Will the Real Nurse Please Stand Up? 

Will the Real Nurse Please Stand Up? 

Have you ever heard a nurse pass judgment on a colleague and say that another nurse isn’t a “real nurse”? Have you noticed some nurses looking down on those who choose to be school nurses or work in home health, dialysis, assisted living, medical offices, or ambulatory surgery?

Judgmental attitudes by one group of nurses against another don’t do anyone any favors, but such thinking is all too common.

So, given that there are still nurses who think in such old-fashioned ways, what then constitutes a “real nurse” anyway, and how do we know when a nurse is the real deal? (Hint: they’re all the real deal.)

That’s Not “Real” Nursing

When we’re in nursing school, it often seems that everyone and their mother has their sights set on “sexy” specialties like trauma, emergency nursing, and critical care. When a peer talks about having a goal of working in public health, school nursing, elder care, home health, community health, or some specialty that isn’t highly technical or soaked in adrenaline, some may scoff at such a notion.

“School nursing? That’s not real nursing — all you do is put band-aids on boo-boos and give kids aspirin for headaches.”

“Home health? Do you want to go from house to house checking blood pressures and filling little old ladies’ med boxes?”

“Why would you want to do public health? That sounds so boring.”

Looking down on nurses who don’t want to follow the straight and narrow path of the more fast-paced or complex acute care areas is an all too common way of thinking about others’ choices. When a nurse isn’t inherently drawn to the ICU or the ED, some nurses may be quick to judge that nurse for being lazy, not smart enough, or simply not a “real” nurse.

For those who think that school nursing is just band-aids and aspirin, think again: kids come to school with trachs, vents, complicated medication schedules, brittle diabetes, and all manner of chronic illnesses.

School nurses have to think on their feet, sometimes manage multiple schools, and also tend to the medical needs of teachers and administrators. And in rural and underserved areas, the school nurse may be a student’s primary connection with the healthcare system, not to mention parents.

In home health, patients can come home with complex surgical wounds, including a wound vac, IV antibiotics, and other medications administered by a programmable IV pump.

Home health nurses may also encounter patients receiving TPN and other complex situations necessitating expertise and highly skilled care. And when a home health nurse is out in the field, that nurse is all alone — there are no colleagues, doctors, or specialists to lean on with questions and concerns.

The home health nurse is by nature autonomous and independent and can face life-or-death decisions without the benefit of others to confer with.

According to the American Association of Colleges of Nursing (AACN), approximately 55% of nurses work in general medical and surgical hospitals. So, where do the other 45% of nurses work if this is the case?

When it comes to “real” nursing, there’s nothing fake about home health, public health, ambulatory care, community health, or school nursing. All nursing is real, and those who think otherwise are gravely misguided.

The Big Tent of Nursing

Nursing is anything but homogeneous. Dozens of nursing specialties make it an exciting, fascinating, and varied profession, and these many choices give nurses multiple potential career paths. Nursing is a profession with a big tent under which nurses of all stripes and persuasions can find career satisfaction.

No nursing specialty or area of practice is more worthy than another. Under our big nursing tent, all nurses are welcome, and whatever each nurse chooses to do for a living is a valid choice.

When you hear another nurse talking negatively about another nurse’s valuable contributions to society, you can rest assured that that nurse’s opinion has no merit, and every colleague’s career choice has its role to play within a noble and highly respected profession.

Nurse of the Week: Home Health Nurse Julie Lakomiak Donates A Kidney to Someone She’s Never Met

Nurse of the Week: Home Health Nurse Julie Lakomiak Donates A Kidney to Someone She’s Never Met

Last Wednesday, Julie Lakomiak, a home health nurse from Plainfield, Illinois, donated her kidney to a “non-directed recipient.” This week, she’s our Nurse of the Week.

Lakomiak doesn’t know who the recipient of her kidney will be. But as a nurse for almost 20 years, she wanted to help someone in need and make others aware of the need.

“I heard something recently: ‘God blesses us with two kidneys, and we only need one,’” Lakomiak says. “And He does that so we can share.’ So, I think there’s a lot of truth to that.”

Lakomiak first considered donating a kidney in 2021. She had read on social media that the kidneys of Lizzie Reyes, 14, of Joliet, had unexpectedly failed and that she desperately needed a kidney transplant.

Home Health Nurse Julie Lakomiak Donates A Kidney to Someone She’s Never Met

Julie Lakomiak, a Health Care Nurse with Newsome Home Health, checks a patient during her volunteer work in San Pablo Philippines in 2017

But Lizzie received a kidney before Lakomiak, a nurse with Newsome Home Health, was even tested for a possible match. Then she met someone who needed a liver and kidney transplant but was too sick to qualify for the transplants. That’s when she made up her mind.

“I just felt like a lot of these signs in my life was God saying, ‘You’ve got to do this,’” Lakomiak says. “Why not help when there’s so much of a need?”

According to the U.S. Division of Transplantation, more than 106,000 people are on the national transplant waiting list – and 83% need a kidney.

But deciding to donate a kidney doesn’t mean it will happen. According to the National Kidney Foundation, a potential donor must undergo a medical history, physical and psychological exams, and many tests, including chest X-ray and electrocardiogram, imaging tests, and compatibility tests.

Lakomiak donated through Northwestern Memorial Hospital in Chicago and spent 11 hours there one day with tests.

Lakomiak says she occasionally had “waves of emotions” as the day drew near and random thoughts like, “Oh, gosh! Maybe I don’t have enough life insurance!” and making sure she has short-term disability, “in case something happens.”

But Lakomiak didn’t change her mind. She’s serious when she says it’s important for her to have faith. “We can’t always live life on ‘what if?'”

For information on becoming a living donor, visit kidney.org/atoz/content/living-donation.

Continuity of Nursing Care Improves Patient Outcomes

Continuity of Nursing Care Improves Patient Outcomes

People with dementia receiving home health care visits are less likely to be readmitted to the hospital when there is consistency in nursing staff, according to a new study by researchers at NYU Rory Meyers College of Nursing. The findings are published in the journal Medical Care , a journal of the American Public Health Association. 

Home health care—in which health providers, primarily nurses, visit patients’ homes to deliver care—has become a leading source of home- and community-based services caring for people living with dementia. These individuals often have multiple chronic conditions, take several medications, and need assistance with activities of daily living. In 2018, more than 5 million Medicare beneficiaries received home health care, including 1.2 million with Alzheimer’s disease and related dementias. 

“Nurses play a pivotal role in providing home health care,” said Chenjuan Ma, PhD, MSN, assistant professor at NYU Meyers and the study’s lead author. “As the population ages and older adults choose to ‘age in place’ as long as possible, the demand for home health care for people with dementia is expected to grow rapidly.”

For most patients, their home health care often begins after being discharged from the hospital. Given that hospital readmissions are a significant quality, safety, and financial issue in healthcare, Ma and her colleagues wanted to understand if having continuity of care, or the same nurse coming to each home visit, could help prevent patients from being readmitted.

Using multiple years of data from a large, not-for-profit home health agency, the researchers studied 23,886 older adults with dementia who received home health care following a hospitalization. They measured continuity of care based on the number of nurses and visits during home health care, with a higher score indicating better continuity of care.

Approximately one in four (24 percent) of the older adults with dementia in the study were rehospitalized from home health care. Infections, respiratory problems, and heart disease were the three most common reasons for being readmitted to the hospital.

The researchers found wide variations in continuity of nursing care in home health visits for people with dementia. Eight percent had no continuity of care, with a different nurse visiting each time, while 26 percent received all visits from one nurse. They also found that the higher the visit intensity, or more hours of care provided each week, the lower the continuity of care.

“This may suggest that it is hard to achieve continuity of care when a patient requires more care, though we cannot exclude the possibility that high continuity of care results in more efficient care delivery and thus fewer hours of care,” explained Ma.

Notably, increased continuity of home health care led to a lower risk for rehospitalization, even after the researchers controlled for other clinical risk factors and the intensity of home health care (the average hours of care per week). Compared to those with a high continuity of nursing care, people with dementia receiving low or moderate continuity of nursing care were 30 to 33 percent more likely to be rehospitalized.

“Continuity of nursing care is valuable for home health care because of its decentralized and intermittent care model,” said Ma. “While continuity of nursing care may benefit every home health care patient, it may be particularly critical for people with dementia. Having the same person delivering care can increase familiarity, instill trust, and reduce confusion for patients and their families.”

To improve continuity of nursing care, the researchers recommend addressing the shortage of home health care nurses, improving care coordination, and embracing telehealth in home health care. 

“Multiple structural factors present challenges for continuity of care for home health nurses and other staff. These can include long commute times, few full- or part-time staff, agencies relying mostly on per diem staff, and organizational cultures that do not foster retention of home health care staff,” said Allison Squires, PhD, RN, FAAN, associate professor at NYU Meyers and the study’s senior author. “Proposed legislation in Congress that seeks to increase nursing and home health care frontline staff salaries will pay for itself because agencies can improve continuity of care, and therefore reduce penalties associated with hospital readmissions.”

A hybrid care model of in-person visits and telehealth visits could also help achieve more continuity of care, the researchers note. They encourage policymakers to consider expanding coverage for telehealth visits in home health care.

In addition to Ma and Squires, study authors include Margaret McDonald and Penny Feldman of the Visiting Nurse Service of New York, Sarah Miner of St. John Fisher College Wegmans School of Nursing, and Simon Jones of NYU Grossman School of Medicine. The research was supported by the Agency for Healthcare Research and Quality (R01HS023593) and the NYU Center for the Study of Asian American Health under a National Institute on Minority Health and Health Disparities grant (3U54MD000538-18S1).

How Home Health Nursing Has Changed in the Era of COVID-19

How Home Health Nursing Has Changed in the Era of COVID-19

Home health nursing is a niche for nurses who have experience and enjoy being on the move and working independent from the hospital. Visiting nurses, now termed home health nurses, date back to the 1800’s. Lillian Wald founded the Visiting Nurse Service of New York in the late 1800’s and the current structure of home health care is based off that model.

Home health nursing consists of providing nursing care in an individual’s home. The nurse must possess ingenuity as the conveniences and equipment found in the hospital are generally not available. Nurses carry their own supplies and regularly utilize the nursing process and honed assessment skills.

There are many varied clinical responsibilities the home care nurse has. Some of these are reconciling medications, managing foley catheters, providing drain care, and teaching the patient. Serving as a case manager is another responsibility. This means caring for the patient from beginning of service to discharge back into the community or prior baseline. This includes coordinating with doctors, family members, and other members of the health care team. Building rapport and familiarity with a patient is more important than ever with the current COVID-19 epidemic.

The COVID-19 epidemic poses one of the biggest challenges across the entire health care arena including home care. Due to this epidemic, changes have been made to the delivery of home health care. These include utilization of telehealth, increased incidence of homebound patients, changes to PPE usage, and temporary waivers and allowances of Medicare requirements. Changes are evolving frequently and this information is current at the time of this post.

Due to COVID-19, nurses may provide telephone or telehealth assessments in addition to in-home visits if the patient’s condition is stable. These “visits” are allowed if the patient’s doctor permits. A combination of telephone/telehealth and in-person visits lessens the number of exposures the nurse has with the patient.  A phone call or telehealth assessment involves asking questions in order to determine the patient’s status and identify any new or worsening health issues.  If the patient has current technology telehealth video visits can be conducted that allow for the nurse to see the patient on the computer screen.

In order to qualify for home care a patient must be deemed homebound. This may be determined from a doctor’s order or due to the patient’s health condition. A patient can be admitted into home health if he or she is homebound. Due to recent temporary Medicare changes if a patient is suspected COVID positive or confirmed COVID positive, he or she can be considered homebound. These measures reinforce the stay at home theme to help in lessening COVID spread.

Changes to PPE usage are the same as the requirements in the hospital.  If a patient is COVID positive, Airborne and Contact Precautions are taken.  This means the home health nurse would wear a N95 mask, face shield, goggles, gloves, gown, and perform proper donning.  Upon exiting the patient’s home, the nurse would doff and leave the used PPE outside the home according to his or her agency policies. 

Current guidelines from the CDC and NAHC (National Association for Home Care and Hospice) require all home care staff to wear masks when in contact with any patient.  If the patient is COVID positive, then a N95 mask must be worn.  Patients who are COVID positive must stay separated from others in the home preferably in a room with a closing door to assist in quarantining. It is also recommended that all patients — regardless of COVID status — wear a cloth mask during each visit.

Home health nurses are providing increased education to patients and their families focusing on infection prevention in the home. Handouts from reliable sources such as the CDC are being provided to family members. Nurses are also providing education on proper hand washing technique and disinfection guidelines for laundry, surfaces and other areas of the home. 

As noted earlier, COVID-19 has impacted all areas of health care and home health is no exception. By providing increased education to staff, patients, and families; the goal is to decrease the intensity and mortality rate of this pandemic. Nurses are on the front lines and need to stay abreast of frequent changes to Medicare rules. It’s also necessary to take current measures to protect themselves and their patients during this challenging time in history. 

“It’s a beautiful thing to witness…” A Talk with the Director of the VNSNY Gender Affirmation Program

“It’s a beautiful thing to witness…” A Talk with the Director of the VNSNY Gender Affirmation Program

In early 2016, Mt. Sinai Hospital* approached the Visiting Nurse Service of New York (VNSNY) to propose that VNSNY offer home care services to post-operative transgender patients. This was the genesis of VNSNY’s Gender Affirmation Program (known as GAP), which to date has provided home care to over 400 transgender patients.
*a strategic partner of VNSNY

DailyNurse recently interviewed Shannon Whittington, RN MSN PCC C-LGBT Health, the Clinical Director of GAP at VNSNY. We asked her about the nature of gender affirmation treatment, the home nursing care that VNSNY provides, and the outstanding LGBT-friendly services that VNSNY offers to patients across the Tri-State New York area.

 Shannon Whittington, the Clinical Director of the Gender Affirmation Program at VNSNY
Shannon Whittington, the Clinical Director of the Gender Affirmation Program at VNSNY

DailyNurse: What is gender affirmation surgery (GAS)?

SW: A surgical procedure that creates or removes body parts that align with the patients’ gender expression. E.g. vaginoplasty, phalloplasty, metoidioplasty, facial feminization, breast augmentation/masculinization.

DN: Is this the same thing as “sex-change surgery?”

SW: It is the same thing but we don’t use the terms “sex-change surgery” anymore.

Gender Affirmation or Gender Confirming surgeries are the correct terms now.  Understanding that this is a linguistically fluid language, words and meanings are always changing and we need to be mindful of correct terminology.

DN: What are the components of the VNSNY Gender Affirmation Program?

SW: The program emphasizes home care following surgery from other providers. I train clinicians (nurses, social workers, physical therapists, home health aides, speech and occupational therapists) in cultural sensitivity as it particularly relates to transgender patients.  The training is extensive and they are also educated in how to teach the patients to care for their new or altered body parts (i.e. penis, vagina, breast, face)

DN: How did you come to specialize in the treatment of Gender Affirmation surgery patients?

SW: Fortunately, I was chosen for this project by my manager.  I had no idea what I was saying yes to but this has literally changed the trajectory of my career path.  I discovered a passion that I did not know I had!

DN: What sorts of clinical training do nurses in the program need to take care of GAS post-surgery patients? 

SW: They need to know what to assess for and what is normal and what is not.  They learn about vaginal dilation because the patients who undergo vaginoplasty must do this on a regular basis. Patients come home with VACs, JP drains, foleys and supra pubic catheters. Although the nurses are already familiar with these devices, they need to teach the patients how to manage them. The clinicians are also trained in social determinants of health for this cohort.

DN: What sorts of cultural issues do nurses need to learn about before tending to a GAS patient?

SW: We really need to understand that these patients, like all of our patients, are patients first who happen to be transgender. We must respect their chosen names, their pronouns and their gender expression. We focus on getting them better and integrated back into society. It’s a beautiful thing to witness and an honor to be associated in such a transitional journey.

DN: How does the Gender Affirmation Program reflect the larger VNSNY commitment to LGBT patients?

SW: It reflects our commitment to this population on an agency wide basis.  What is great is that we are now getting non-operative transgender patients who are seeking home care services for reasons other than gender affirming surgeries.  They feel safe here and seek care outside of gender affirming surgeries. 

We are initiating various ways to continue to be inclusive along the binary spectrum by hiring gender non-confirming and non-binary individuals. These individuals have a lot to offer and need to be the best expressions of themselves in their work environment just like the heteronormative society we all live in.

DN: And can you tell us something about the SAGE training in your organization?

SW: All divisions of the Visiting Nurse Service of New York have been awarded Platinum certification (the highest level possible) from SAGE , the world’s largest and oldest organization dedicated to improving the lives of LGBT older people.

More than 80 percent or more of VNSNY’s clinical and other staff have received SAGE Care LGBT cultural competency training, further establishing VNSNY as a preferred health care provider for New York City’s LGBT residents.

The SAGE training is designed to increase awareness among VNSNY clinical and administrative staff of cultural issues and sensitivities around sexual orientation and gender identification, so as to ensure a welcoming and respectful health care environment for all individuals within the LGBTQ community.

Among other things, the training stresses the importance of approaching each patient in a non-judgmental fashion and never making assumptions about anyone’s sexual orientation or family structure. We want every patient to feel they can be totally open about who they are with every member of our GAP team who walks through their door.

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