Hospital and Community-Based Nursing

Providing nursing care in a patient’s home is different from providing care in a hospital. Patients must sign a release form to stay and receive treatment in a hospital. They have little control over what happens to them, and they are expected to comply with the hospital’s rules, regulations, and schedule of activities. They sleep in the hospital’s beds and often wear hospital gowns or clothes. They are given care, treatments, baths, and medications at times that are usually determined by institutional schedules rather than convenience for the patient. Although hospitalized patients may select meals from a daily menu, there is a limited choice in the type of food they are offered. Family members and friends visit during the hospital’s visiting hours. By contrast, the home care nurse is considered a guest in the patient’s home and needs permission to visit and give care. The
nurse has minimal control over the lifestyle, living situation, and health practices of the patients he or she visits. This lack of full decision-making authority can create a conflict for the nurse and lead to problems in the nurse–patient relationship. To work successfully
with patients, no matter what the setting, it is important for the nurse to be nonjudgmental and to convey respect for the patient’s beliefs, even if they differ sharply from the nurse’s. This can be difficult when a patient’s lifestyle involves activities that the nurse considers harmful or unacceptable, such as smoking, use of alcohol, drug abuse, or overeating. The cleanliness of a patient’s home may not meet the standards of a hospital. Although the nurse can provide teaching points about maintaining clean surroundings, the patient and family determine whether they will implement the nurse’s suggestions. The nurse must accept the reality of the situation and deliver the care required regardless of the sanitary conditions of the surroundings. The kind of equipment and the supplies or resources that usually are available in acute care settings are often unavailable in the patient’s home. The nurse has to learn to improvise when providing care, such as when changing a dressing or catheterizing a patient in a regular bed that is not adjustable and lacks a bedside table ( Johnson, Smith-Temple, & Carr, 1998).
Infection control is as important in the home as it is in the hospital, but it can be more challenging and requires creative approaches. As in any situation, it is important to cleanse one’s hands before and after giving direct patient care, even in a home that does not have running water. If aseptic technique is required, the nurse must have a plan for implementing this technique before going to the home. This applies also to standard precautions, transmission-based precautions, and disposal of bodily secretions and excretions.
If injections are given, the nurse should use a closed container to dispose of syringes. Injectable and other medications must be kept out of the reach of children during visits and must be stored in a safe place if they are to remain in the house. Nurses who perform
invasive procedures need to be up-to-date with their immunizations, including hepatitis B and tetanus. The home environment often has more distractions than a hospital. The home can be filled with background noise and crowded with people and objects. A nurse may have to request that the television be turned down during the visit or that the patient
move to a more private place to be interviewed. Friends, neighbors, or family members may ask the nurse about the patient’s condition. A patient has a right to confidentiality, and information should be shared only with the patient’s permission. If the nurse carries the patient’s medical record into the house, it must be put in a secure