The Role of Schedule Volatility in Home Health Nursing Turnover

Despite considerable research on nursing turnover, few studies have considered turnover among nurses working in home health care. Using novel administrative data from one of the largest home health care organizations in the United States, this study examined turnover among home health nurses, focusing on the role of schedule volatility. We estimated separation rates among full-time and part-time registered nurses and licensed practical nurses and used daily visit logs to estimate schedule volatility, which was defined as the coefficient of variation of the number of daily visits in the prior four weeks. Between 2016 and 2019, the average annual separation rate of home health nurses was over 30%, with most separations occurring voluntarily. Schedule volatility and turnover were positively associated for full-time nurses, but not for part-time nurses. These results suggest that reducing schedule volatility for full-time nurses could mitigate nursing turnover in home health care.

Home Health Nurses’ Journey Toward Culture-Sensitive/Patient-Centered Skills: A Grounded Theory Study

Introduction. Home health patients, who are members of minority and vulnerable groups, suffer disparate outcomes. Patient-centered care (PCC) and culturally-competent care (CCC) aim to facilitate high-quality, equitable care. How home health nurses incorporate PCC and CCC principles into their assessment and care-planning practices has not been -investigated. This study answers the question, “ What is the process by which home health nurses develop their culture-sensitive/patient-centered assessment and care planning skills?” Methods. Home health nurses (n= 20) were recruited into this grounded theory study from agencies around the United States via flyers, websites, and contacts. We conducted in-depth recorded interviews using a semi-structured interview guide to ask questions about nurses’ assessment and care-planning practices, their understanding of CCC and PCC principles, and facilitators/barriers to CCC and PCC practice. Results. Participants primarily gained their CCC and PCC assessment and care-planning skills through a “seat of your pants,” trial-and-error process, with little educational or agency assistance. They combined caring, diverse patient experiences, and critical, creative self-reflection on their experiences to gradually learn helpful, though not optimal, CCC and PCC strategies. However, they reported numerous barriers that discouraged or distressed them in their quest to deliver culturally-competent and patient-centered care. Only a few nurses demonstrated the resilience to overcome these challenges creatively and happily. Conclusion. If we accept that patient-centered care and culturally competent care are key elements of high-quality, equitable care, this grounded theory may help home healthcare clinicians, administrators, educators, and policy-makers identify impact points for enhancing CS/PC practices.

Work Shifts

This chapter takes a closer look at caregiver/nurse interactions. It includes an analysis of the identities and emotional labor of home health nurses. As professionals who possess valuable disciplinary knowledge, how do they feel about transferring their skills to lay caregivers? Nurses' orientation to the labor and the effects on interactions with caregivers are key features in the labor transfer. Nurses were able to gradually transfer the skilled labor through strategies such as “gently encouraging” or “forcefully 'pushing' ”caregivers to learn, and “if the caring work appeared too difficult or technical, nurses simplified or 'downplayed' these aspects, or they would insist that the caregiver was 'smart enough' to learn.” Nurses often stated that the goal was to make patients and families “independent” in their care. Nurses thus draw heavily on the ability of home care to provide holistic nursing practices. Nurses' focus on patients' physical and emotional health refutes a vision of nurses as purely “ideological workers” — an image that implies an insensitive and coercive nature in the transfer of skills. The relationship between nurses and caregivers is critical for nurses, who identify heavily with the education component of their profession.

On-the-Job Training

This chapter talks about the different teaching strategies nurses employ to train caregivers, and the different ways in which caregivers learn in training. Nurses develop strategies based on caregivers' and care recipients' readiness and different levels of knowledge. One of the first things they report doing when making initial contact is to find out what the expectations are, and manage them. Another strategy nurses say they use, especially if someone is hesitant or has anxiety, is to give emotional reassurance, including “lots of praise,” positive reinforcement, and encouragement. In terms of hands-on work, all nurses state that the general process is to demonstrate to the caregiver and/or care recipient exactly what they are going to do, allow them to watch and ask questions, and then observe a return demonstration. It is evident that there is a great deal of variability in how home health nurses convey information. While some of this may be due to agency policies or norms, nurses have different teaching philosophies and styles and are often given much leeway as to how they transmit information. The fragmented nature of the system means that caregivers may experience vast differences in communication processes and in the training they receive. The chapter discusses how caregivers train in three different conditions: caregivers who received prolonged training in rehabilitation facilities and hospitals, caregivers who received some training in hospitals, and caregivers who received little or no training in hospitals.

Home health nurses’ views on participating in pre-ambulance emergency treatment: A qualitative descriptive study

As part of the Health Care Interaction project that was rolled out in western Sweden, home health nurses (HHNs) were called on as first responders to provide emergency treatment to patients, while waiting for the ambulance to arrive. The aim of this study was to evaluate the Health Care Interaction project in terms of the training and preparation of HHNs and the competencies that the nurses felt they needed to develop to feel confident in these assignments. In this qualitative descriptive study, 11 home health nurses from six municipalities that implemented the project were interviewed, and the data were analysed using content analysis. The COREQ guidelines were followed in the reporting of this study. The findings show that some municipalities did not have a training or preparation course in place, and guided the HHNs to refer to self-education material. The HHNs emphasised the importance of continuously updating their knowledge and skills through regular training. Further, feedback and reflection were considered important as reinforcement of learning.

Bringing the R Back to SBAR: A Focused Heart Failure SBAR Tool

This article describes a quality improvement (QI) project implemented in a home health setting among a population of patients with heart failure (HF). It was discovered there was a lack of nurse-led recommendations and ineffective use of the situation, background, assessment, and recommendations (SBAR) tool among home health nurse when communicating with providers about HF patients. Therefore, the QI project focused on creating and implementing a focused HF SBAR tool and a self-care patient checklist to be utilized by all home health nurses for all visits with HF patients. The focused HF tool was created and laminated and became part of home health nurse’s identification badges. The implementation phase took place over a 60-day time period. Following implementation, outcomes were measured and demonstrated an increased use of SBAR, and an increase in nurse-led recommendations documented. In addition, there was a decrease in acute hospitalizations for HF among home health patients. Furthermore, there was an increase in nurse-led interventions implemented in the home along with an increase of referrals to physical therapy (PT) and occupational therapy (OT). The educational session was well-received and prompted a practice change in the delivery of future continuing education content. Finally, organizational leadership reported increased confidence and improved interprofessional communication among home health nurses and providers.