Home Health Nursing

11 July 2007, Wednesday








(Entrance into the Frederiksberg Kommunes Hjemmepleje, Home Care)


I could not sleep well last night with fear of not being able to get up early enough to meet Jette at 7:30, because I did not bring an alarm clock. I finally went to sleep after 2 a.m. but was able to get up and bring down the bicycle to go to the Home Health Agency. It was a short walk from the Nursing school to the agency. We met Trine, a veteran home health nurse, at the agency. She is very lively and energetic person. She had her ADN education in the States and lived there with her American husband so she speaks fluent English. Her husband is the first year graduate of the DIS (Danish International Study Program) and they met while he was studying here. Lucky guy, I thought. Trine and I will be spending the next two days on bikes maneuvering streets of Frederiksberg to visit people’s homes. This Home Health Agency is the only such kind, in the Frederiksberg municipality, that takes care of about 2,000 elderly residents. In Denmark, citizens older than seventy years old get two preventive health visits a year. In Frederiksberg, home health nurses fulfill this health policy. Some municipalities use general physicians to do this checkup in their clinics not people’s homes. Home health nurses play a tremendous role in post-hospital care of medical and surgical patients. It reduces the hospital stay of patients and helps cut down the hospital portion of the health care cost. Other main target populations for the home health care are the elderly with chronic diseases and dying patients at home. Nurses in home health nursing area enjoy their independence and interaction with clients in their home greatly. Trine has worked in the hospital only in the States. Once in Denmark, she took some courses to acquire Danish nursing license and since then only worked in the home health care because she loves working in the community. There is another kind of community nurse called, Health Nurse, who covers citizens from birth to school ages. They do visit people’s homes to check and weigh infants and to help mothers to raise their children. They also work in schools to promote good health. Health Nurses have their own center from which they organize and originate the pediatric nursing care. Trine says that WHO wants to expand the role of nurses and Danes would want Health Nurses to cover citizens of all ages. It would be comparable to Family Nurse Practitioner in the States without the prescription privileges. Hopefully it becomes a reality soon in Denmark for nurses’ sake. For Trine, she would retire before it would be adopted in the educational system.

It's cloudy, windy, and a bit chilly. The rain starts to drizzle. It is still early morning hour of 8:30. Trine and I hop on our bikes and venture out to the busy streets of Frederiksberg. As soon as we get to the first traffic light to make a right turn, she tells me of her history of being ticketed twice by passing the red light there. She was a bit late for her morning home visit and told the police officer about it. But he already knew home health nurses turning on red lights there and was adamant that she should pay 500 Kr ($100). I have never heard of bikers getting ticketed but this is Denmark. Is this maybe another evidence of Danish inflexibility? Trine rides fast and talks at the same time as she rides her bike. My butt starts to get wet and I try to listen to what she is saying. It is quite a joy ride. I slow down to prepare for the right turn as Trine gives me the hand sign, and immediately I get shouted by a biker behind me for not giving a hand sign. OK, I get it. Next time I will do it.

Our first client, Trine insists calling them clients not patients, is an elderly woman who has been discharged from the hospital yesterday. She had been admitted with pneumonia and still has some secretion from both lungs. She also has hypertension, glaucoma that makes her almost blind, osteoporosis, constipation, and dry irritating vaginal wall. Trine’s work today is to fill up her medicine bins and apply the eye ointment. The drug bottles and boxes fill up a big basket randomly and it is tricky to find all the meds, almost dozen of them. Some medicine runs out first and either client’s family or social/health helper should go out and buy the refills. This lady takes a lot of pills in the morning, more than 10, and the pills fill up the small morning bins quickly. It is easiest but takes the most time to fill up the med bins. Nurses need to cross-check each bin, by going through the day of the week, from Monday to Sunday. It is confusing to me because Danes use the comma as decimal point. Also one needs to check if the unit is mg or number of pills. After Trine applies glaucoma ointment on her left eye, we are on to the next patient.

It is still raining outside and chilly. We meet a friendly gentleman who is an insulin-dependent diabetic. He has arthritis in his hands and cannot use the insulin pen to inject himself. He sits down on his armchair and starts talking. Trine introduces me to him as a nursing student from Virginia. It is interesting they do not use the country name, the U.S. or America. They use the State name, either Virginia or Tennessee. Many Danes love Jazz and in early July multiple sites in and around Copenhagen have Jazz concerts everyday. Somebody said NATO has something to do with the US-Denmark relationship. He talks about American politics. He does not like the current administration but is very much fond of Hillary. He says she has written many more books than Bill has. He hopes she gets elected. Trine prepares the insulin pen and gives him a SQ shot on his abdomen. It is the only shot for the day, a mixture of short acting and regular. I asked Trine if he gets another shot in the evening and she said no. It is a problem for him that he does not want to get the evening insulin shot. He is afraid of being hypoglycemic in the morning that he might not wake up. His father and his brother were also diabetic and he grew up watching them suffer. Trine suspects that he and his General Physician (GP) might have some kind of pact and his GP does not order the evening insulin. It bothers Trine a lot because she knows his GP would retire soon and does not really care. He was encouraged to go to the Endocrinologist or diabetes care team but refused. She worries that, in the long run, his organ would be damaged unless his blood sugar is controlled. His flat already smells like urine. She has checked his morning blood sugar level several times and it was always high. It is client’s autonomy and needs to be respected. What would American nurses do in this kind of case, I wonder. Another interesting thing I have observed was nurses here do not use alcohol swab to clean the injection site. I asked Trine about it and she said it was to prevent the drying of skin. She said hospital nurses do use the swab. Later, from a literature search, I found that recently using an alcohol swab at home, here they say ‘spirit’ rather than alcohol, was also recommended.

Next stop is for a right great toe amputee from his diabetes. Trine needs to check the dressing and replace it. Wound care is one of the main nursing care duties for home health nurses. There is a wound care specialist nurse as well as an outpatient wound care clinic in the home health agency. Trine cleans up the wound site with gauze soaked with lukewarm water. She says they have to use very hot water and mix it with cold water to prevent germs from the old pipes in the building. Home health nurses do not carry sterile normal saline for wound care. He twitches a bit when she touches a spot. He shows Trine a doctor’s note that says he needs more months to stay away from his job. He was expecting to go back to his work but now he needs to get the load off his right foot for many more weeks. I mention an antique gun in his dining room and he says that he is a hunter. A vertical cabinet on the corner of the room has more shot guns, he says. I ask him how he is coping with the disability like this and he points a deck of old chest drawers. He bought some old furniture to restore them at home. Trine says he is noncompliant and walks to stores and parks. He also refuses to wear the Care-cast boot at home. He can stay home for up to 6 months while his toe heals. He still gets the full salary and the health care is free. Hopefully he enjoys his time-off and goes back to work before the weather gets too cold.

We are about half done for today. Home health nurses visit 10 to 15 clients during the shift. Similar to nursing home staff schedules, there are three shifts a day, morning, evening, and night. Evening and night nurses drive small red cars owned by the municipal government. They are parked across the Agency in the local fire department parking lot. Trine gets only 5 clients when she precepts nursing students. Her manager complains because of that. This home health agency exclusively accepts nursing students from Diakonissestiftelsen. I could read the pride from her voice that the agency produces excellent nurses through their training program. Nursing students are trained for 8 weeks, from Monday to Thursday. Trine mentions that in the early weeks, the students do not know how to interact with clients. Some students excuse themselves, saying some clients refuse their visits. But near the end of 8 weeks, they start to learn the fun side of the home health nursing. There is a nursing student working during the summer as an SHA to help filling up gaps created by staff on vacation. Home health nurses in their late 40s and early 50s train young nurses who just start their new nursing career in this agency. The number of home health nurses has not increased in Frederiksberg because more young people move in and the elderly population has not increased as much. But there are more demands for SHHs all the time.

The next client is a smoker and drinker evidenced by the smell in his apartment and a bunch of liquor bottles in the shelf. He has had leukemia and now colon cancer for which he has colostomy. Trine is supposed to change the bag today unless he has already done it yesterday by himself. He says he did it and the tissue around the colostomy connection site is pink and not swollen. His apartment wall is filled with Dali and Klimt. His TV shows stock prices. I asked Trine if she attempted asking him to quit smoking. She says not until she has enough rapport with her client. Usually she does not mention such a thing until two months from the new encounter with a client. Otherwise, some clients ask for a replacement. Trine says she needs to assert herself in that kind of situation by apologizing and keep addressing and nursing them. Backing off is not an option, she says. It is for their health and shrewdness in establishing relationship is a key issue in home health nursing. I like her more and more.

The last client gave me a chill, not because of her wound but because of her whole situation. She has never been outside of her 5th floor dilapidated apartment for 11 years. The building does not have an elevator and it looks like it has been quite a while since any maintenance work was done. Trine knocks on the door and it seems like forever when she finally opens the door. Here is a small and soft-spoken old lady who barely walks using her walker. Trine warns me before she opens the dressing wrapped around her right lower half of her leg below the knee. She has had chronic ulcer on her left leg that was healed and now she has even more severe one on her right leg. It has been like that for a long time, maybe more than a year. Trine says she has refused to see doctor or have a doctor visit her. Only the agency wound care team visited her and treated the wound. She used to take antibiotics but now she is not taking any because of the resistance. She suspects Pseudomonas but it has not been cultured recently. She opens up the wound and green pus is everywhere, oozing out and down to her foot. The wound circles almost all the way around her leg. It must be at least stage three ulcer. Not quite to the bone level but pretty close. It is something that I would see in the States with the patient admitted in a hospital, getting Zosyn IV drip for days. I am puzzled. Why is she here in her tiny flat alone without Antibiotics? Is this the respect for client’s autonomy or some kind of system failure? I checked her pulse after asking for permission. The pulse is thready and slow but regular. Home health nurses rarely listen to heart and lung sounds unless the clients’ symptoms warrant as such. I do not understand if this is palliative care or regular would treatment. Even if it is palliative, one does not need to have pain from the wound. Maybe I am missing something.