Where the Heart Is

When Ran Li, MSN, RN, entered the home of her elderly Chinese patient, she wasn’t surprised when the woman refused to make eye contact. While some nurses might have assumed the patient was being rude or trying to hide something, Li understood that in traditional Asian cultures it is considered disrespectful to make eye contact with a person of authority.

“In Asian cultures, to look someone directly in the eye implies equality,” says Li, who works for Addus HealthCare, a home care agency in Concord, California. “Since [Asian] patients often consider a physician or a nurse to be superior, lack of eye contact is their way of showing respect.”

Li is one of many minority nurses across the United States who are employed in the field of home health care. Experts say nurses like Li, who have firsthand knowledge of ethnic minority patients’ language and cultural needs, can eliminate barriers to care and improve patient-nurse communication, resulting in better patient outcomes.

Home health nursing in the U.S. began about 100 years ago with visiting nurses who dedicated themselves to providing care for frail elderly and other homebound patients. Today, according to the National Center for Health Statistics (NCHS), the nation has more than 11,000 home care and home hospice agencies in operation, providing a range of services designed to care for chronically or terminally ill patients who wish to remain in their own homes or in assisted living facilities. In the year 2000, approximately 1.4 million Americans were home care patients, according to a National Home and Hospice Care Survey conducted by NCHS.

And the field continues to grow by leaps and bounds. The Bureau of Labor Statistics predicts that the number of patients receiving home health care will continue to increase dramatically through the year 2012, as baby boomers continue to age and more patients opt to remain in the familiar, independent environment of their homes.

Flexibility and Opportunity

Nurses who work in home health care enjoy flexibility, autonomy and opportunities for career growth, as improved medical technology allows for more complex procedures, such as dialysis, to be performed in homes. The burgeoning growth of the home health industry, combined with the nursing shortage, is creating a tremendous need for more nurses to enter this specialty. And with the nation’s ever-increasing racial and ethnic diversity, there is an urgent need for more minority nurses who can bring culturally and linguistically competent care directly into patients’ homes.

“Caring for patients at home requires much more than knowledge of disease

processes,” says Geri-Ann Galanti, PhD, a medical anthropologist who teaches courses on cultural competence at the UCLA School of Nursing. “Home health nurses can play an important role in decreasing health disparities among underrepresented minority groups.”

Galanti notes that attending to the special needs of racially and ethnically diverse patients requires respect, sensitivity, patience and awareness of cultural differences. Yet she also cautions nurses not to stereotype ethnic groups.

“Patients from different countries and ethnic groups have different attitudes toward the health care system,” she explains. “You can’t make a sweeping generalization about an entire culture. While Asian immigrants from rural villages of China may be unfamiliar and fearful of Western medicine, patients from Hong Kong are usually very comfortable with American treatments and practices.”

When Li visits patients in the local Chinese American community, she brings with her a sense of familiarity and comfort. Li, who speaks Mandarin, understands not only the patients’ language but also the cultural beliefs that shape their lives. Before emigrating to the U.S. from China in 1991, Li worked as a pediatrician in her native Shanghai. Upon her arrival in the San Francisco Bay Area, she enrolled in nursing school and received her MSN from San Francisco State University. After graduation, she began working as a home health nurse.

“I love working in the field of home health,” she says. “As the mother of two young children, my job gives me a lot of flexibility.”

Her workday typically begins at 8:30 a.m. and ends at 2:30 p.m., leaving her time to pick up her children from school and take them to extracurricular activities in the afternoon. She often completes her charting at night after the children have gone to bed.

Because she is a home health case manager, Li also oversees the work of other home health nurses who perform a range of skilled nursing services, including hydration, pain management and wound care. The nurses also assess each patient’s living situation and make recommendations for personal care aides, physical therapists, meal programs and other social services.

“There are tremendous opportunities for nurses who want to work in the home

health field,” Li emphasizes. She notes that most home health agencies only require that nurses have one year of experience working in either a skilled nursing facility or a hospital. And with no end to the nursing shortage in sight, many agencies have begun to waive this requirement by offering home health training programs for new nursing graduates.

In the diverse Bay Area, Li has encountered many situations where her cultural background and language skills have proven beneficial in helping Asian patients. “Patients from various cultures can have a different way of doing things,” she says. “I look at my job as being a liaison between the patients and their doctor. [I’m there to] help make their transition from hospital to home as easy as possible.”

Part of the Family

Privately owned home care agencies and hospices aren’t the only places where nurses can find rewarding careers in home health care. Many home health nurses work for Visiting Nurse Associations (VNAs), which are not-for-profit, community-based home health organizations. According to the Visiting Nurse Associations of America, VNAs care for nearly four million people each year.

As both a visiting nurse and the national secretary of the National Association of Hispanic Nurses (NAHN), Jennifer Figueroa, BSN, RN, hopes to see more nurses of color enter the field of home health.

“We’re seeing more elderly Hispanic patients and fewer Hispanic nurses,” says Figueroa, who works for the Visiting Nurses of Westchester in White Plains, N.Y. “Cultural competency requires more than just being able to speak [an ethnic minority patient’s] native language. It also means understanding cultural differences, such as customs, traditions and taboos.”

As an example, Figueroa, who is of Puerto Rican descent, cites the increasing number of Hispanic patients who are being diagnosed with diabetes and cardiovascular problems. “Most diabetics are told to control their intake of complex carbohydrates,” she says. “But for Hispanic patients, complex carbs are a big part of their diet. Rather than saying don’t eat carbs, I work with patients to cut their portion sizes and add vegetables.”

Providing culturally competent care can also extend to a patient’s family members. “In the Hispanic culture, discussions of death and dying often involve family members rather than the patient,” Figueroa explains. “They want to shield their loved one from bad news.”

While it’s a subject she approaches carefully with the families of patients who are terminally ill, she believes it’s important to be honest with the dying person. “I don’t push too hard, but I also tell families I’m not going to lie or withhold information from the patient,” she says. “Sometimes patients really want to know their prognosis so they can say their goodbyes and put their affairs in order.”

Prior to becoming a visiting nurse six years ago, Figueroa worked in medical-surgical nursing. Now, she says, she has found her niche in the home health specialty.

“I see patients ranging from babies to seniors,” she declares. “We typically care for patients for a five to seven-week period of time. During that time you truly become a part of their family. I still keep in contact with many of my former patients.”

Figueroa thinks the home health field is a perfect fit for nurses who have strong assessment and time management skills and who desire flexibility and the opportunity to work independently. “It’s the best of both worlds,” she says. “You have autonomy, but you’re supported in your job by a team of other medical professionals. The patients are always happy to see you and they’re thankful for the care you provide.”

Home Care for Kids

Pearl Boone, RN, loves caring for children. Boone, who is African American, has been a nurse for 18 years and began working in home health care two years ago. She divides her time between working in the neonatal unit at Texas Children’s Hospital in Houston and serving as one of the hospital’s home health nurses.

During the past two decades the demand for pediatric home care has exploded. According to the federal Centers for Medicare & Medicaid Services (CMS), this is the fastest-growing segment of the home health care industry. CMS anticipates that the pediatric market will represent a $3.5 billion business in the next decade.

Most of Boone’s home health charges are infusion patients who have metabolic diseases. She also treats young children who have sustained wounds and infants who require apnea monitors.

With a maximum patient load of 10, Boone makes home visits on her days off from the hospital. “I love the flexibility of working in home health and the bond you have with your patients and their families,” she says. “As a home health nurse, you have the benefit of working with patients for an extended period of time. I have two families that I’ve been with for over a year.”

Boone thinks some nurses might be hesitant to explore careers in home health care because of misconceptions about the field–misconceptions she is quick to dispel. “I know with rising gas prices, many nurses worry about paying for their own gas and the wear on tear on their cars,” she says. “My employer reimburses for mileage, and because there is such a severe need for home health nurses, most of them can opt to work in areas in close proximity to where they live.”

In addition, the growing use of telehealth technology allows nurses to spend less time on the road. In some rural home health programs, for example, patients are equipped with audio and video devices in their residences, which enable them to interact with their home care nurses via computer. This also lets nurses augment their regular home health visits. Whereas a nurse in a rural area might spend hours driving from one location to another, telehealth technology gives nurses the opportunity to check in with 15 to 20 patients a day without physically traveling to their homes.

For Boone, one of the most enjoyable aspects of home health nursing is patient education. “I love having the time to teach patients about hygiene, nutrition and coping skills,” she says.

While the flexibility of working in home care makes this career appealing for nurses who have young children, Boone, a single mom with a daughter in college, says it’s also the perfect fit for her lifestyle. “You work your schedule around what is convenient for both you and the patient,” she explains. “And the interaction with patients is priceless. They are all part of my second family.”

Bringing It Home: Getting Started in Home Health Nursing

Home health nurses make visits to a variety of acute and chronically ill patients who are “homebound” and in need of skilled nursing care under a treatment plan that is developed and signed by the patient’s physician. Nurses in this specialty can choose from a variety of employment options, including hospitals’ home health departments, private home health agencies, hospices, Visiting Nurse Associations and public health departments.

Although some nursing schools–such as the University of Michigan and the University of Pennsylvania–offer master’s-level programs in home health nursing, there are currently no specific educational requirements for working in this specialty beyond a BSN degree and basic licensure as an RN. Most home health employers require or prefer at least one year of hospital experience, particularly in critical care. However, many home care agencies have begun to offer on-the-job training programs for new nursing grads.

Home health nurses must have strong clinical and communication skills, including competency in teaching patients various medical procedures and self-care activities. They also need excellent assessment skills in order to detect early signs of potential or actual problems and alert the physician that a change in the plan of care is needed. Documentation of care is also important in this specialty. In addition, home health nurses need to be self-directed and must be able to work both independently and in collaboration with a multidisciplinary team.

More information about home health nursing is available from:

• Home Health Nurses Association, www.hhna.org

• Visiting Nurse Associations of America, www.vnaa.org

• Hospice and Palliative Nurses Association, www.hpna.org.