Standards of Practice

By Marianna Herrera, RN, IgCN

"I am of certain convinced that the greatest HEROES are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel." – Florence Nightingale

These words resounded in my head when learning about the pioneer of nursing, the great Florence Nightingale. I've always taken pride in doing my best, no matter how small or how big my assigned duty was. In becoming a nurse that work ethic increased 10-fold, in my eyes at least. I was now responsible for the care of someone's mother, father, brother, sister, son or daughter! Their lives greatly depended on my care for a certain number of hours in a day and in many occasions the care provided indicated how the patient's prognosis would be. My decision on whether I wanted to become a PRESCRIBER or "just" a nurse was determined with my first experiences in the hospital. A prescriber, although a very respected profession, did not allow to have a 1:1 connection with patients. A prescriber goes in and out, solves a problem and moves on to the next patient. Nursing on the other hand allows to build rapport with patients, with their families and that is what I valued most and made the decision easy to choose to become a nurse.

Why did you become a nurse?

This is a simple question but answering it can be extremely simple or extremely hard. For people who are not nurses, pay is one of the top answers mentioned. For us nurses, we know we could never get paid enough to do some of the things required in nursing and to do so to strangers, who may never even know what you did for them. Nursing also is very demanding and at times you sacrifice your own family or even yourself to care for others. But even so, with the hours, pay rates, ratios, politics and with great sacrifices many of us still love being a nurse and do it with heart. So again, ask yourself, "Why did I become a nurse?"

Answering that question can change your nursing practice. In "working" as a nurse, many forget, and their practice becomes subpar. Not a lot of people have a calling to become nurses, but those of us who do, can too easily forget at times. According to the American Nurses Association (ANA) nurses must always stress human rights protection and uphold the values and ethics of the profession. Meaning what really? The answer, as stated in the beginning of this blog, is to practice as Florence Nightingale states: "…do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel". There is no statistical or physical evidence showing nursing outside a clinical setting changes the practice of nursing, but being a part of home infusion, I can state some of the issues that occur in the home are instances that would be very difficult to put into play in a clinical setting. It is a privilege to be a part of the home infusion community. The perks it offers are outstanding, which may be hard to understand because nursing practice can vary so much from that in a clinical setting. The following recommendations may be used in both the home and clinical settings but are more geared to reminding nurses of why you became a nurse and how to provide care and care for patients and not just "work" as a nurse.

Respect the patient/client and preserve human dignity care for your patients.

When caring for patients please do not change your form of care for patients with a medical background. Making a transition from being a caregiver to patient is a journey of its own and even with all the knowledge a medical professional has, it's a whole new world when becoming a patient. Assess the situation and tailor your care to each individual patient. There is more to getting to "know" your patient than just reviewing their orders and reviewing their charts. Take your time to call your patients ahead of time (and always the day before to remind them to hydrate and to pull their medication out of the refrigerator- just good practice), introduce yourself, ask them for any past accessing issues, and adverse reactions to be able to come up with a game plan. Also ensure you are respecting being in someone's home and wearing a mask and any other PPE the patient would like you to wear. Hand washing is also a very sensitive issue now, verbalize to your patient every time you wash your hands or every time you change activities and sanitize. Having a patient hear and see your actions helps them feel better and confident that you are being thorough with infection control practices.

Social media: to follow or not to follow?

Having to change with the times has moved nursing practice away from a black or white area of right or wrong. There are so many grey areas that could allow a professional relationship to quickly cross the line. It is not wise to follow patients or patient family members on social media so relationships stay strictly professional. At the end of the day you are providing a service to these patients and if the "customer" isn't happy with the service, the provider is usually the one at fault. Not engaging in such a practice just keeps you in the safe zone, no matter how "close" you've become with the family. That brings us to the next topic. Politics and religion. Since the beginning of time, that has been a rule, strongly emphasized, by Dale Carnegie, writer of, How to Win Friends and Influence People: "There is only one way to get the best of an argument—and that is to avoid it." Nothing good ever comes from engaging in a conversation that is solely based on feelings. If your opinion is asked, respectfully decline a response and engage in a different activity.

Maintaining patient's privacy and commitment to confidentiality.

Trust is the biggest asset a nurse can develop with a patient. Don't hinder established trust by being careless with sensitive patient information. It is seen all the time on the news that a nurse posted pictures of a patient on Instagram or Twitter to only share with their immediate followers and within an hour or even minutes posts become viral and shared across the internet. There is never a just reason to post anything about a patient under your care on social media. According to Gallup (American analytics and advisory company), nurses have been voted the most trusted profession for 18 years in row and it is of no surprise to those who practice ethically. When seeing patients in their own home, nursing practice should not change because of the setting. Home infusion offers a great autonomy to the nurse, but this does not mean the practice should differ from in a clinical setting. Family members, whether it be a two-legged or four-legged family member, should not be brought to the home despite the relationship you've developed. It is never okay to do something in the home per se that is not allowed in a hospital. If you are a designated mentor, shadow visits maybe required for on-boarding a nurse. However, several steps must be taken before showing up to the patient's home with a second nurse, including permission from both the patient and specialty pharmacy.

Practice to professional obligations.

Infusing a patient in the comfort of their own home, is a plus for many reasons. This, however, does not mean the patient may be left unsupervised for any amount of time. The nurse should remain with the patient for the entirety of the infusion. Having a plan for long infusions is key. Some infusions may not be scheduled for long periods, but the time could increase significantly depending on a patient's tolerance. If you will be in a patient's home for an extended period, eat prior to your scheduled time, pack a lunch or ask the patient if delivery is permissible. Please be conscious of your food when a patient is infusing. This would not be the best time to take the left-over deviled eggs and potato salad from the cook-out the night before. The patient will greatly appreciate the nurse not contributing to potential side effect of nausea. Also, please arrive to the home scent free and smoke-free to not aggravate the patient's side-effects. It is crucial to be tidy and clean up after yourself. If you notice a patient is on a blood-thinner, move the patient's favorite beige quilt out of the way before sticking them. Ask the patient for a trash can or use a bag to discard trash. A patient should not have to clean up after a nursing visit, especially for those patients whose infusions take a huge toll.

Accountability, responsibility and consciousness.

Always be punctual to your patient appointments. Scheduling patients in time blocks allows wiggle room to prevent tardiness. Your time frame should be set as Friday, January 8th between the times of 8:30 am to 10:30 am. Especially adhere to this type of scheduling when seeing multiple patients in a single day. All infusions are unpredictable and may require some more time than planned. Once heading to a patient's house, make a courtesy call advising of your estimated arrival time. Also advise your agency of last-minute changes so they can be informed and not be surprised when an upset patient calls, asking for an update. If everyone is on the same page and well-informed everything tends to run smoothly.

Commitment to honesty and loyalty.

When monitoring a patient in the home, leaving to the drive-thru to pick up some food quickly between vitals is unacceptable. In a clinical setting, this is considered patient endangerment and job abandonment. There is no difference between the two settings and in the home the nurse is to remain with the patient throughout the entire infusion period. Also, when caring for patients in their home, it is unacceptable to accompany your patient in a nap. Ensure you plan your day accordingly and don't schedule a long infusion with a patient after a long 12 to 13-hour shift. It is unprofessional and uncomfortable for the patient to have to wake up a tired nurse from a deep slumber. If witnessed by a clinical director in a healthcare facility, this too would be highly unacceptable. Again, the autonomy is great in the home and allows for vast perks, however, you always need to be responsible and professional. Autonomy comes with a great deal of integrity, which means you won't falsify documentation and will be honest with all aspects of patient care. Home infusion allows for continuum of care, for even years at a time. This however, does not change the professional relationship between a nurse and patient. Do not get involved in family dynamics, unless patient safety is a concern (and immediately contact Nufactor).

Continuous adherence to practical competence.

"With great power comes great responsibility." - Voltaire (or more recently B. Parker). It is with no surprise nurses are voted the most trusted and most ethical professional. With this power we must be conscience of what we verbalize and suggest to patients. Bad mouthing another healthcare professional is not only in poor taste, when coming from a nurse the patient takes it to heart and may lose respect for the person being disparaged or worse, lose respect for the nurse taking part in such an unprofessional manner. Also, a nurse needs to understand the limitations of our scope of practice. Making innocent suggestions such as "You're such a hard stick, you should consider requesting a Port-A-Cath" is usually not appropriate. This suggestion, although true in many cases, is beyond our scope of practice and can greatly hurt the relationship the patient has with their prescriber if the prescriber does not agree to the suggestion. Suggested alterations to therapy should be discussed with a pharmacist from the specialty pharmacy. The two of you may have a professional discussion and the pharmacist may proceed to initiate the suggested change. Also, if your opinion differs from that of the patient regarding their care, prescriber or specialty pharmacy, never voice or discuss with the patient. Again, it is in poor taste and can greatly affect the way a patient sees you professionally.

Appropriate communication: professional to professional.

Multi-disciplinary care of patients is common practice in patient care. Keeping constant and accurate communication is essential for better patient outcomes. Being a home infusion nurse, you become the eyes and ears of the prescriber and pharmacist. Communicate changes the patient reports from other disciplines, changes to medications and inform the pharmacy if you notice any changes in tolerance of infusion. All side effects must be reported to the pharmacy and in cases of an emergency, the prescriber must be informed after the patient is stabilized. Adhering to pharmacy-specific expectations will ensure patients will be safe and will ensure trust is built in every aspect of care for the patient.

Compassion and Kindness.

Practicing with compassion and kindness is ultimately the answer to why I became a nurse. I have always and will continue to care for my patients in the same manner I wish my family will be cared for in their time of need. Life has a funny way of paying it forward and the best way is to practice with compassion and kindness with every single patient you service.

These suggestions all fall under the ANA recommendations to always stress human rights protection and uphold the values and ethics of the profession. It just serves as a reminder that no matter the setting nurses should uphold standards of practice to the highest expectation. Practicing in such a manner will ensure your practice stays consistent and is always exceptional.