
220
HF Education Is Critical
HHNs thought that patient and family caregiver education
was the most important nursing intervention: “Education is
the number one key with HF patients and their families. They
have to know what to look for, what to go to the hospital for,
what an emergency is, and what is not.” HHNs expressed the
uniqueness in educational needs from patient to patient and
the importance of tailoring content to fit the needs of patients
and household members. One HHN stated, “You have to
think of feeding the whole family in that it is a whole culture
change for the family and not just the patient.” HHNs
described how assessing family diets and patterns were crucial to learning what triggered problems such as a routine
diet of “pizza rolls” that were leading toward “his (the
patient’s) weight gain” and consequential “readmissions for
HF.” It was important to know patients well enough to contrive ways to make diet changes last. For example, one HHN
who learned of a patient’s passion for gardening encouraged
growing and eating vegetables for heart health.
HHNs described creative approaches and ways to tailor
teaching to meet patient and family caregiver needs. For
example, a HHN called the doctor in the presence of the
patient and the family to reinforce teaching and role model
how one talks to the doctor:
I call right in front of the patient so they hear the way I talk to the
doctor and afterward I will say, now did you hear how I said that?
That’s why you are watching your weight every day, why you
check your legs every day for edema, so when you notice it, you
can call them (the doctor’s office) instead of calling an ambulance.
HHNs described using visual aids when teaching to
include HF-specific self-care booklets or packets. One HHN
described the process this way: “I have them read over the
HF booklet. Then, I ask, what are three things that you think
are important? It’s really good with older patients because
we can then go back and do it again and again.”
Eyes and Ears of Physicians
HHNs were confident in saying that they were the “eyes and
ears of physicians.” One HHN stated,
I go in and assess the patient and find they are filling up with
fluid. They are short of breath and I make the call right away and
suggest that we change the Lasix. Or, do you want them to go to
your office. Or, do they need to be sent for a chest X-ray?
This example also demonstrates how HHNs felt the need
to “lead the physician” so the right medication(s) or test(s)
got ordered for patients. In the words of one HHN,
Often the doctor says, have them come into my office. But, the
patient then says, “I don’t have transportation,” or “it’s too
cold,” and doesn’t want to. So I say, “Why don’t we discontinue
Home Health Care Management & Practice 26(4)
the medication and I’ll monitor the patient and call you in 3 days
to let you know what is going on. The physician agreed.”
Overall, HHNs expressed confidence in their abilities to
detect problems, know and articulate patient care needs to
physicians, and negotiate treatment plans to suit all parties
involved.
High Reward/High Commitment
HHNs found their roles to be highly rewarding for many reasons: “You can actually sit down and talk (to the patient),”
“they know who their nurse is,” “I do more nursing care in
home health care than in the hospital,” “patients actually
smile, say thank you, and enjoy your visit,” and “every day is
just totally different.” HHNs felt special being in the patient’s
home, “When you see these patients in their home, you really
get personable with them. When you see them in the hospital, you say ‘that’s a HF patient.’ In the home, they are a
person.”
HHNs verbalized pride in working independently and
thinking critically. One HHN stated, “In home care, I have to
be vigilant and aware of every aspect of care and not just carrying out an order in the hospital. I am a better nurse now
being a HHN.” It was also rewarding to see patients with HF
improve over time. One HHN expressed,
I started to see the demonstration of what I was teaching and
actually happening in the home and before it was every 6 weeks
this patient would be back in the hospital. So we get to 6 weeks,
then 8 weeks, 9 weeks, and no more hospital stays. The family
was so grateful. That was one of the most rewarding experiences
I can think of.
If the patients did well, HHNs felt, “you know you’ve
done your job.”
HHNs voiced their commitment to their roles by giving
out their personal telephone numbers to patients and family
caregivers to avert problems. One HHN stated,
One time one of our HF patients went into the hospital and then
home and we (the agency) didn’t know yet. The wife called me
at 7 p.m. (when I was off work of course) to see who was going
to change his bag. It was also a holiday weekend and there was
a bad storm out too. Over the phone, I told her how to change the
bag and she did it. If she would have called the agency, they
would have told her to go …
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