Hospital in the Home and Community Health Nurse: Now and the Future

Louise Moffatt is a community health nurse who provides nursing care to communities, including Hospital in the Home (HITH). Louise began nursing eight years ago, starting with the completion of her AINs, ENs and then graduating as an RN at 46. Louise has a passion for community nursing and loves plants and crochet outside of nursing!

Louise shares her experience in the increasingly important fields of community health and HITH nursing, and provides practical advice for nurses interested in these areas. Read on to find out why you need to consider community health as a career!

What is HITH?

HITH, or Hospital in the Home, is a service aimed at keeping patients out of hospital. In my facility, it is a separate-but-integrated field. We work closely with Ambulatory Care (Amb Care) departments in the hospital, as well as GP centres and other referrers. I was listening to a podcast on the way home the other day, and it was described as ‘hospital avoidance’, which is appropriate. If there is something that a patient needs to have done in a hospital, but it can be done at home and it will prevent an admission, we do it!

What is the role of a HITH nurse?

In our centre, HITH mainly encompasses antibiotics delivered via IVC or PICC; drain management can also come under HITH. Referrals mostly come in from Ambulatory Care (Amb Care) departments in the hospital. Patients attend ED for, say, cellulitis, and are prescribed antibiotics. Amb Care ‘take on’ the patient and refer them to community. We receive an LOA (letter of authority, or medical chart: an “order” to give the patient drugs) and a brief background of the patient. We triage the patient by phone, then make arrangements to administer the antibiotics. Sometimes, the patient attends our clinic. Home visits are not guaranteed – if we are busy, especially with sicker patients, or the patient can drive, they come to us.

What makes a good HITH nurse?

A good HITH nurse will be friendly and non-judgemental. We go into all sorts of homes, from hoarding and squalor situations to mansions. Our patients are international businesspeople to the unemployed, parents, older people and every family situation/culture/religion you can think of. They could be bird people, cat people or dog people, and homes with fleas and cockroaches, or whose floors you could eat off. A big smile and a pleasant greeting will set the tone for a smooth encounter. Of course if you don’t feel safe, you need to be able to recognise it, and get yourself out of the situation.

Knowing how to earn the trust and respect of your patient is essential. It might be the difference between them taking on board your advice or writing it off. Being honest and authentic will mean they’ll be open to listening to you – trying to convince an older patient to go to hospital will be much easier (but not assured) if they like and respect you! Sorting out a nugget of information from waffle, and knowing how to tease out more helpful details, is also a good quality.

What has your career path in community health looked like?

Even before I received my EN registration, I obtained a position as a Clinical Case Manager with an aged care provider. It was a good introduction to wound management and caring for people in their homes. I began working as an EN at a local community health centre while completing my RNs and fell in love with the field. When I finished my RNs, I was lucky enough to receive a new grad placement at another community centre, with a great NUM and CNE. I completed 11 months of my new grad but unfortunately there were no full-time positions available at the time. I left to work in a medical centre but never really felt at home. I went back to work at NSW Health as a Student Compliance Nurse (ensuring students undertaking placements in NSW Health facilities have the correct vaccinations and Police checks etc). After three months, the NUM from my new grad centre called me to offer a permanent full-time position, and I hurried back.

Why did you switch to nursing from other careers?

I’ve worked as a recruitment officer with a major security provider to the 2000 Olympics, as a freelance writer on the websites of banks and telecommunications businesses, and as a loss prevention manager with department stores. I fell into nursing completely unintentionally, so there was no real “switch” or light-bulb moment. It was a natural progression from AIN to EN and then RN, and I have loved every step of the journey. I suppose that’s why I’ve stuck with it, even when there were no lunch breaks – or toilets – in sight.

How was your experience studying as a mature-age student? What’s your advice to other mature-age students?

I was the typical mature-aged student in so many ways. I answered all the questions, attended all the lectures and completed all the quizzes. I’m sure I was a complete pain! I completed my ENs with a scholarship and couldn’t afford to ruin the opportunity; working full-time with two daughters, I made the most of it. While doing my RNs, the residential schools were a little holiday for me (Residential schools were periods of up to a week where you attend campus for clinical lessons. You also attend placements in facilities to put these lessons into place). I booked into whatever hotel I could afford, and enjoyed early nights and the peace and quiet.

My advice to other mature-aged students would be to go for it. If you can, rope in anyone you know to help. The time will pass anyway, so you may as well follow your goal/s along the way. Approach your workplace to see if there are accommodations, or even scholarships, you can take advantage of.

When I applied for positions, I was rarely the youngest applicant, but some employers appreciate older nurses. We offer different qualities than our younger colleagues. Never discount yourself or your lived experience.

What does your role involve as a community health nurse? What do you love/dislike about your job?

I describe my work as “anything a nurse does in hospital, we do in someone’s home, by ourself”. This includes, but is not limited to, catheters and trial-of-voids, antibiotics via cannula/PICC/intraperitoneal, wound management, palliative care, Pleurx/Rocket drains, nephrostomy drains, falls risk screens, pressure injury screens, assessments for potential allied health referrals… the list of competencies we need to work through is huge! CHNs (Community Health Nurses) work as part of a larger team incorporating medical officers, other nurses, allied health (occupational therapists, physiotherapists, dieticians, social workers), private organisations, families and colleagues. We drive (new) cars, look after people in their own homes, see them improve and heal (or not), and become a tiny part of their lives for a period of time. Breaks are when and where we enjoy them, sometimes with colleagues – at our favourite cafes or takeaways – picking up meat for dinner, or madly typing notes in the car while shovelling a sandwich down our throats. Afternoon huddles are an opportunity to debrief, seek advice or have a laugh. No two days are the same, no two homes are the same, and no two patients are the same.

I love the independence and freedom. We manage our patients ourselves and liaise with other clinicians. You learn to rely on intuition and advocate for your patients, making fast decisions sometimes in the absence of second opinions and advice.

I don’t always like the lack of toilets! Although, you soon get to know what cafes in your area have the best coffee and cleanest bathrooms. Being out in the weather can be a drag, but you quickly dry out/cool down/warm up.

What are the qualities of community health nurses?

1. Inventiveness – I call it “MacGyvering”. If you’re in a home and don’t have exactly what you need, you need to think about what else you can use. You can’t pop out to the storeroom to get another item, so you rummage around in the box of goodies at the patient’s house for something you can use (every patient ends up with a collection of stock, especially the recurrent patients – items from previous admissions to community health that were never used).
2. Fast thinking – how to make the most of the hours you have. Minimising driving, maximising time, having the necessary conversations with patients without running late to the next, or someone feel like an inconvenience.
3. Advocating for your patients when you’re not in a clinical setting – escalating a sick patient and not being able to get through to the clinical governance holder can be frustrating, so you learn how to manage situations alone, including advocating for your patient. This is where policies are your best friend.
4. Being strong – sometimes you need to say no, and it can be very difficult to “stick to your guns”. We can’t be everything to everyone and setting boundaries for both our personal and professional capabilities is essential.

Tell us about your interests in palliative care, infection prevention and control, and mentoring?

I kind of fell into infection prevention and control. We needed a second “champion” at work, and I volunteered. Sometimes I think I bit off more than I could chew, because it is a lot of work: hand hygiene audits, PPE audits, aseptic technique audits, training… I enjoy it though – it has a valuable role in any setting, but especially health. I can tie it into my passion for mentoring, too. Showing new staff and students how to don and doff PPE (personal protective equipment – masks, goggles, gowns and gloves) can prevent a severe infection in both the nurse/student and our patients. Hand hygiene done correctly is equally important. Consistency and modelling the correct behaviours help cement the actions. I’m passionate about making sure people have a comfortable learning environment. Mentoring new staff and students means I can deliver consistent training in a safe setting, where people can make mistakes and learn before hitting the road alone.

Palliative care in the community is vastly different to hospitals; it is support, education, symptom management and advice. I love this aspect of my work – it’s cliched but providing a patient the opportunity to die in their own home (if possible) is an amazing privilege. Again, trouble shooting, answering questions and providing safe care in a home to someone at an incredibly vulnerable time of their lives is an area of community nursing I thoroughly enjoy. I’d love to pursue palliative care further at some point in my career.

What are some barriers/red tapes you face in community health?

Barriers include not being able to escalate – if you’re trying to contact a GP or MO at a hospital and not having any luck, it can impede our work and, potentially, impact on the patient’s health.

On occasion, being short staffed can impact not only the team but our patients as well; we frantically make calls and move or cancel those patients who can safely wait for the service until we have the staff available.

There are no mandated ratios for how many patients we can safely manage as a clinician. Dedicating your best efforts to so many can leave yourself short, so you’re always striving to maintain a healthy work-life balance.

Where do you see the future of community health?

Community health is going to be very important in the coming years. With increased antimicrobial resistance (I think COVID-19 and now the emerging ‘monkey pox’ might be a forewarning for other infections that will increase hospitalisations) and, therefore, the necessary increase in patients being nursed at home, community nurses will be what keeps patients out of hospital. Our aging population too will mean more older people staying at home. Whether they are cared for by public community health nurses or private companies, community health will be a crucial field.

Why should other nurses consider community health nursing? What tips do you have to enter the field?

Community nursing requires you to be a jack-of-all-trades. Our orientation period is extensive – you need to have many competencies under your belt before you can go it alone and manage your own patients. Your first visit of the shift might be an intravenous antibiotic, then you need to remove a catheter for a trial of void, then manage several wounds before you return for a bladder scan on the second patient and a potential catheter insertion. You may have to make several phone calls to have a GP write a script for antibiotics for a wound patient with new cellulitis, then visit a dying patient to reload their syringe driver. This means you can step into any area of clinical nursing with ease.

Almost every student RN I spend the day with tells me they either had never heard of community nursing, or it was nothing like they’d imagined (in a good way!). They love extending a clinical setting to the patient’s home and experiencing the different skills we employ. Their ideas of CHNs showering elderly people or just doing wounds is shattered and many ask how they can obtain a new grad position in the community.

If you’re considering community nursing, keep an open mind and be prepared to be challenged. Don’t be scared to ask for help. Get to know your policies. Brush up on your time management skills. Don’t expect to know everything in the first few months (I’m still learning several years later). And learn to leave work there.

What’s been a memorable experience you’ve had so far in your career?

Recently I saw a new patient. She’d had a mastectomy and aside from a drain, had no other medical history. I took her vitals as part of admission to our facility. Her BP was 230/110. I escalated to the clinical governance holder (the surgeon) who wasn’t concerned and said he didn’t think an ambulance was necessary. I called the patient several times later that evening and her BP didn’t improve, so I sent her to ED. Usually, I feel like I’ve overreacted and wasted the time of ED nurses (especially if they are sent home only a short time later) however the patient was admitted for several days under cardiology for extreme hypertension. It doesn’t always have such a good result, but in this instance, I was justified.