03.02 Practice Settings

Hi guys! Welcome to the Practice settings lesson. If you’ve had clinical rotations you know that nursing is everywhere. There is no shortage of where you can work and in what capacity. The same is true for community nursing. We’re going to talk about where community nursing takes place in this lesson. Let’s get started!

Home health is a big piece of community nursing. It’s a multidisciplinary approach to care for clients in their home. We want to provide ADL and iADL care to those individuals that don’t necessarily have the ability to be independent in all areas. We talked about ADLs in earlier lessons. These are Activities of Daily Living. Remember these are basic essentials to our daily functioning and they include bathing, dressing, toileting, and things of that nature. iADLs are instrumental ADLs. These are slightly more complex like transportation, errands, finances, housekeeping, things that are not so basic but still essential. Then we have medical needs in home health. Wound care, medication management, this list is not exhaustive, but gives you an idea of the complexities we can face in the community.

Who gets home health?  We provide home health care to people who are not as independent as they once were at home, but aren’t quite nursing home ready or have a desire to remain in the home as long as possible. Remember we want to honor the wishes of our clients so we make that happen for as long as we can. Maybe they don’t have the same access to their resources as they used to and they need help with that. The situation can be temporary, like after a hospital stay following surgery or rehab,  or it can be a permanent decline like a terminal illness. In some cases, we are providing a support system and contributing to any safety needs a client in the community may have so we can avoid further hospital stays.

Providing home health care helps in all of these areas. We help clients maintain their independence in the home for as long as they can, which helps avoid hospitalizations because we are working to manage their personal safety and slow down any declines in their condition. We are also always assessing for changes so we can update care and resources as needed.

As I’m saying we’re always assessing, here comes the question what do nurses do in home health care? We provide any medical treatments as ordered. This includes medication and wound care as I said earlier which may be fairly easy, but also more complicated treatments like trach care and tube feeds. Assessing for changes is clearly important because I keep saying it, but this is always a priority. Client needs are almost always changing so we have to stay prepared for that. Then there’s patient education, which we are always doing as well. We want to make sure that patients and caregivers know what to expect and what to do if problems arise and we aren’t there.

Hospice care is popular too. Lots of people get confused by what it actually is. I have a friend who posted online about her fiancee’s mother being placed on hospice recently and she says “I don’t understand because she doesn’t have cancer.” I thought it was horrible that she hadn’t been educated that that’s not what hospice is. Hospice is end of life, comfort care. When you’re terminally ill and  given 6 months or less to live, most doctors will order hospice care to help manage your symptoms. It’s NOT curative treatment, we’re just providing comfort and focusing on QUALITY of life as opposed to extending it. What’s interesting about hospice care is it’s interdisciplinary. When we say interdisciplinary we mean that all the disciplines work together with the same goal. It’s not social workers work on the social aspects, nurses and doctors work on the medical. Everyone involved is there to comfort the patient and family members, so roles can be interchangeable sometimes.

Even though roles can change, I’ve highlighted some of the nursing roles in hospice care. The nurses role is to coordinate care to manage symptoms. This is the comfort care. We are always looking for what works for the current set of problems. From there we make recommendations on different interventions based on those problems. Again, we administer medications if ordered. The goal in mind for this is always comfort. Remember this is not curative so a lot of the medications here are for pain management.

Hospice and home health are the more obvious community nursing jobs, but community nurses work in other areas that are just as important. Occupational health focuses on workplace health and safety. These nurses work on health promotion and maintenance by watching disease trends, assessing risks and hazards in the workplace and educating employees on how to avoid those risks and diseases by way of trainings and competencies. What does this all mean? Occupational health is all about prevention.  Every job I’ve had, I’ve had to provide proof of recent PPD or chest xray and immunizations in some cases. These records stay with occupational health and they are monitored. Monitoring trends means there has to be data, right? I have to provide those records for a reason. If my PPD is positive, there are precautions that need to be taken. This data helps us to determine how we train employees on safe practices to maintain their safety. This isn’t strictly for diseases, it’s also useful when assessing risks and hazards as well.

Who doesn’t love a school nurse? In elementary school we lined up in the gym for scoliosis tests. I don’t think they do that anymore. School nursing has evolved since then. The goal remains the same though: to protect and promote student health by enhancing student school performance, controlling the spread of diseases, addressing student health issues as they come up and follow-ups. We have to stay age appropriate here so the approach will change as the level of schooling changes. For now, my biggest issue is  I can’t send my kids to school until they are fever free for 24 hours without Tylenol. If I try, they get turned right back around. That’s some serious follow up.

Something people don’t have a lot of knowledge about is working for the federal government as a nurse. You can act as a civilian at the VA or Armed Forces, or you can be active duty and that’s all we know, right? Well, there’s also the CDC and the NIH in DC where nurses are good for policy management and research. They can also be used during disasters. Then you have the prison system. Yes, we are everywhere!

What do we do in the government? These are all roles I probably just mentioned but I want you to see them clearly. We monitor and research health trends. We work to improve access to care for everyone and usually that’s by way of policy development and coming up with new education and interventions for different disease trends.

Mental health is a big deal in the community and we do what we can to manage it in the community before someone has to be hospitalized. I could go on for days but I’ll keep it short. Behavioral health management comes in the form of mental health and addiction services in clinics and at home visits. What do nurses do? We provide crisis intervention. We evaluate the immediate needs of a client in crisis. Do they need medication, hospitalization or a more short term intervention like a crisis team? We provide medication management with oral and injectable medications for longer lasting effects in those not compliant with oral medication. Now, clients with mental illness are a vulnerable population in the community and require lots of support, guidance and advocacy. Nurses aren’t the only ones to provide this, but we are on the forefront.

Let’s talk key points. Home health care promotes client independence in the home. We want to maintain as much as possible to continue honoring a client’s wish to remain at home if they can. Hospice care is not curative! We want to promote quality of life and provide comfort to client and family. Nurses wear a lot of hats and in the community, it’s no different. There are no two client situations that are the same, but no matter what the situation is, the goal in each area will be the same. Remember, nursing is not cookie cutter but one way or the other we are providing resources, educating, advocating and caring!

That’s all for the practice settings lesson. Make sure you check out all of the resources attached to this lesson. Now, go out and be your best self. And as always, happy nursing!