Some infusion therapy has seen sharp growth in the past decade because of changing models for healthcare financing. 1 Shorter hospitalizations, faster diagnosis and treatment of health problems, earlier discharge from the hospital, and reduction in reimbursement for services are just some of the changes that challenge the home infusion industry. As homecare therapies become more advanced and the homecare patient is sicker, highly competent nurses are needed to provide infusion therapies in the home. With limited resources immediately available, home infusion nurses must have sharp problem-solving and interpersonal skills, detailed knowledge of the therapies and their effect, and technical skill in working with equipment. Because the requirements for employment as a home infusion therapy nurse vary with regard to education and the length and type of previous clinical experience, it is unclear how nurses develop the specialized knowledge to perform their tasks.
One way of measuring competence in a defined practice area is through “certification” by an external organization. This voluntary process distinguishes theoretical knowledge and abilities that are beyond basic licensure. 2 Although certification by a national organization may indicate advanced competence, it is expensive and not required by most boards of nursing or employers. Requiring home infusion therapy nurses to become certified may limit patient access to home infusion.
In the Federal Register of November 1998, the Maryland Board of Nursing mandated that registered nurses “complete an infusion therapy program of study which contains didactic content and a clinical practicum consistent with the standards of practice established by the INS [Infusion Nurses Society]” to provide basic infusion nursing. 3 The Maryland Board also mandated that the registered nurse “complete a second specialized educational program in infusion therapy with the standards established by the ONS [Oncology Nursing Society]” to administer chemotherapy agents and to insert and remove both a peripherally inserted central catheter (PICC) and a midline catheter. 3
The Joint Commission on the Accreditation of Healthcare Organizations simply states that nurses must be appropriately qualified and competent in the infusion field, 1 leaving homecare agencies to determine what those qualifications are and how competency is verified and monitored. Some agencies may prefer to hire nurses who are INS or ONS certified, but it is not a requirement for employment.
Blue Cross and Blue Shield of Hawaii proposed that the home infusion therapy nurse must “be certified by the Infusion Nurses Certification Corporation (INCC) and must maintain such certification” for the agency to be reimbursed for its services. 4 Blue Cross and Blue Shield of Hawaii also stated that by requiring certified registered nurse infusion (CRNI) for care of their patients, they are ensuring that the best quality and most cost-effective care will be provided in the home by an experienced, competent nurse. 4
Before addressing whether nurses are prepared to face the challenges of home infusion therapy, more information about the clinical and educational characteristics of this group was needed. Therefore, this research was undertaken to learn more about the nurses performing home infusion therapy and the therapies they encountered.
The Delmarva Peninsula, a nonmetropolitan, geographically isolated region on the East Coast comprising the eastern shore of Maryland, Virginia, and the two southern counties of Delaware, was selected for this study. The Delmarva Peninsula is surrounded by the Chesapeake Bay to the west and south and the Atlantic Ocean to the east. The Peninsula is accessible by the Chesapeake Bay Bridge connecting it to the western shore and the Chesapeake Bay Bridge Tunnel connecting it to the mainland of Virginia. Farming and aquaculture (eg, fishing, crabbing) are two of the area’s main industries.
A partial replication of a recently published 1999 study by MacPherson was conducted to determine the educational and clinical backgrounds of the home infusion therapy nurses employed by home health agencies on the Delmarva Peninsula. A survey instrument was used to elicit answers for the following questions:
- What are the demographic characteristics (age, gender, ethnicity) of the home infusion therapy nurses in this region?
- What are their clinical characteristics?
What are the educational characteristics of this group?
- a. Length of time as a home health nurse
- b. Length of time as a home infusion therapy nurse
- c. Type of position held
- d. Number of hours worked
- e. Areas of previous nursing experience
- f. Infusion therapies and skills performed, and how often
What beliefs do these home infusion therapy nurses have about certification?
- a. Highest degree of education held
- b. How the agency or institution prepared the homecare nurse to provide home infusion therapies
- c. Certification status
The survey was distributed to a convenience sample of six home health agencies who delivered home infusion services on the Delmarva Peninsula. Consent to participate was implied with the return of the completed survey.
The survey instrument was distributed to a total of 78 nurses. It was completed and returned by 37 of these nurses, for a response rate of 47.4%. Descriptive statistics were calculated, yielding the demographic characteristics shown in Table 1. The sample was an all-female, predominantly white group with a mean age of 43 and 6 years of homecare or home infusion experience.
The clinical characteristics listed in Table 2 show that the overwhelming majority of the sample had past experience in home health (86.5%) and medical/surgical nursing (75.7%). Nearly one fourth (24.3%) reported previous critical care experience. Other specialty experiences included oncology (16.2%) and IV team (13.5%) work. Other areas of previous experience included cardiology, detoxification, emergency department, obstetrics, geriatrics, hospice, pediatrics, psychology, transport, and utilization review. Each of these areas was reported by fewer than 10% of the participants. Many respondents had previous experience in more than one area.
Because little was known about the infusion skills performed, the infusion devices used, and the therapies administered by these nurses, they were asked to indicate from a list which they skills they performed and how frequently. The skills performed most frequently (either daily or weekly) were central venous catheter care (32.4%), insertion of peripheral venous catheters (13.5%), and access of venous implanted ports (8.1%). Interestingly, most of the nurses had never placed a PICC or midline catheter (90.5%); 16.2% had never inserted a peripheral venous catheter; 8.1% had never performed central line catheter care; and 16.2% had never accessed an implanted port.
The infusion devices the nurses used most frequently (either daily or weekly) were ambulatory infusion pumps (24%), gravity infusions (18.9%), and stationary infusion pumps (13.5%). According to their reports, 25 of the respondents (67.5%) had never used an elastomeric infusion device. The types of therapy and frequency of administration are shown in Table 3.
The third question investigated the educational characteristics of this group. The results displayed in Table 4 show that most of the respondents (43.2%) held an associate degree, whereas 24% had acquired a bachelor’s degree in nursing, 5% held a bachelor’s degree in another field, 21.6% were diploma graduates, and 8.1% held a master’s degree in either allied health or business administration. Whereas one nurse stated that she learned her job by “on-the-job training,” the majority (89%) reported that in-service and orientation prepared them for home infusion therapy. Other strategies included attending a conference or workshop (27%) or reading a home infusion therapy manual (24.3%).
To investigate the participants’ beliefs about certification, they were asked whether home infusion nurses should be certified in infusion therapy or any specialty area and why. Approximately one third (32%) believed that home infusion nurses should be certified in infusion therapy only, whereas another 8% thought that they should be certified in oncology only. Only 28% believed it was necessary to be certified in both infusion and oncology, but 30% thought that no certification was necessary to provide home infusion therapies.
The respondents then were asked to comment on whether home infusion therapy nurses should be certified in infusion therapy, oncology, both, or neither. Of the 37 nurses surveyed, 25 answered the question. Of these, 9 stated that nurses should be certified in infusion therapy only, 1 that certification was needed only in oncology, 7 that nurses should be certified in both, and 8 that neither was necessary.
Although 68% favored some kind of certification, their explanations indicated confusion about what the term “certification” meant. For example, one nurse favoring certification in infusion therapy only stated that the nurse should be “certified by the agency, but not as a CRNI secondary to lack of CRNIs available to home health agencies.” Another stated that “we are already certified in chemotherapy through the agency” and therefore need only infusion certification. Another nurse in favor of infusion certification stated that “good IV training prepares you for home infusion.” One respondent was in favor of oncology certification “only if we are to infuse chemotherapy agents.” One of the nurses favored both infusion and oncology certification “only if the agency pays for it. It is expensive.” Another simply stated “ideally yes.” Those who answered “no” to any certification argued as follows: “it should not be a requirement,” “good inservicing can accomplish the same end in competence,” “if certified in one area will then need to be certified in all areas,” and “experience accounts for a lot of knowledge.”
Although several nurses demonstrated their knowledge of certification as a measure of quality assurance, their numbers were small. Three nurses in favor of either infusion alone or both infusion and oncology certification stated that certification was needed “to provide the best patient care and education,” “to avoid errors,” and for “patient safety.”
A large portion (76%) of the nurses surveyed held no certification. The most frequent reason given for no certification was that it was not needed for employment (67.6%). The following reasons also were cited: not important to the employer (24.3%), cost and lack of knowledge about certification (16.2%), and not important to the respondent (10.8%). Among the 18.9% (n = 8) who were certified, increased earning potential was cited as the most common reason for becoming certified followed by personal satisfaction (13.5%) and professional opportunities (10.8%). The types of certifications held by the nurses in this sample are shown in Table 4.
This survey conducted in a nonmetropolitan area was a partial replication of a 1999 study conducted by MacPherson 1 in a metropolitan area. The results of the two studies were similar despite their geographic disparities. MacPherson 1 described the typical New England nurse respondent as a 41-year-old, white woman who had a bachelor’s degree in nursing, prior work experience in medical/surgical nursing, and no certification in any specialty. The replicated survey showed that a typical home infusion nurse of the Delmarva Peninsula was a 43-year-old white female who had 6 years of homecare or home infusion therapy experience, an associate degree in nursing, and previous work experience in a medical/surgical setting. She did not hold any certification and she administered a wide variety of home infusion therapies.
Because the term “certification” was not defined in the survey instrument, it may have influenced responses on that topic. Respondents seemed to interpret “certification” as technical skills validation through their agency rather than recognition from a national organization for advanced theoretical knowledge.
The Virginia Nurses Association reported the results of the largest study ever on the certified nursing work force, conducted by the Nursing Credentialing Research Coalition. The findings indicated that certified nurses experienced fewer adverse events and errors in patient care than their noncertified counterparts. Certified nurses reported feeling more confident in their ability to detect early signs and symptoms of complications, and received higher patient satisfaction ratings. Also, fewer disciplinary events and work-related injuries were noted among certified nurses. These nurses reported more growth and satisfaction with their job and more competence in their practice. Some noted salary increases, advancement, bonuses, and reimbursement for certification testing expenses. 5
In this study, reported years of experience as a home health nurse (6 years) were virtually the same as reported years of experience as a home infusion therapy nurse (5 years). The respondents did not differentiate between the subspecialty of home infusion therapy and general homecare nursing. Most of the respondents were prepared for home infusion therapy by attendance at an orientation sponsored by their employer. This raises questions for future investigation including how home infusion therapy is viewed by home health agencies, either as a specialty or as one of many things that a homecare nurse does. A comparison of job descriptions is needed for nurses performing home infusion therapies to help determine what education is required beyond a registered nurses’ license and what competency validation is needed before they can provide infusion therapies at home.
Although the nurses in this study identified themselves as home infusion therapy nurses, almost none of them had inserted a PICC or midline catheter, and about half had inserted peripheral lines on a yearly basis. This left the investigators wondering whether most patients were discharged home with a preexisting line. What happened if the line became nonfunctional? Did patients return to the hospital to have a new line placed, or was therapy discontinued early? Further study investigating home infusion nurses’ knowledge of the care needed for inserting and maintaining a variety of midline and central catheters might be informative.
When the nurses were asked about the equipment they used most and least frequently, 59.1% said they used infusion pumps daily or weekly, but 67.5% reported that they never had worked with elastomeric pumps. Although the use of elastomeric pumps is reported to be declining because of their high cost, a home infusion pharmacy working with this sample of nurses reported dispensing almost all the antiinfective therapies that meet stability and frequency requirements in an elastomeric pump. This conflicting information led the researchers to wonder whether the nurses, instead of using the generic terminology for these pumps (elastomeric), refer to them by trade (ReadyMed or Eclipse Pump) or colloquial (baby bottle or infuser balls) names.
The results regarding the types of therapies provided suggested that “blood–blood products” frequently are part of home infusion nursing practice. However, when the homecare agency managers were questioned directly, none reported infusion of blood at home. Respondents may have confused drawing blood for laboratory diagnosis with administering blood, blood products, and gammaglobulin.
It was noted that rarely were any home infusion therapies provided on a daily basis. Respondents reported performing home infusion therapies at a frequency of monthly, yearly, or never. Because most home infusion therapies are performed daily, the researchers wondered whether many different nurses were seeing the same patient over the duration of the therapy. If so, this suggests that there is not a dedicated team of home infusion therapy nurses. Questions about the number of patients requiring infusions and the variety of therapies provided by each agency would produce better data about the range of services needed and the number of agencies able to provide these services. Because infusion therapy is such a specialized area, there may be value in each agency providing only certain kinds of therapy so that every agency (and every nurse) does not need to be a specialist in everything. Alternatively, agencies could “train” their own specialists in certain therapies and share them to provide the best patient care. Ultimately, the concern is that the nurses and their employers may be called on to provide therapies for which they are ill prepared.
Some limitations of this study were the use of a relatively small and convenient sample, its design as a survey rather than an experiment, and confusion related to terminology used in the survey instrument. Although all six homecare agencies were represented with a 47% response to the survey, an increased return rate would have strengthened the study.
The survey instrument was modified from the original used by MacPherson 1 in the New England area. Because of differences in geography (New England versus mid-Atlantic) and location (metropolitan versus nonmetropolitan), it would be important to revise some of the potentially confusing terminology. Although the experts who reviewed the modified survey before data collection believed that the terminology was clear, it may not have been clear for the respondents. Because many of the respondents did not seem to understand the terms, the survey items may have been answered in a way not intended by the respondents. When the survey is conducted again, definitions or examples should be provided for respondents.
The population to whom the survey was distributed may have affected the outcome. The data retrieved from the survey was intended to describe the clinical and educational characteristics of home infusion therapy nurses. Instead, it seems to have described the characteristics of homecare nurses who occasionally provide home infusion therapy. The survey was distributed to six home health nursing agencies, all of which advertise that they can provide infusion nursing. Agencies may be marketing services that are not delivered at the level they should be.
Because there is an increased need for infusion services, and because it makes good business sense, agencies want to be responsive. However, this may not always result in good patient care. The time and resources available to orient registered nurses to the wide variety of infusion therapies and technology may be limited, so the reality may be that nurses truly learn as they go. However, what do homecare agencies and health insurers, as ethical professionals, want for their patients? A study of outcome data comparing patients who had specially trained home infusion nurses with those who did not could be revealing to health insurance companies. Patients should get the best outcome in the most cost-effective manner. Perhaps other states need to follow the leads of Hawaii, Maryland, and Virginia and fund research in the specialty of home infusion.
Continued investigation using a wide range of homecare agencies in different geographic settings is needed to learn more about who home infusion nurses are and what they do. Clearly, there is a need for infusion research to advance practices that ensure quality patient care and prepare nurses to deal with the complexities of the ever-changing field of home infusion.