7:00 am: Amelia Muir, psychiatric home care nurse begins her day by logging into her laptop. After checking e-mails and confirming appointment times with patients, Amelia is ready to enter the field for her four scheduled home visits in Queens, New York. Queens, a borough of New York City, is home to more than 2 million residents and is considered one of the most diverse areas in the country.

8:00 am: Amelia’s first visit is to see Ms. A., a 62-year-old woman who has been living with HIV for the past 25 years. Ms. A. was referred to Amelia by her caseworker, who noticed signs of depression and anxiety following a recent hospital admission. For the first 30 minutes of the visit, Amelia provides counseling to Ms. A. using cognitive behavioral therapy techniques, which aim to help her reframe negative thought patterns and begin to change ineffective coping mechanisms. After her patient has had the opportunity to express her feelings openly, Amelia shifts the visit to focus on specific symptoms she and Ms. A’s doctors have been closely monitoring. The home care visit is a vital way to keep doctors updated on a patient’s condition as many patients feel certain symptoms are either not important enough to call their doctors or nurses about.

The last 15 minutes of Amelia’s visit with her patient focuses on goal setting and educating the patient about her recommendations for whatever issue they had been discussing. In addition to patient-centered goal setting, Amelia also adds her own suggestions, such as taking a walk around the neighborhood with the home health aide for exercise and stress relief, calling an old friend, or taking time to sit down with a good book. “Many of my depressed patients are in need of more joy in their lives. It may seem overly simple but with the right frame of mind, escaping into a novel or a hobby can have noticeable effect on someone’s mood.” To close the visit, Amelia reviews a list of important symptoms to report to her nurse or doctor with Ms. A. Establishing good communication between patient, nurse, and doctor helps prevent hospitalizations by addressing issues at the earliest appearance. Ms. A. tearfully hugs Amelia at the end of most visits and thanks her for her support. The authentic relationship established between clinician and patient after weeks or months of working together cannot be understated.

Back in her car and mobile office, Amelia checks voicemails and e-mails from other clinicians and patients. Between every visit, arise that require careful coordination. It is often said in the office that being in the patient’s home is the easy part, meaning the real work is often done by clinicians behind the scenes. The case management aspect of home care nursing can drive the stress level up in this specialty.

10:00 am: Amelia’s next patient is Ms. G., a 74-year-old who is experiencing a high level of anxiety because of her progressing amyotrophic lateral sclerosis disease. Amelia has been coming for several weeks after Ms. G.’s daughter begged her to accept psychiatric treatment when she noticed her mother’s motivation to care for herself significantly declined. The first half of the visit is again focused on allowing the patient to have time to express her feelings openly to her nurse. Ms. G. describes how her breathing has become more difficult. One of the interventions Amelia teaches her is how to preform deep abdominal breathing exercises to decrease anxiety and improve lung expansion. She also recommends that Ms. G. play classical music during this exercise to give an added stress-relieving quality. After reviewing goals for the week and target symptoms to report, Amelia begins a short relaxation exercise with the help of aromatherapy oils and acupressure. “I love home care because I have more flexibility to try different strategies with my patients.” Using a simple acupressure technique on both hands creates a calming sensation for Ms. G. She teachers her how to use this technique on her own.

Technology is also an important part of Amelia’s teaching strategies for patients who have access to computers or tablets. Ms. G. was an accountant before she retired 3 years ago and is part of a growing group of tech-savvy seniors. On and earlier visit, Amelia helped Ms. G. explore Web sites, such as YouTube, that provide free instructional videos on topics relevant to the wellness teaching she provides including guided meditation, chair yoga for seniors, and breathing exercises. Ms. G. is also learning to use her tablet for recreation, “I love the videos of the New York City Ballet. It brings me back to when I could move like that!”

1:00 pm: At a nearby apartment complex, Amelia greets her next patient’s wife, who is the primary caregiver for her husband. Mr. C. is in the middle stages of Alzheimer’s disease and has been experiencing many behavioral changes that have caused great stress for his wife. Amelia sits down with the couple in their brightly lit kitchen and reviews symptoms over the past week. During her visits, Amelia explains the different stages of his illness, communication techniques, safety precautions, tips for managing insomnia, and encourages Ms. C. to keep her husband’s mind stimulated with structured activities and recreation. Another important topic Amelia covers is caregiver burnout and she encourages Ms. C. to take time for herself whenever possible.

3:00 pm: For her last visit, Amelia visits Mr. B., a man in his late 50s who is now homebound as a result of Parkinson’s disease. Despite increasing physical challenges, Mr. B. is determined to stay as independent as possible and spends 3 days per week doing intensive treatments with a physical therapist. Amelia visits this patient every 2 weeks to fill his medication box as muscle weakness in his hands prevents him from doing this for himself. Mr. B. updates Amelia on symptoms over the past week and excitedly discusses his progress with his rehabilitation program. Amelia finishes the visit with a quick check on his vital signs.

At the end of her visit, Amelia returns back to her car to make the trek back to her home where she will complete her visit notes and make some final calls to doctors. After another emotion-filled day, Amelia tries a breathing exercise of her own. “Helping patients with depression and anxiety can take an emotional toll on clinicians and it’s vital for me to have self-care rituals so that I don’t become burned out,” adding “I want to do this work for the rest of my career and my goal is to take good care of myself along the way.”

Written by Amelia Muir, BSN, RN-BC

Amelia Muir is a Psychiatric Field Nurse, Behavioral Helath, Visiting Nurse Service of New York, New York City, New York.

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