Hitt, Jennifer M. RN, MSN; Tatum, Eva RN, MSN; McNair, Mary RN, MSN; Harrington, Marilyn PhD, RN; Stanton, Sandra D. RN, MSN; Askew, Rebecca PhD, RN; Lofton, Susan PhD, RN; Walker, Jean T. PhD, RN; Robertson, Amy BA, MSIT
Self-care tends to be a term that nurses often do not associate with their own professional role. However, most nurses will readily acknowledge that only by taking the necessary steps to care for self, can one holistically care for the patient. As nurses, we often tend to run out of energy by day's end, rarely recognizing our own limitations. Attending to our own physical, psychological, and social needs rarely becomes a priority as we strive to meet the multifarious needs of our patients in an ever-changing and increasingly complex healthcare environment. This ever-changing healthcare environment has resulted in much sicker patients, with greater physical and emotional care needs assuming responsibility for their own care in their home. The very nature of home care has changed due to abbreviated hospital stays and increasing numbers of patients receiving hospice home care. Hospice care subjects the home health nurse to intense stress secondary to patients and families' crisis, grief, and increasing complex physical needs. This places enormous work-related stress on home health nurses and subjects them to potential physical and psychosocial injuries (Or et al., 2009).
This article aims to assist the home health nurse in increasing awareness of self-care management principles while developing new tools and strategies to reenergize the body and soul. The result of self-care for the home health nurse may result in enhanced job satisfaction, patient outcomes, work hardiness, and longevity. Self-care management practices are discussed in terms of work ergonomics, theory, and application.
Definition of Ergonomics
The International Ergonomics Association (IEA) (2010) defines ergonomics as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance” (IEA, p. 1). The association further defines this unique discipline as an integrated holistic approach that takes into account considerations of physical, cognitive, social, organizational, environmental, and other relevant factors. These ergonomic domains may be found in a variety of models that may be readily applied.
One model that will be discussed primarily for this article is the Health Self Management Model developed by Stephens (2006). Using the principles of interaction, the model expands the concept of health among three interactive domains: the intrapersonal domain (body, mind, spirit); the interpersonal (social) domain; and the extrapersonal (environment). Stephen's model identifies the individual as central to the three interactive domains.
The authors of this article also believe that as manager of self, the home health nurse is the center of this model, with a goal of attaining health, well-being, and a balanced life. This Self-Care Model for Home Health Nurse Ergonomics model was developed by the authors using concepts from the common body of knowledge and literature (Figure 1). These concepts are further discussed in depth throughout this article.
A review of relevant literature conducted by Punnett et al. (2009) found support for the concept that belief in one's own capacity to improve and maintain health significantly influences health mastery. This review of relevant literature was conducted to explore conceptual frameworks surrounding occupational health issues that correlate to individual worker's health promotion principles. These same authors noted two interventional studies that were conducted in healthcare and other industrial settings as the basis of their findings. A review of “316 work health programs reported positive results for weight control; borderline positive results for nutrition, exercise and cholesterol management; and weak results for health-risk appraisals” (p. 4). The healthcare study noted in this review of literature from the nursing home industry included 920 registered nurses (RNs) and nursing aides who responded to a survey regarding health and self-care. Thirty-five percent of the subjects indicated having chronic health conditions with hypertension being the most common. An overwhelming 70% of the subjects indicated they had experienced significant muscle injuries in the preceding three months. Additionally, data from this study indicated that “staffing, work hours, and general overload clearly represented a major challenge to these employees” (p. 7).
Punnett et al. (2009) also discussed the findings of intervention programs to prioritize self-care practices, with access to resources such as healthy eating choices, exercise in the workplace, and having time to perform health behaviors as essential. They stated that self-care practices and beliefs are intrinsically influenced by the physical environment, culture, and human relationships within the workplace. This influence is pervasive and impacts the individual outside of the physical workplace setting as well as their extended relationships. The researchers also assert the need for a work environment that reinforces and supports the individual's healthy self-care decisions, with personal safety and physical well-being as the priority.
The authors of this article also believe that such dynamic organizations naturally create and expand synergistic systems that support healthy and positive relationships. It is this belief that provides the framework for the Self-Care Model for Home Health Nurses Ergonomics (see Figure 1).
Three Domains of Ergonomics
According to the IEA (2010), domains of support and influence within the discipline of ergonomics are defined as follows and are similar to the three domains defined by Stephens (2006):
1. Physical ergonomics: the anatomical, anthropometric, physiological and biomechanical characteristics as they relate to physical activity. Examples include working postures, repetitive movements, workplace layout, safety, and health policies and procedures;
2. Cognitive ergonomics: mental processes, such as perception, memory, reasoning, and motor response, such as mental workload, decision-making, skilled performance, human–computer interaction, human reliability, work stress, and training;
3. Organizational ergonomics: the optimization of sociotechnical systems, including their organizational structures, policies, and processes, such as communication among the health team members, staffing patterns, shift schedules, and training competencies. (IEA, 2010, p. 2)
These three domains of ergonomics have been studied extensively. Lundstrom et al. (2002) conducted a meta-analysis of 61 studies regarding healthcare workers and the influence of organizations on health, safety, and patient care outcomes. The healthcare workers noted in the 61 studies were physicians and registered nurses (RNs) predominately working in acute care settings. No other demographics of target populations were presented by the researchers.
Lundstrom et al. (2002) reviewed specific organizational factors that influenced job satisfaction, health, safety, and well-being, among this population of healthcare workers. They also identified many pertinent work place issues that directly affect individual self-care practices. These issues include stress, job burnout, and safety concerns in the work environment, lack of teamwork, staffing ratios, and shift work demands. The authors further identified the lack of organizational and role clarity, and a sense of not being recognized for job performance as significant issues that negatively influence the work environment (Lundstrom et al., 2002).
The authors of this article believe it is this myriad of issues that support the need for home health nurses to attend to self-care practices. Because home healthcare nurses are an integral part of the larger organization, the theory of ergonomics applies. Therefore, for nurses to develop a constructive and positive plan for self-care, these ergonomic issues need to be examined by each individual within three domains of self-care.
Three Domains of Self-Care
Intrapersonal: Body, Mind, and Spirit Connection
Cohen-Katz et al. (2004) conducted a study to evaluate a support program for nurses to decrease stress and burnout, including such manifestations as anxiety, depression, and detrimental physiological responses. The researchers explored a mindfulness-based stress reduction (MBSR) program at a Magnet hospital employing 1,400 RNs. Self-care is at the heart of MBSR and supports nurses in strengthening their therapeutic presence defined as “spirit to spirit contact and includes non-judgment, intuition, and love” (p. 305). This training helps the nurse to be “fully present” for themselves as well as others. Some of the major points of this study for the nurse include
1. Commit daily to self-care;
2. Less self-criticism;
3. Forgiveness of self and others;
4. Self-compassion: the deepest level of self-care; and
5. Meditation: awareness of frequent thoughts (p. 307).
Or et al. (2009) also recommends a systematic approach to self-awareness and monitoring of self-care management support. These authors state that incorporating diaries and journals of self-reflection, accountability, and insight on a daily basis is essential for enhancing cognitive processes, and recommend written action plans that the home health nurse may reflect on daily to measure improvements in the three domains and for affirmation of progress. The home healthcare nurse may gain insight and understanding through the journaling process. Reflecting on issues such as conflicts with staff or patients, communications, frustrations of the day and personal reactions, opportunities to react differently, and best things about the day (e.g., patient outcomes or personal accomplishments) provides reaffirmation and validation for the nurse.
In addition, Or et al. (2009) recommends behavioral incentives be a major part of the self-care management and planning process. Incentives are thought to improve outcomes and adherence to action plans. Incentives need to be determined by each individual as to what they truly value, anticipate experiencing, and find pleasure in. For example, movies, lunch with a friend, quiet time, music, and meditation are incentives of renewal and may be readily embraced as part of the individual self-care plan (SCP). As SCPs evolve, the individual may find increasing self-awareness, affirmation, and care provide a direct benefit to their interpersonal effects and the physical realm (2009).
The home healthcare nurse needs to evaluate personal incentives weekly and ensure that time and opportunity to accomplish the incentives are provided. Through the process of daily self-care, the nurse may find an increasing sense of forgiveness and compassion to the self and others, as well as a diminished perception of personal stress and increasing joy and personal satisfaction.
In another study regarding the intrapersonal domain, Brulin et al. (1998) examined home health workers in Sweden to explore the physical and psychological impact of the work environment on the workers. Three hundred sixty-one people participated in the study by completing a questionnaire regarding lifestyle factors and the impact of their work in home health. The authors did not define the role of the subjects in this study. However, the authors indicated that 172 were employed in “sheltered living” and 188 were employed in “home help services.”
The results of the Brulin et al. (1998) study indicate the major psychological factor that negatively affects the home health worker is the inability to influence the planning of their work. The researchers state that the subject group had little control over the patient home conditions that serve as the work environment, thereby limiting the home provider's ability to manipulate the environment to meet the provider's needs. Such inability to manipulate the environment often results in psychological stress. The authors further assert that it is this lack of control and sense of helplessness that directly correlates to detrimental physical outcomes for these workers, such as neck pain, neck muscle stress, and lower back problems. The researchers suggest organizations focus more attention on a holistic view of the work environment and assist home health workers to establish a sense of control and personal well-being within that work environment (Brulin et al., 1998).
Home healthcare nurses often have little to no control over the home conditions of patients. Seeking a holistic view and accepting that poor home conditions exist and provide barriers to care may release the nurse from the need to control that environment. The control for the nurse may come in working around barriers and conditions and may include actions such as:
1. Two nurses making the visit together to assess and problem solve;
2. Involving the patient's family and friends orvolunteers to improve conditions when possible;
3. Using equipment where possible and consult other disciplines where necessary (lifts, slings, devices); and
4. Patient care conferences with administration and other nurses to present complex care situations to brainstorm possible resolutions.
Interpersonal: Social Relationships and Culture
According to Gavin and Mason (2004) Americans spend less than 20 hours a week in leisure time, which is significantly less than “their counterparts in other countries” (p. 3). They believe this diminished time for self leaves little room for self-reflection, or relaxation and renewal of the mind, body, and spirit. It also leaves little time for cultivating positive relationships. These authors discuss two types of companies in manufacturing and construction that are extremely successful in creating a culture of support for workers. The major components of these companies success is in; creating a work culture permeated with excitement for the work and for being different; training for every possible event so people are ready; treating each other and the customer better than is expected, exceeding the minimal; creating mutually beneficial relationships and looking out for each other... an “all for one and one for all” culture. Gavin and Mason state that such a culture supports self-care practices and sense of belonging and well-being of its workers (2004).
Lundstrom et al. (2002) also believe social networks within the work setting can have a powerful influence on interpersonal wellness. The researchers state that as a result of a lack of social support from coworkers, job burnout results often producing a myriad of symptoms, such as depersonalization and emotional exhaustion.
Home health nurses need to create social connections within the work setting that are supportive and affirming. Setting up weekly lunches with colleagues for support, monthly staff meetings to discuss complex issues, recognizing accomplishments, and jobs well done are essential to creating such positive interpersonal networks.
Extrapersonal: Physical, Environment
Brulin et al. (1998) discovered that untoward physical sequelae resulted for some workers in the home healthcare environment in a Swedish study. They found that “standing in forward-bent and twisted postures' and standing in awkward postures” (p. 108), contributed significantly to worker injuries. The 361 home care workers studied reported experiencing significant musculoskeletal injuries in the previous 7 days with: 44% having neck injury, 47% shoulder injury, and 40% with lower back injury. According to Brulin et al. (1998) this study was the first to determine that a combination of physical and psychosocial elements in the work environment resulted in an increase of shoulder and neck pain and injury.
Punnett et al. (2009) supported the Swedish findings and cited that the Occupational Safety and Health (OSH) focus “is on ergonomics because of the many influences on physical and work organization hazards on musculoskeletal, cardiovascular, and mental health” (p. 1). In their review of related literature the authors state that “Musculoskeletal, mental, and cardiovascular diseases share several occupational risk factors, both physical and psychosocial” (p. 2). They also acknowledge that work demands on employee time, coworker and supervisor support, job satisfaction, and sense of purpose have significant positive or negative effects on cardiovascular and mental health.
Similarly, Or et al. (2009) evaluated extrapersonal human factors related to ergonomics in home healthcare. The authors state that five key elements of the home health organization impact the well-being of home health nurses and providers. These key elements are listed as:
1. Person: characteristics of nurses and patient;
2. Task and job design: task complexity and available resources such as time, staffing, and information;
3. Tools and technology used: forms, lists, Web sites, and computers;
4. The work environment: patient home, space, and lighting; and
5. Organization characteristics: structure and culture of the home health organization, practice model, and care policies (p. 202).
These five key elements are greatly affected by three major aspects of home healthcare that include (a) accessing information; (b) communication on multiple levels with providers, colleagues, and patients; and (c) patient self-management processes including monitoring and evaluation (Or et al., 2009). If any of these elements or critical aspects is misaligned or inadequate, then it creates a burden on the home health nurse related to the care delivery process. These authors support the use of health information technology (HIT) in the home health industry as a means to minimize problems with acquisition of information for the home healthcare nurse. The use of HIT would enhance the nursing care delivery processes by improving communication among providers, peers, and patients, and allowing patients to engage in self-management with reporting and recording their own health continuums (Or et al., 2009).
Home healthcare nurses now have tremendous opportunity to integrate technology into the work place to expand resources. Smart phones, iPads, and the like allow for immediate communication, consultation, and clarification regarding patient care needs. These devices can provide immediate retrieval of patient education material or clinical reference material as needed. They also provide the home healthcare nurse the means to develop, organize, implement, and manage their individual self-care programming.
Central to the theme of self-care programming, McElligott et al. (2010) explored outcomes from implementing a holistic program called the Collaborative Care Model (CCM) in conjunction with a constructed SCP to promote healthy behaviors in hospital nurses. A convenience sample of 185 RNs was used with n = 100 participating in the CCM and SCP during an 8-hour program. A control group was utilized with 85 RNs not receiving any intervention (n = 85). All 185 subjects completed the Health Promoting Lifestyle Profile II (HPLP II), which is a 52-question Likert scale for examining health promoting variables. These variable subsets include nutrition, stress management, spiritual growth, health responsibility, physical activity, and interpersonal relations.
Posttest results collected 3 months after the pretest indicated a significant increase in the overall HPLP II mean (p = .02), spirituality (p = .04), interpersonal relations (p = .04), and nutrition (p = .04) using repeated measures ANOVA for the experimental group over time when compared to the control group. The findings indicate a significant increase in spirituality, nutrition, and interpersonal relations in the interventional group. The researchers conclude that the use of the CCM in conjunction with the development of an SCP significantly increases overall health promoting behaviors, spirituality, interpersonal relations, and nutrition scores in the study participants (McElligott et al., 2010).
To achieve optimum well-being, home health nurses may find that applying a model of self-care is a viable method to create awareness and longevity with new healthy habits and lifestyle choices. The model in this article (see Figure 1) was created encompassing the major ergonomic domains and self-care practices cited in the literature. The model may serve as a daily reminder for home health nurses to attend to each domain. The process of application of this model is used in the case study.
Daisy is a 42-year-old home healthcare nurse. Her geographical territory is in a large metropolitan seaside town, where she is primarily working with recent Laotian immigrants to the United States. Daisy has been an RN for 3 years. She entered nursing after being downsized in a corporate environment on two different occasions, and decided that entering the nursing workforce would provide a more stable income source for her three children.
Daisy is 5 ft 4 in. tall, and weighs 168 lb. She carries most of her weight around her middle, and often experiences significant bouts of indigestion and mild shortness of breath upon exertion. Daisy smokes approximately 10 cigarettes each day, and occasionally uses a nicotine patch to help ward off nicotine cravings. She has attempted to stop smoking as a New Year's resolution for each of the past 6 years.
When Daisy was hired, she received limited orientation of less than 12 hours due to chronic staffing shortages within the home health organization. Her immediate supervisor always tells Daisy to “call me if you have problems in the field, or just need guidance.” However, on the occasions when Daisy has attempted to contact this supervisor, her calls are generally unanswered or answered in a manner not timely to the situation.
Today, Daisy is visiting her seventh client of the day. She feels particularly stressed because of new expectations for lengthy documented client assessments using a new charting system and new laptop computers. In the last 3 months, a new management has taken over the home healthcare organization that employs Daisy. Daisy previously enjoyed a very flexible schedule, which she considered the top perk of her job, allowing her to run home each day to assure that her three children arrived home safely after school. Now, the new management team has installed GPS tracking on each nurse vehicle. No new policies and/or directives have been given regarding employee expectations with the new tracking system, but Daisy feels uneasy with following her old, established schedule.
When Daisy enters the home of Client 7, she finds a very sick older female, in bed, complaining of acute abdominal pain. The client's husband is clearly intoxicated and belligerent toward Daisy for not arriving sooner. Twice, while Daisy is on the phone arranging for an ambulance, the husband begins yelling profanities in her direction. Once again, Daisy's immediate supervisor fails to respond to Daisy's phone call for assistance.
Points to Ponder
* Daisy is well above her ideal body weight, which negatively impacts her physical abilities and self-image.
* Daisy has been unable to successfully maintain tobacco cessation strategies for any prolonged period of time.
* Daisy has manifested physical outcomes, impacted by stress, of shortness of breath, dyspnea on exertion, and indigestion.
* Daisy has significant job role ambiguity, and little confidence in receiving support from her supervisor.
* Daisy was poorly oriented for this job position.
* Daisy is unsure of her computer literacy and/or understanding of the new documentation methodology.
* Daisy has an unclear understanding of how her role will be impacted by the new administration, particularly regarding schedule flexibility that she treasures.
* Daisy has a very high client load secondary to organizational staffing issues.
* Daisy works with a population that is chronically underserved, with very limited resources and high geographic community stress.
After 2 weeks of prolonged stress, Daisy seeks advice from a community counselor available through her church network. The counselor requires Daisy to write down on paper those tangible things that give her clarity and a sense of purpose. The counselor also leads Daisy to write down long-term goals and shorter-term objectives that will help provide a roadmap to successfully implementing an SCP for her life.
Eight Strategies for Successful Self-Care
* Daisy determines her life priorities, which immediately provokes internal dialogue regarding her employment priorities. She recognizes that maintaining a position with very flexible hours is essential for her life priority of assuring her children's daily safety.
* Daisy recognizes that regular exercise is sorely lacking from her weekly routine. After determining a long-term goal of spending more quality time with her children, Daisy embarks on a family exercise plan involving short bike rides interchanged with neighborhood walks with the children each evening. As the weight comes off, Daisy plans to join a local group of nurses who practice twice weekly yoga sessions together.
* Daisy strongly desires to quit smoking. Smoking cessation fads have been unsuccessful in the last 5 years, and Daisy determines to seek the help and guidance of her family nurse practitioner to begin this quest anew.
* Recognizing that her busy schedule has become a crutch for poor nutrition, Daisy begins a weekly meal plan for her family, involving fewer trips to any fast food establishment, and planned grocery shopping. When in the grocery, Daisy now hits the colorful food aisles, generally located in every grocery perimeter. Colorful food is healthy food... Daisy looks for bright fruits and vegetables, and now doesn't fill her cart with empty calories. Although Daisy knows this takes a bit more time to carefully prepare food at home, she is involving her children in the food prep each night, and finds this to have a calming and healthy influence on her life. She is also recognizing significant savings in her bank account!
* Daisy establishes a formal and ongoing conference time with her supervisor. Rather than entering the conference empty handed, Daisy takes a notepad, on which she has carefully written down a list of her concerns. A high priority for Daisy is the immediate need for additional training on the computer system and new documentation system. Daisy also finds a voice when she discusses her feelings of abandonment when her phone calls for support are frequently ignored. Daisy is calm in her demeanor, and provides ideas for solutions. She brings in a list of times and days that she can manage to be out of the field for further instructions, and requests updated telephone rosters and a written chain of command for use when she has an immediate need for support while in the clients home.
* At this same meeting, Daisy asks for a copy of her job description, to assure that she knows exactly what is expected of her in the role. She also seeks clear clarification of flexibility of hours. Daisy recognizes that changes in an organization are not only inevitable, but also necessary for organizational growth. However, by knowing job expectations clearly, even expectations regarding flexibility of hours, Daisy is in the driver's seat. Should her current position no longer offer her flexible hours, Daisy can determine whether to seek other employment or build new family networks in her community to help meet her child-care obligations.
* Daisy recognizes that staffing is not likely to significantly improve in the near future, as costs are trimmed and budgets are more closely inspected. Daisy begins to closely track her daily schedule, and through systematic data collection about each element of her day, is able to begin developing some time saving strategies, which brings down her job stress. Simple ideas as changing driving routes during peek traffic patterns, organizing her car so that her common documents and work equipment are close at hand, and documenting in real time dramatically impact her workday.
* Daisy can request a transfer to a different client population. However, Daisy has developed a close relationship with many of her longer-term clients, and determines to stay with her current client assignment. She does bring up the issue of safety in the first staff meeting with the new management, and offers to serve on a task force to develop a specific policy for dealing with disruptive clients and families in the home environment.
Home healthcare is a diverse and constantly changing industry that has increasing demands for innovations in nursing care delivery. This increasing demand, along with ergonomic domains, creates a powerful opportunity to enact change in the home health industry, one nurse at a time. Ergonomics does indeed provide a broad framework for home healthcare nurses to improve their individual physical, psychological, cognitive, and spiritual well-being through application of models for self-care planning. The model provided in this article offers a road map for success to greater psychological, spiritual, and physical well-being. As the home health nurse becomes stronger, more resilient and work hardy, then the benefits to the individual, as well as the work organization and ultimately the clients will grow exponentially. This intrinsic individual growth will assist home health nurses to develop self-care planning practices that lead to healthy lifestyles and improved quality of life.
© 2012 Lippincott Williams & Wilkins, Inc.