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Home and Community Care Nursing Handbook
Published by the authority of the Minister of Health
© Minister of Public Works and Government Services, 2003
Cat. H35-4/46-2003E
ISBN: 0-662-35571-7
Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.
(PDF Version - 1,106 K)Table of Contents
- 1. About this Handbook
- 2. The First Nations and Inuit Home and Community Care (FNIHCC) Program
- 3. Community Overview
- 4. Regulatory and Professional Nursing Organizations
- 5. Home & Community Care Nursing Practice
- 6. Nursing Human Resource Issues
- 7. Nursing Support and Consultation
- 8. Quality Assurance and Risk Management
- 9. Liability and Insurance
- 10.Appendices
This Home and Community Care Nursing Handbook was drafted by the First Nation and Inuit Home and Community Care Program Nursing Working Group. The group consisted of:
- Mireille Bilodeau
- Nunavik Regional Board of Health and Social Services
- Helene Boyer
- First Nations and Inuit Health Branch (FNIHB), Quebec Region, Health Canada
- Janet Currier
- FNIHB, Pacific Region, Health Canada
- Lori Duncan
- Ta'an Kwach'an Council, Yukon
- Claire Goldie
- FNIHB, Northern Secretariat, Health Canada
- Ialeen Jones
- Government of North West Territories
- Deborah Kupchanko
- FNIHB, Saskatchewan Region, Health Canada
- Michele Landry
- Union of Nova Scotia Indians
- Debi Matias
- FNIHB, Manitoba Region, Health Canada
- Heather Nicholas
- Oneida First Nation Health Centre
- Marlene Nose
- FNIHB, Health Canada
- Brenda Roos
- FNIHB, Atlantic Region, Health Canada
- Sharon Stanton
- FNIHB, Health Canada
- Edna Stevens
- FNIHB, Manitoba Region, Health Canada
- Florence Tarrant
- Cross Lake First Nation, Manitoba
- Charlotte Thompson
- FNIHB, Pacific Region, Health Canada
- Cathy Ulmer
- FNIHB, Saskatchewan Region, Health Canada
- Dela Wilkins
- Nishnawbe Aski , Ontario
- Heather Young
- FNIHB, Alberta Region, Health Canada
- Janet Mc Vicar
- Northern Intertribal Health Authority, Saskatchewan
- Bob Walker
- FNIHB, Northern Secretariat, Health Canada
This document is available on the Health Canada website and the 
Assembly of First Nations website.
About this Handbook
A Note to the Reader
This Home and Community Care Nursing Handbook is a tool designed to assist First Nations and Inuit Communities in promoting the effective and safe practice of Home Care nursing. It also provides information with respect to the recruitment and employment of nurses.
This Handbook is intended for:
- Administrators/Managers of community/tribal/regional First Nations and Inuit health organizations and authorities; and
- Home and Community Care Nurses employed or contracted by these organizations to provide nursing services within their respective community(ies).
While the needs of each group are distinct, there is information relevant to both groups contained within this handbook. To avoid duplication and maximize efficiency, one comprehensive handbook has been created as a resource for both groups.
Using this Handbook
This Handbook is a guide and provides specific references to applicable program policies and guidelines. The handbook is designed to provide general guidelines and information, with the goal being to increase understanding of the nursing profession and the practice of Home Care nursing. This increased understanding will support Home and Community Care service delivery in First Nations and Inuit communities.
The aim of planning, developing and implementing the Home and Community Care Program is:
- to build and sustain an effective Home and Community Care service for all First Nations and Inuit communities;
- to provide services that meet the assessed needs of community members;
- to ensure that the services can be provided as long as they are needed;
- to establish a foundation for making the program better as the years go by; and
- to promote understanding about the scope and parameters within Home and Community Care.
The planning, development and implementation processes are ever evolving. This ensures Home and Community Care services continually adapt to new and innovative ways of responding to the needs of each First Nation and Inuit community within resource allocation limitations.
Templates
Throughout the handbook, references are made to standards and policies templates. These references apply to the templates developed by Health Canada with St. Elizabeth Health Care (2000) for the program. While it is recognized that many communities have developed their own policies and procedures, for the purposes of this handbook references will be made only to the aforementioned templates.
Home Care Nursing Handbook Reference Kit
A CD-ROM sample Reference Kit accompanies this handbook. It contains copies of other documents and forms that are referenced throughout this document.
The Home and Community Care Nursing Handbook is intended to complement the First Nation and Inuit, Home and Community Care Planning Resource Kit (2000).
The First Nations and Inuit Home and Community Care (FNIHCC) Program
Introduction
In 1999, the Federal government approved funding for a national First Nations and Inuit Home and Community Care (FNIHCC) Program.
The FNIHCC Program provides basic Home and Community Care services designed to be comprehensive, culturally sensitive, accessible, effective and equitable to that of other Canadians and which respond to the unique health and social needs of First Nations and Inuit communities. The Program is a coordinated system of home and community based health-related services that enable people with disabilities, persistent or acute illnesses and the elderly to receive the care they need in their home communities.
Program Objectives
The primary objectives of the FNIHCC Program are:
- to build the capacity within First Nations and Inuit to develop and deliver comprehensive, culturally sensitive, accessible and effective home care services;
- to assist First Nations and Inuit living with persistent and acute illness in maintaining optimum health, well-being and independence in their homes and communities;
- to facilitate the effective use of home care resources through a structured, culturally-defined and sensitive assessment process to determine service needs of clients and the development of a care plan;
- to ensure that all clients with an assessed need for home care services have access to a comprehensive array of services within the community, where possible;
- to assist clients and their families in participating in the development and implementation of the client's care plan to the fullest extent and to utilize community support services where available and appropriate in the care of clients; and
- to build the capacity within First Nations and Inuit to deliver home care services through training and evolving technology and information systems to monitor care and services and to develop measurable objectives and indicators.
Eligibility
The eligible recipients for this program are:
- First Nations and Inuit of any age;
- who live on an Inuit settlement, First Nations reserve or First Nation community North of 60;
- who have undergone a formal assessment of their continuing care service needs and have been assessed to require one or more of the essential services; and
- who have access to services that can be provided with reasonable safety to the client and caregiver, within established standards, policies and regulation for service practice.
Program Elements
Essential Service Elements
Essential service elements provide the foundation upon which future program enhancements can build. They include:
- a structured client assessment process that includes on-going reassessments and determines client needs and service allocation. Assessment is a structured dynamic process of continuous information gathering and knowledgeable judgements that attach meaning to the information being gathered. Assessment and reassessment processes can involve the client, family and other care givers and /or service providers;
- a managed care process that incorporates case management, referrals and service linkages to existing services provided both on and off reserve/settlement;
- home care nursing services that include direct service delivery as well as supervision and teaching of personnel and family providing personal care services;
- the delivery of home support personal care services that are determined by the community needs assessment plan and that do not duplicate, but enhance existing Department of Indian Affairs and Northern Development (DIAND) adult care services (e.g. bathing, grooming, dressing, transferring, care of bedbound clients including turning, back rubs and routine skin care, etc.);
- provision of in-home respite care;
- established linkages with other professional and social services that may include coordinated assessment processes, referral protocols and service links with hospital service providers, physicians, nurse practitioners, advanced practice nurses, respite and therapeutic services;
- provision of and access to specialized medical equipment,supplies and specialized pharmaceuticals to provide home and community care;
- the capacity to manage the delivery of the home and community care program that is delivered in a safe and effective manner, if existing community infrastructure exists; and
- a system of record keeping and data collection to carry out program monitoring, ongoing planning, reporting and evaluation activities.
Supportive Service Elements
It is expected that the essential service elements of the Home and Community Care Program be developed initially in each First Nation or Inuit community. The Home and Community Care Program may expand to include support service elements based on community needs and priorities, existing infrastructure and availability of resources.
Supportive elements that may be provided within a continuum of home and community care might include, but are not limited, to:
- facilitation and linkages for rehabilitation and therapy services;
- respite care;
- adult day care;
- meal programs;
- home-based mental health services for long-term psychiatric clients and clients experiencing mental or emotional illness. These services might include traditional counselling and healing services, and medication monitoring;
- support services to maintain independent living;
- home-based palliative care;
- social services directly related to continuing care issues; and
- specialized health promotion, wellness and fitness.
FNIHCC Program Limitations
The FNIHCC Program:
- will not fund the construction and/or delivery of long term care institutional services; and
- will not duplicate funding for existing on reserve adult care services.
Program Evaluation
A Results-Based Management and Accountability Framework (RMAF) forms the evaluation framework for the FNIHCC program. This framework describes the integrated approach by which the FNIHCC program will measure, manage and report on results throughout its life cycle. It also contains an evaluation plan, which includes information such as what, when, and how to evaluate.
The RMAF describes the roles and responsibilities for Health Canada and First Nations and Inuit communities in the implementation and delivery of the FNIHCC program. It presents a clear and logical program design that links program resources to expected outcomes through a chain of activities, outputs, and expected outcomes. It lays out an appropriate performance management approach that includes ongoing performance measurement, an evaluation strategy, reporting on achievements and accountability for results.
The RMAF represents an understanding between all partners in program delivery as to what they aim to achieve, how they will work together to achieve it and how they will measure and report on outcomes. The RMAF is a tool for better program management and continuous learning.
Top of PageCommunity Overview
Introduction
The purpose of this section is to provide the Home Care nurse with an overview of the community.
This section is unique to each community . As such, each community is asked to include important community information in this section of the handbook. The community leadership and the Home and Community Care Program staff can work together to provide information for this section. It is intended to be an area where First Nations & Inuit Communities can share specific Home and Community Care Program information with staff.
This section could include a summary of staff and working relationships between the Home and Community Care Program, the leadership, and other health departments in the community.
If the Home and Community Care Program is operated at a health authority or tribal council level, information on the collective group of communities as well as the individual communities that make up the collective could also be included.
Other information recommended for inclusion in this section includes:
- a copy of a Community Profile;
- the most recent Community Needs Assessment;
- the approved current Service Delivery plan for the program;
- a current Staff Contact List;
- information on the availability of health service providers (e.g. nurses, social services, etc.); and
- community Personnel Policy Manual.
Each of the above is described in the next few pages. All of these items can be copied and inserted directly into the binder in this section.
Of course, the community may also choose to include other pertinent information and/or documents in this section in addition to those recommended.
Community Profile
A Community Profile contains general information about the location, history and population of the community. A copy might be available from the band administration office. This document often includes a map of the community with the location of homes and businesses.
Home and Community Care Needs Assessment
A Community Needs Assessment was conducted in the planning phase for the Home and Community Care Program. A copy of the most recent Community Needs Assessment is available from the Home Care Coordinator. It is recommended that a copy of this document be placed in this section of the handbook.
Service Delivery Plan
The Service Delivery Plan for Home and Community Care describes how the program will be delivered in the community. It is suggested that the service delivery plan be reviewed and updated annually. It includes a description of the services, the staffing, and the organizational chart for the program. The plan also indicates where the Home Care nurse will obtain professional support and consultation. It is recommended that a copy of the most recent Service Delivery Plan be included in this section of the handbook.
Staff Contact List
The development of a contact list is suggested with names and telephone numbers for:
- Home Care and Nursing Station/Health Centre staff; and
- Chief and Council members and Health Board or Health Committee members with responsibility for the Home and Community Care Program.
Other programs could also be included here (e.g. Diabetes, Mental Health, Healing and Wellness, etc.). A sample contact list set-up is included in the Reference Kit.
Availability of Health Service Providers
It is important for First Nations & Inuit Communities to include information on the availability of the Home and Community Care nurse (e.g. Monday to Friday, first week of each month, three days every third month, etc.) and on who to contact when the Home Care nurse is not available. Information regarding access to nursing services and other primary care services after hours could also be included.
Summary Suggestions
The information in this section of the handbook is community-specific and regular updates are recommended whenever:
- there is a new community profile;
- the Needs Assessment is updated;
- the Service Delivery Plan is revised for submission to the Region;
- there are staff changes in Home and Community Care; or
- Chief and Council or Committee membership changes.
Regulatory and Professional Nursing Organizations
Introduction
Each province/territory has regulatory bodies, which provide a vital role:
- to ensure the public's right to quality health care service; and
- to support and assist professional members.
Health professionals such as nurses, doctors, pharmacists and many others are regulated and licensed by regulatory bodies as required by provincial/territorial legislation. All nurses are required to be licensed to practice with their designated provincial/territorial nursing regulatory body.
Role and Purpose of Regulatory and Professional Nursing Organizations
Nursing regulatory bodies, also known as Colleges or Associations, are responsible for the licensing of nurses within their respective province/territory. Nursing regulatory bodies receive their authority from legislation, which gives them the ability to:
- set and enforce standards of nursing practice;
- monitor and enforce standards for nursing education;
- monitor and enforce standards for nursing practice; and
- set the requirements for registration of nursing professionals.
All of these activities are vital to ensure protection of the public interest.
Provincial / Territorial Laws
Each provincial/territorial jurisdiction has legislation in place governing their respective regulatory body. In some jurisdictions, the law is all encompassing and covers all health professions while in other areas it is specific to each discipline. Nursing Colleges and Associations establish their respective regulations in accordance with their own provincial/territorial legislation.
Quality Assurance Programs
In order for regulatory bodies to guarantee the public that its members are adhering to the Standards of Practice and are delivering safe and competent care, they require members to participate in quality assurance programs. These quality assurance programs vary in each jurisdiction, are typically determined by the nursing regulatory bodies, promote continuing competence for practicing nurses, and enable nurses to undergo a reflective practice process. Compentencies describe integrated knowledge, skills, abilities, attitudes and judgement required of the Home and Community Care nurse to provide safe and effective care (practice).
Nursing self-assessment is a process whereby nurses identify the knowledge and skills they possess, as well as those they need to strengthen in order to improve their practice. Nurses then participate in a peer review process that confirms areas of strength and areas for future development. The next step in a reflective practice process is to develop a learning plan based on the identified developmental needs of the nurse. This is an ongoing annual process, as nurses must continually evaluate their learning needs and improve their practice.
Regulatory bodies have several methodologies that nurses can utilize to review their practice. Self-assessment is only one of many tools. They have also developed programs that will assist employers in assessing the workplace as a quality practice environment. More information on these and other practice review programs are available on each provincial/territorial regulatory body's website. Appendix B provides a list of all jurisdictions with associated contact information.
Mandatory Reporting Requirements
Many regulatory nursing bodies have established guidelines for employers of nurses regarding mandatory reporting requirements. For example, termination of a nurse from employment requires the employing agency to report this incident to the nursing regulatory body.
It is important for employers and nurses alike to verify the mandatory reporting requirements from their respective jurisdictional regulatory body (see appendix B for a full listing of regulatory bodies).
Home & Community Care Nursing Practice
Introduction
Nursing practice is defined in each province and territory through its own consistent Standards of Nursing Practice. These standards provide parameters through which competencies are developed and which practising Home Care nurses are expected to possess.
Competencies identify the extent to which the Home and Community Care nurse can practice and limitations to his/her practice.
The following section discusses:
- Delegation
- Nursing Standards and Competencies
- Program Standards, Policies and Procedures
- The Nurse/Client relationship
- Confidentiality
- Record keeping
- Incident reports
Note that the delegated/undelegated roles of Home Support Workers, Standards and Competencies and the Home Care Nursing Standards, Policies and Procedures are specific to each province and territory.
Delegation
Regulated Worker Delegation
Registered Nurses are regulated and thereby accountable to their respective employers, regulatory body and clients. When a nurse decides to delegate a component of care to another regulated worker, he/she is accountable for the decision to delegate and for determining that the provider of care has the necessary knowledge and skills to perform the care safely and competently. The professional receiving the delegation is accountable for determining that he/she has the necessary knowledge and skills to perform the care safely and competently.
Unregulated Worker Delegation
A nurse may delegate a specific task or procedure to an unregulated worker only in specific client situations and if employer policy permits.
In order to ensure client safety, the nurse must determine that:
- the client's health status is stable;
- the client's response to the procedure can be predicted;
- the worker has the ability to perform the task safely; and
- support and supervision would be available to that worker at all times.
Nursing Standards & Competencies
Each nursing regulatory body has Standards of Practice, the majority are based on the Canadian Nurses Association (CNA) Code of Ethics. In addition to the Standards of Practice, nursing bodies have a list of competencies that each new nurse is required to meet in order to be registered. Competencies determine the level of knowledge, skill and judgement required to enter the practice of nursing.
Program Standards, Policies & Procedures
Standards, policies and procedures are valuable tools for program staff, communities and individual clients and their families. They provide clear direction on program tasks and activities. A full description of the benefits and value of standards and policies can be found in the standards and policies manuals. First Nations and Inuit Communities will also need to develop procedures that are associated with each of the policies. Procedures are simply a description of how policies are carried out.
Nurse - Client Relationship
The nurse-client relationship is considered a therapeutic relationship in which the behaviour of the nurse has the primary benefit of improving nursing care to patients, clients, families and communities. This is a relationship built on mutual respect, which is essential to providing safe, competent and ethical nursing care.
Confidentiality
Confidentiality is one of the eight primary values considered central to ethical nursing practice, as outlined in the Nurses Code of Ethics. Nurses have an ethical, legal and moral responsibility to protect information that is obtained in the context of the nurse-client relationship. They are obligated to ensure that the sharing of such information outside of the health care team is done only with the informed consent of the client or as required by statutory law, such as in the case of reporting child abuse.
Client Record Keeping
Client records are confidential legal documents. Documentation of client care is a very important component of providing nursing care. Nurses document the care they give and the services they provide to clients for a variety of reasons including the following:
- Documentation of care is a method of communicating information about the client to other members of the health care delivery team to ensure continuity of care.
- The client record provides a mechanism for ensuring the accountability of nurses to the client for the care they provide and in turn provides the nurse with protection against liability.
- Client records are necessary in order to monitor and evaluate the quality of care and assist in improving quality of care delivery.
- Client records and documentation are a valuable source of health data that can be used to evaluate client outcomes and subsequently improve nursing practice and client care. This data is used in summary totals without client identifiers, patient confidentiality will be maintained at all times.
Limitations to Nursing Practice
As regulated health professionals, nurses must practice within a defined scope of practice as set out by their regulatory body. The scope of practice of a nurse refers to the role, functions, responsibilities and activities that he/she is able to carry out. Nursing Colleges and Associations establish the scope of practice for their membership and define broad limits of practice.
The individual Home Care nurse may have a more limited scope of practice than that defined by the nursing regulatory body. This is dependent upon the:
- type of care needs of the clients;
- policies and requirements of the employer; and
- area or type of setting in which nurses are practicing.
For example, procedures that may be deemed safe in a home setting in an urban area with access to 911 and physician back-up may not be deemed within the scope of practice of a home care nurse working for a Tribal Health Authority in a remote community.
A more specific example of this may be the client requiring chemotherapy. The urban home care program offers a home chemotherapy service that is linked with a local hospital. The chemotherapy is prepared by the hospital pharmacy and administered by the Home Care nurse to the client in his/her home setting. The protocol stipulates what monitoring is to occur and that if any complications arise from the administration of the chemotherapy, the Home Care nurse calls 911 and the client is transported to the hospital.
In a remote/isolated location, the administration of Home Chemotherapy will not be in the Home Care nurse's scope of practice for several reasons. There is no local hospital and/or pharmacist to mix and/or prepare the chemotherapy, no 911 system that can immediately transport the client to a hospital if complications occur and the nurse is not available at all times.
Home Care Nursing Practice is defined in each province/territory by the respective nursing regulatory body. In addition, the practice is further defined and limited by the employer and the setting in which the nurse is employed.
Nursing Human Resource Issues
Introduction
The availability of nursing human resources is an issue across Canada and First Nations & Inuit communities are no exception. There are numerous issues associated with the recruitment and retention of nurses for First Nations & Inuit communities. Various regional strategies are currently being developed to address these issues and support communities in recruiting and hiring home care nurses.
This section provides communities with information to assist in the effective management of nursing human resources. The documents and examples referenced in this section are guidelines for communities which are designed to support and provide appropriate management direction to the nursing staff. These resources are available in the accompanying Reference Kit.
Orientation
All nursing staff should have a complete orientation to their new position. It is important to have an employee orientation policy which outlines the content to be included in an orientation. A sample orientation policy is included in the Home and Community Care policies manual.
Orientation checklists are an excellent way of ensuring that nursing staff have a standardized and comprehensive orientation to the program and the community. Each Home & Community Care Program should develop a checklist specific to their community that includes all of the items comprising an orientation as identified in the policy manual. A sample of such a checklist is available in the Reference Kit, which can be utilized and adapted as appropriate.
Job Descriptions & Qualifications
When recruiting and hiring nursing staff, it is important for First Nations & Inuit communities to indicate in the recruitment advertisement the position title and education, skill sets and work experience requirements. In order to do this, First Nations and Inuit employers must have a clear understanding of the work to be performed and the associated competencies required.
Nurse experience, skill sets, and educational background all contribute to their individual credentials and qualifications. For example, some positions may be more applicable for a Registered Nurse (RN) while others might lend themselves better to someone with a Licensed Practical Nurse (LPN) designation. In other circumstances, nurses with a baccalaureate degree (i.e. BScN) may have the education and corresponding work experience better suited for a particular position's scope of work.
A sample job advertisement for a Home Care Case Manager is provided in the Reference Kit. It can be utilized as a guide when preparing recruiting advertisements.
It is also necessary to have a job description prepared that the nurse candidate can review prior to an interview. The job description should include the position title, the purpose of the position, who the position is accountable to and what the position is accountable for. There should be a summary of the job and a listing of the specific duties and responsibilities. The document should also include the qualifications and experience required, as well as a brief statement about the expected working conditions. Samples of job descriptions are available in the First Nation and Inuit Home and Community Care Planning Resource Kit, Booklet 4, Preparation Activities.
Recruitment & Retention
In order to recruit and retain nurses in today's environment, employers must be able to offer competitive remuneration packages and provide a supportive and professionally challenging work environment.
Competitive remuneration involves more than simply salary. It can also include incentives for continuing education, non-financial incentives such as additional professional development leave days, and a wide variety of other benefits. For example, communities might consider giving educational allowances for nurses in their employ who hold a Bachelor of Science in Nursing (BScN), or provide financial support to nurses who wish to further their nursing education.
The salary and benefits package must be comparable to that which a nurse can obtain from other agencies that are within close proximity. When hiring nurses it is important to compare benefits to similar employment settings. For example, home care nurses will travel extensively within a community. As such, it would be important to have a mileage reimbursement for use of personal vehicle benefit for the nurse. It is helpful when setting salary scales and benefit packages to research information from several other employers within the immediate area.
Conflict of Interest
All employees of the First Nations and Inuit Home and Community Care Program (FNIHCC) must be responsible to their clients, the Program and their co-workers and must perform their duties at all times in a professional and ethical manner. In order for employees to do this, they must be sensitive to potential conflict of interest issues. The employer can facilitate this sensitivity and awareness through a comprehensive policy on Conflict of Interest. A sample is available in the Home and Community Care policy manual.
An example of a potential conflict of interest would be a Case Manager who is required to complete an assessment and determine eligibility for services on a client who is a family member. The Case Manager may feel pressure from other family members to exceed the program guidelines and provide a higher level of services.
A Conflict of Interest policy would identify a method for the Case Manager to disclose a potential conflict of interest situation, such as in the above example. In this situation, the Case Manager should identify the potential for a conflict of interest with program management as well as with the family. Once the Case Manager is placed in a conflict situation, he/she must then declare a conflict and remove him/herself from any further decision making in the case. The program supervisor and/or manager should become involved at this stage.
Health & Safety
An employer has an obligation to provide a safe work environment for staff. The program must have standards for health and safety for both staff and clients in its care. A standard for health and safety can be found in the Home and Community Care standards manual.
There are numerous elements within a Health and Safety program. Employers must develop policies and procedures that address all of these elements. The suggested list of items to address under Health and Safety include, but are not limited to:
- the management of hazardous wastes
- emergency and/or Disaster response
- fire and evacuation plan
- an incident reporting system
- liability protection for employees
- negligence
- client abuse
- infection control
- harassment
Policies addressing all of these areas are available in the Home and Community Care policy manual.
Performance Appraisals
All employees have a right to have their performance evaluated on a regular basis. Employers should have a process in place to evaluate employee performance on an annual basis as a minimum standard. Employees must be evaluated against their pre-assigned work expectations. These expectations should be provided to them upon hiring in the form of a job description. Any changes in work expectations must be communicated to the employee in writing and included in a revision to the job description.
It is also recommended that employers:
- have policies and procedures in place to standardize the performance assessment process within their organization;
- institute a minimum probationary period of six months for all new employees; and
- conduct a probationary performance appraisal at the end of that six-month period.
For informational purposes, a standard for performance measurement along with the appropriate policies can be found in the Home and Community Care standards manual.
Employers can utilize a wide variety of formats for employee performance review and/or appraisal. It is suggested that an annual written review be the bare minimum standard and this can be supplemented with additional verbal and/or written reviews either formally or informally. To assist with this process a sample of an employee appraisal form is available in the Reference Kit.
In addition to a regular performance review and/or appraisal, nursing staff may also be required to complete a self-assessment of their nursing practice according to the standards set out by their specific provincial and/or territorial nursing regulatory body. These standards must be complied with and employers should be aware of these standards in their respective jurisdiction and ensure that their nursing staff is in compliance.
One way of ensuring this compliance is through a process called "professional appraisal" whereby the practice and competence of the Home Care nursing staff is monitored and/or evaluated by a senior nurse manager/consultant. This would be considered a part of the second level services that are incorporated into the program framework. For more information on this issue, please see Section 7 on Nursing Support and Consultation in this manual.
Nursing Support and Consultation
Introduction
The capacity to manage the delivery of the home and community care program is an essential service element within the First Nations and Inuit Home and Community Care (FNIHCC) Framework. The rationale for inclusion of this element into the Program is based on the constantly changing needs of the home care client that may require a high level of management and nursing support.
This section provides communities with information that will help them establish a process for carrying out the necessary program management activities, as well as professional nursing consultation and support. The documents included in this section are meant as guidelines for communities to assist them in developing their own program management and support framework.
Description
Professional nursing support and consultation is defined by a range of activities. These include but are not limited to the following:
- consultation and advice on professional nursing practice issues;
- monitoring and evaluation of nursing services delivery;
- ensuring adherence to the standards for nursing practice by all nursing staff; and
- provision of consultation and support on a wide range of nursing human resource issues.
Management and Support Options
As program support and management is an essential service element in the FNIHCC Program, communities must describe how this will be provided in their service delivery plan. Communities have many options for providing this type of service within their program.
Larger, self-sustaining programs have the option of providing the service themselves . This can be accomplished in several ways including:
- Through a senior nursing manager employed full-time within their program;
- Hiring a program manager for the non-nursing aspects of the management and supporting and hiring a nurse consultant on a contractual basis to provide professional nursing consultation and support; or
- Contracting this service from a larger Home Care Agency such as St. Elizabeth Health Care, Victorian Order of Nurses (VON) or a Provincial Home Care program.
A sample job description for a senior nursing manager and a sample contract that could be used to negotiate the services of a nursing consultant are included in the Reference Kit.
Communities affiliated with a tribal council or a First Nations political organization have the option of working with the larger organization to receive these services using an economy of scale model. In essence, communities contribute program management and support dollars to the larger organization that in turn can provide the service to a group of communities with their combined resources. A sample of a Tribal Home and Community Care Coordinator Work Plan is included in the Reference Kit. Communities can use it as a reference when negotiating such a service with an umbrella organization.
Communities that do not have either of the above options in some areas may negotiate the provision of second level services from a government entity or a regional health authority. The Health Canada's First Nations and Inuit Health Branch (FNIHB) of Health Canada , Provincial/Territorial Health Ministries and/or Regional Health Authorities are agencies and/or departments that may be able to provide these services. The community could negotiate these services with the respective government agency and a Memorandum of Understanding could be developed to formalize this service. The Reference Kit contains a sample Memorandum of Understanding and a Home Care Nursing Consultation Work Plan.
Quality Assurance and Risk Management
Introduction
St. Elizabeth Health Care (2000) states in their Standards Template that "quality is about doing the right things and doing things right". "Quality assurance" and "quality improvement" are processes used to assist programs in service delivery. The two terms are often used interchangeably. Humphrey and Milone-Nuzzo (Humphrey, Carolyn J. & Milone-Nuzzo, Paula, (1996) Orientation to Home Care Nursing, Gaithersburg , Maryland : Aspen Publishers), two renowned home care authorities, describe quality assurance and quality improvement as being the "systematic monitoring process that identifies opportunities for improvement in client care delivery, designs ways to improve the service and continues to evaluate the followup actions taken on those opportunities for improvement."
The implementation of the First Nations and Inuit Home and Community Care (FNIHCC) Program involved the development of many tools that support Quality Assurance, such as service delivery plans, program standards and policies. This section provides communities with information and tools that help to monitor program delivery, identify risk management issues, improve service, and evaluate the followup actions taken for improvement.
Quality Assurance
The FNIHCC Program is committed to providing high quality and client-focused care. Quality Assurance is an ongoing process that examines the efficiency, quality and effectiveness of a program or service.
Effective quality control involves all staff and volunteers. All members of the home care team should be involved in quality assurance, receive training related to it, and be responsible for it. When issues are identified, staff and volunteers are consulted and corrective action is taken to resolve the situation. Regular team meetings and staff meetings are held and information is shared to ensure that an acceptable level of quality control is maintained. The effectiveness of any corrective actions taken is evaluated by the supervisor, using feedback from everyone involved.
There are several sources of information such as client complaints and incident reports. These are reviewed on a regular basis to ensure that quality control measures have been taken, that the correct process was followed and to measure staff judgment and performance.
Tools for Quality Assurance Client
Chart Audit
Client Chart Audits are reviews of clients' clinical records to identify goal attainment and evaluate services delivered and are a critical component of a quality assurance program. These audits can be carried out on a regular basis by a home care nursing supervisor, other nursing peers or a nursing consultant. A sample can be found in the Reference Kit.
Incident Form
Incident Forms areçused to document situations or incidents that are of actual or potential concern with regard to the client, employee or the provision of home care service. A summary incident log is useful and can help to categorize various types of incidents. Examples of each can be found in the accompanying Reference Kit.
Client Satisfaction Survey
Client Satisfaction Surveys are one method that home care programs can use to monitor home care services as perceived by the client. A sample survey can also be found in the Reference Kit.
Risk Management
Risk is defined as current or potential harm that can occur . Areas of risk include:
- abuse (e.g. physical, emotional, psychosocial, sexual, or financial)
- personal injury
- medical
- environmental (e.g. fumes, smoking, pets, equipment)
- property
- financial
- reputation
Risk Management is essential for ensuring the overall viability of an organization. Specifically risk management helps to:
- enhance the quality of the service delivered;
- promote accountability to clients and funders;
- enhance the safety of clients, caregivers and paid staff/volunteers;
- identify and reduce or eliminate potentially harmful situations;
- avoid liability situations that could impact significantly on an agency's financial stability and reputation;
- make paid staff and volunteers more aware of risk situations when carrying out work-related activities;
- instill client confidence in the organization and its services; and
- reduce insurance claims and satisfy insurers that the agency is risk conscious.
Continuous Risk Management Process includes:
- identification of risk;
- prioritization of risk;
- development of strategies to address risk;
- establishment of indicators and targets for monitoring success in managing risk;
- collection and analysis of data to determine success in managing risk; and
- implementation of continuous quality improvement to improve strategies to manage risk.
Risk Management Plan
A Risk Management Plan is necessary to reduce potential harm to the program, staff, and clients. A sample of a Risk Management Checklist can be found in the accompanying Reference Kit.
All members of the home care team should be involved in risk management, receive training related to it and be responsible for it. Through a thorough orientation, which includes discussion and review of risk management / quality assurance documents, the new employee will be better able to determine where he/she fits in the quality improvement process. All staff needs to be provided with training as to the use of the tools. The tools and the processes will need to be continually refined to meet the ongoing service delivery requirements of the program and program changes made evident by the quality improvement program's findings. By having these programs in place, the FNIHCC Program will be better prepared for accreditation should health employers wish to enter into the process.
According to the Canadian Council on Health Services Accreditation (CCHSA), accreditation is a voluntary process in which many organizations participate. The process allows them to receive an objective assessment of the quality of the care delivered and the services offered to clients. The accreditation program is based on a continuous quality improvement model whereby organizations can compare themselves to national standards. Using these standards, the organization can monitor and improve its performance on an ongoing basis. The program is administered by the Canadian Council on Health Services Accreditation and further information can be obtained from their website.
Liability and Insurance
Introduction
Liability issues and insurance requirements are critical issues that need to be considered by all health care delivery organizations/agencies. There are many First Nation communities delivering health and social services under a variety of agreement and administrative arrangements. Within these funding arrangements, there are also contractual agreements, Memorandum of Understandings and/or protocol agreements with independent health professionals and health/social authorities for the provision of specific services. All of these arrangements entail multi-jurisdictional relationships, some of which are defined by provincial legislation, federal Acts and evolving First Nations and provincial legislation.
The introduction and implementation of First Nations and Inuit Home and Community Care (FNIHCC) Program has raised a number of issues around risk for liability. The FNIHCC Program has developed a handbook and training resource designed to build awareness about the risks for liabilities and risk reduction activities. This handbook is not intended to replace legal advice. Rather it is to raise awareness about liability and to facilitate informed decision making by the community and/or delivery authority. In addition, the First Nation and Inuit Health Branch (FNIHB) Health Transfer program has developed a resource guide around insurance, which can be obtained from your Regional (Health Canada's First Nations and Inuit Health Branch) FNIHB Health Transfer office.
Appropriate liability and malpractice insurance is required to cover the employer and the staff delivering services. The following provides a brief definition of liability and insurance requirements with references to the above mentioned resource material.
Liability
Liability refers to the legal risk that a person or body may be held accountable for if another person or body suffers an injury or loss. It requires that there be some sort of relationship between the person or body who suffered the injury or loss and the person or body being called accountable for it. That injury or loss can arise from an act or from a failure to act, or from the breach of a term of a contract or duty. (Draft Liability Handbook, 2000)
Insurance
As an employer of Home and Community Care health services staff, the First Nation or Inuit health authority/organization must obtain necessary insurance coverage and is legally responsible for any harm or damage resulting from its own activities and those of its employees working in the health program. The employer could also be held liable if someone were to have an accident on the property occupied.
First Nations and Inuit health authorities and/or organizations areçurged to seek independent advice as to their potential liabilities and insurance requirements as well as those of their employees and contract workers.
Types of insurance required as per terms and conditions in your Contribution Agreement for Home and Community Care health services include:
- malpractice and liability insurance for professional health staff;
- liability insurance for other health staff;
- general liability insurance; and
- property insurance (not included but recommended).
Appendix A - Glossary and Definitions
Code of Ethics for Registered Nurses gives guidance for decision-making concerning ethical matters, serves as a means for self-evaluation and reflection regarding ethical nursing practice and provides a basis for peer- review initiatives. (CNA, 2002)
Confidentiality is the safeguarding of information learned in the context of a professional relationship. (CNA Code of Ethics, 2002)
Competence is the judicious application of knowledge, skills, attitudes and judgments expected of a practitioner. (RNANS, Entry-Level Competencies for Registered Nurses in the year 2001, 1998)
Competencies are the integrated knowledge, skills, attitudes and judgments expected of a practitioner. (RNANS, Entry-Level Competencies for Registered Nurses in the year 2001, 1998)
Continuing Competence is the ongoing ability to integrate and apply the knowledge, skills, judgment and personal attributes required to practice safely and ethically in a designated role and setting. (AARN Continuing Competence Handbook, 2000)
Delegation is a formal process whereby a nurse following assessment of a client, permits the performance of a particular nursing task or procedure by a support-worker on a client-specific and non-transferable basis. (ARNNL, Delegation of Nursing Task and Procedures to Support Workers in Community Settings, 1995)
Home Support Workers can also be referred to as Home Health Aides, Home Care Worker, Personal Care Worker, Continuing Care Assistants, Personal Care Aides, Home Health Worker, and Resident Care Aides.
In-Home Respite Care is a service to provide a "respite" or safe care of a client for a short time (usually there is a time limit) to support the caregiver so that she/he can continue to provide care for the client and therefore delay or prevent the need for institutional care.
Liability refers to the risk that a person or organization may be held accountable for an injury or loss suffered by another.
Memorandum of Understanding is a contractual agreement between a government agency/department (Federal, Provincial, Regional and/or Municipal) and another agency (can be either of the above or a First Nations community/tribal council) that stipulates what one governing agency will provide to another agency and the context in which those services will be provided.
Performance Appraisal is a written description of the knowledge, skills and professional behaviors of the staff that include strengths, weaknesses, and a plan for improvement.
Probationary Period is a designated period of time (typically 6 months) that is allotted at the commencement of employment for employees to adjust to their new job duties and responsibilities, at the end of which a formal performance appraisal is completed.
Professional Boundaries are those lines which separate therapeutic behavior of a professional from behavior which, whether well intentioned or not, could detract from achievable health outcomes for patients and clients receiving nursing care. (CRNNS, 2002)
Professional Organization acts as an advisory and/or advocacy body for a specific group of health professionals. Some professional organizations also perform the function of regulating their membership.
Provincial Health Ministry is the department of the provincial or territorial government responsible for funding and overseeing the delivery of provincially and/or territorially mandated health services.
Quality Assurance is an ongoing process that examines the efficiency, quality and effectiveness of a program or service. (Saskatchewan First Nations Home Care Program Guidelines, 1995)
Quality Assurance Programs are established and maintained to promote continuing competence among the members of a profession. (CNO, Glossary)
Quality Control Measures are actions taken which will result in improvement in the efficiency, quality and/or effectiveness of a program or service.
Quality Improvement is an organizational philosophy that guides the analysis of information to identify trends and make changes in processes and/or procedures. These changes enhance programs and services to meet client and/or community needs, reduce organizational risk, improve efficiencies and improve the work environment.
Quality Practice Environments are workplaces that support quality professional nursing practice. (CNO)
Reflective Practice is a component of a quality assurance program. It is a process that helps nurses to maintain their competence in today's rapidly changing health care environment. (CNO, Glossary)
Regional Health Authority is an organization that has been given the responsibility for providing health care services to a particular geographic area and/or region.
Regulatory Body is an organization that has a mandate in law to regulate a profession in order to protect the public interest. It would set requirements for entry into the profession, enforce the standards as set out by the organization and be responsible for ensuring the quality of care delivered by its' members.
Regulated Health Care Workers are professional health care providers mandated in law by a Regulated Body such as registered Nurses, Physicians, Dentists etc.
Remuneration is the payment of a reward or compensation for a service provided. (Webster's)
Risk Management is a process that includes the identification of risk issues, prioritization of the risk, development of a plan and strategies to address the risk and monitoring the management of the identified risks.
RMAF (Results-based Management Accountability Framework) is a framework that uses an integrated approach to measure, manage and report on results.
Scope of Practice encompasses the activities practitioners are educated and authorized to perform. The overall scope of practice for the profession sets the outer limits of practice for all practitioners. The actual scope of practice of individual practitioners is influenced by the settings in which they practice, the requirement of the employer, and the needs of their patients or client. (CNA, 1993)
Standards of Practice set out the expectations for nurses' conduct and practice. The three major components are professional standards, practice expectations and legislation and regulations. ( College of Nurses of Ontario , Glossary)
Therapeutic Relationship is a relationship established and maintained with a client by the nurse through the use of professional knowledge, skills and attitudes in order to provide nursing care expected to contribute to the client's health outcomes. ( College of Registered Nurses of Nova Scotia )
Unregulated Health Care Workers are health care providers who are not regulated in law by a Regulatory Body such as Home Support Workers, Personal Care Workers, Physiotherapy Assistants etc.
Work plan is a written document that identifies the goals and objectives of a program or service and the tasks required to achieve those goals and objectives.
Appendix B - Nursing Resources
The purpose of this section is to provide nursing and case management some suggested resource information for the new or visiting Home and Community Care nurse.
This section includes:
- Texts
- Journals
- Nursing Associations
Texts
Title: Nursing Handbook for Home Care Procedures
Author: Jaffe, Marie
ISBN: 0-8273-4508-9
Publisher & Year: Delmar, 1992
Price (US$): $31.50
Title: Client Teaching Guides for Home Health Care
ISBN: 0-8342-1054-1
Publisher & Year: Aspen Publications, 1997
Price (US$): $109.00 (includes disk)
Title: Clinical Policies and Procedures for Home Health Organizations
Author: Ondeck, Deborah Ann et Barbara Stover Gingerich
ISBN: 0-8342-0939-X (5458)
Publisher & Year: Aspen Publications, 1997, LC 97-1073
Price (US$): $155.00
Title: Lippincott's Home Care Manual Package
Author: Chestnut, Mary Ann
ISBN: 0-7817-1622-5
Publisher & Year: Lippincott W & W, 1997
Price (US$): $127.00
Title: Home Health Nursing: Assessment and Care Planning
Author: Jaffe, Marie et Linda Skidmore
ISBN: 0-8151-4877-1 (28203)
Publisher & Year: Mosby Inc., 1996, LC 96-23053
Price (US$): $29.95
Title: Handbook of Health Assessment
Author: Rudy, Ellen B. et V. Ruth Gray
ISBN: 0-8385-3602-0
Publisher & Year: Prentice Hall, 1991
Price (US$): $30.40
Title: Medical - Surgical Nursing Care Plans
ISBN: 0-8385-6263-9
Publisher & Year: Prentice Hall, 1996, LC 95-477
Price (US$): $45.00
Title: Nursing Care Planning Guides for Adults in Acute, Extended and Home Care Settings
Author: Puderbaugh Ulrich, Susan et al
ISBN: 0-7216-9215-X
Publisher & Year: 1998, LC 00-50507
Price (US$): $39.95
Title: Fundamentals of Case Management
Author: Siefker, Judith M. et al
Publisher & Year: Mosby Inc. 1998
Price (US$): $36.95
Title: Clinical Nursing Skills and Techniques
Author: Perry, Anne G. et al
Publisher & Year: Mosby Inc.
Price (US$): $83.95
Title: Fundamentals of Case Management
Author: Seifker, Judith M. et al
Publisher & Year: Mosby Inc., 1998
Price (US$): $36.95
Title: Home Care Nursing Handbook
Author: Humphrey, Carolyn J.
ISBN: 0-8342-1017-7
Publisher & Year: Aspen Publications, 1998, LC 94-4346
Price (US$): $40.00
Title: Managing Risk: Policies and Procedures for Community Agencies
Author: Association ontarienne de soutien communautaire
ISBN: 0-9684329-2-1
Publisher & Year: AOSC, 2000
Price (US$): $49.00
Title: Provincial Standards and Guidelines for Case Management
Author: Association ontarienne de soutien communautaire
ISBN: 0-9684329-6-4
Publisher & Year: AOSC, 2000
Price (US$): $25.00
Title: Standards and Indicators for Personal Support and Homemaking Services
Author: Association ontarienne de soutien communautaire
ISBN: 0-9684329-5-6
Publisher & Year: AOSC, 2000
Price (US$): $49.00
Title: Evaluation Handbook
Author: Association ontarienne de soutien communautaire
ISBN: 0-9684329-0-5
Publisher & Year: AOSC, 1999
Price (US$): $69.00
Title: Trousse de ressources de planification pour le Programme de soins à domicile et en milieu communautaire des Premières nations et des Inuits
ISBN: 0-662-28516-6
Publisher & Year: Direction générale la santé des Premières nations et des Inuits, Santé Canada, 2000
Price (US$): $31.50
Title: First Nations Home and Community Care Program Policy and Procedure Manual Template
Author: Association ontarienne de soutien communautaire
ISBN: 0-9730254-0-9
Publisher & Year: AOSC, 2000
Price (US$): $490.00
Title: Introduction to Quality Assurance in Health Care
Author: Avedis Donabedian
ISBN: 0-19-515809-1
Publisher & Year: Oxford United Press, 2003
Journals
The following journals / newsletters are publications of their respective agency(s). Associated website addresses are included.
- (Canadian Association for Community Care National Bulletin)
- (Canadian Home Care Association Quarterly Newsletter)
- (Caring Magazine, National Association for Home Care & Hospice)
- (Case Management Advisor, Thomson American Health Consultants)
- (Official Journal of the Canadian Intravenous Nurses Association)
The following is a comprehensive but not exhaustive list of journals that pertain to the practice of home care nursing.
A complete (listing of journals) can be found at www.cinahl.com
- Advances in Skin Care & Wound Management
- American Journal of Hospice & Palliative Care
- Canadian Journal of Infection Control
- Care Management
- Home Health Care Consultant
- Home Health Care Management & Practice
- Home Health Care Services Quarterly
- Home Healthcare Nurse
- Hospital Case Management
- Hospital Home Health
- Inside Case Management
- Journal of Case Management
- Journal of Hospice & Palliative Nursing
- Journal of Pain & Symptom Management
- Journal of Palliative Care
- Journal of Wound Care
- Ostomy & Wound Care Management
- The Journal of Long Term Caring
- Wound Repair & Regeneration
Nursing Organizations
Canadian Nurses Association (CNA)
50 Driveway, Ottawa ON K2P 1E2
Telephone: 1-800-361-8404 ext. 301
Fax:(613) 237-3520
E-Mail: action301@cna-nurses.ca
Registered Nurses Association of British Columbia (RNABC)
2855 Arbutus St., Vancouver BC V6J 3Y8
Telephone: (604) 736-7331
Fax:(604) 738-2272
E-Mail: brunke@rnabc.bc.ca
Alberta Association of Registered Nurses (AARN)
11620 - 168th St. , Edmonton AB T5M 4A6
Telephone: (780) 451-0043
Fax:(780) 452-3276
E-Mail: aarn@nurses.ab.ca
Saskatchewan Registered Nurses Association (SRNA)
2066 Retallack St. , Regina SK S4T 7X5
Telephone: (306) 757-4643
Fax:(306) 525-0849
E-Mail: info@srna.org
College of Registered Nurses of Manitoba (CRNM)
647 Broadway Ave. , Winnipeg MB R3C 0X2
Telephone: (204) 774-3477
Fax:(204) 775-6052
E-Mail: sneilson@crnm.mb.ca
College of Licensed Practical Nurses of Manitoba (CLPNM)
463 St. Anne's Road, Winnipeg, MB R2M 3C9
Telephone: (204) 663-1212
Fax:(204) 663-1207
E-Mail: info@clpnm.ca
College of Nurses of Ontario (CNO)
101 Davenport Rd , Toronto , ON M5R 3P1
Telephone: (416) 928-0900
Fax:(416) 928-6507
E-Mail: cno@cnomail.org
Registered Nurses Association of Ontario (RNAO)
438 University St. , Suite 1600, Toronto ON M5G 2K8
Telephone: (416) 599-1925
Fax:(416) 599-1926
E-Mail: dgrinspun@rnao.org
L'Ordre des Infirmieres et Infirmiers du Quebec (OIIQ)
4200 Dorchester Blvd, Montreal, QC H3Z 1V4
Telephone: (514) 935-2501
Fax:(514) 935-1799
E-Mail: inf@oiiq.org
Nurses Association of New Brunswick (NANB)/Association des infirmières du Nouveau-Brunswick (AIINB)
165 Regent St., Fredericton NB E3B 7B4
Telephone: (506) 458-8731
Fax:(506) 459-2838
E-Mail: nanb@nanb.nb.ca
College of Registered Nurses Nova Scotia (CRNNS)
Barrington Tower Scotia Square, Suite 600, 1894 Barrington St,Halifax NS B3J 2A8
Telephone: (902) 491-9744
Fax:(902) 491-9510
E-Mail: info@rnans.ns.ca
Association of Registered Nurses of Newfoundland and Labrador (ARNNL)
P. O. Box 6116 , 55 Military Rd., St. John's NF A1C 5X8
Telephone: (709) 753-6173
Fax:(709) 753-4940
E-Mail: jandrews@nf.aibn.com
Association of Nurses of Prince Edward Island (ANPEI)
137 Queen St., Suite 303, Charlottetown PE C1A 4B3
Telephone: (902) 368-3764
Fax:(902) 628-1430
E-Mail: anpei@pei.sympatico.ca
Yukon Registered Nurses Association (YRNA)
Suite 14 , 1114 - 1 AvenueWhitehorse YT Y1A 1A3
Telephone:(867) 667-4062
Fax:(867) 668-5123
E-Mail:yr na@yukon.net
Website: (No website)
Northwest Territories Registered Nurses Association (NWTRNA)
P.O. Box 2757 , Yellowknife NT X1A 2R1
Telephone:(867) 873-2745
Fax:(867) 873-2336
E-Mail:nwtr na@internorth.com
Aboriginal Nurses Association of Canada (ANAC)
56 Sparks Street, Suite 502 , Ottawa , Ontario K1P 5A9
Telephone:(613) 724-4677
Fax:(613) 724-4718
E-Mail: info@anac.on.ca
