As age advances, 90 percent of elders above age 70 years would need some assistance in activities of daily living. This is due to age related decline in functions and also due to complications of some of the diseases they develop. The change in the family dynamics and nuclearisation of families deprive them of the traditional carers like children or immediate family members. Elders are often left to themselves to maintain independence in daily living by hiring people to help them with task which they find difficult to do on their own.
The usual practice
In India, where home nursing is unorganised, home nurses mean a wide variety of things. It can start from a servant maid who stays with the family who does everything from changing diaper to cooking. These servant maids are often uneducated who is able to assist elders in activities of daily living by only engaging in these task as per their understanding without any formal training. Hiring them is easy and cheap too but they have high turn around and families struggle to keep up with the agencies recruiting them. They often leave their job unannounced and usually work 4-6 months every year to meet some financial objectives. Home nursing agencies provide them good opportunity to earn money in short term. Such a maid servant usually earns 20,000 to 25000 every month with food and accommodation taken care by the family.
Advantages of hiring such maid servants is that they provide elders assistance in ADLs as well as IADLs- cooking, laundry, cleaning, shopping and many more. An elder who needs just supervision in IADLs and a person to do IADLs would benefit hiring a maid servant. At the same time, maid servant wouldn’t be able to monitor their health parameters, manage their medicines, look out for red flags in their health and do proper health monitoring.
Trained home nurses
Trained home nurses falls under the following categories
1. Trained Attender
These are 10th or 12th graduates who have undergone minimal period of training in a nursing course- recognised or unregistered and have some experience working in hospital sector. They are often recruited as home nursing agencies as home nurses but are not technically nurses. They often end up working as servant maids as it gives them better money.
2. Qualified Nurse Assistants
They are qualified nurse assistants (NA) who have undergone atleast 1 year of professional nursing assistantship course and have experience in patient working either at home or with patients at home. They are skilled enough to check vital signs, alert senior level nurses for clinical escalations and manage emergencies by providing first aid. They are educated enough to understand medical instructions, give subcutaneous injections, read instruction manuals and administer nebulisations, oxygen therapy and provide professional care in ADLs.
3. Registered Nurses (RN)
Registered nurses are hired by elders to administer skilled nursing care at home. Such elders are often sick and needs specialised nursing care like advanced wound dressing, catheter care or stoma care (tracheostomy care, colostomy care and more). End of life care is usually provided by such RNs. Such RNs with ICU experience also manage intensive level care at elder’s home who is very sick. RNs are qualified nurses who have completed GNM (General Nursing and Midwifery) or B.Sc in nursing. They are usually registered with state nursing council.
How to choose which category of home nurse you need?
You need to first list down the requirement. Few charts are available which indicate the level of dependence needed in daily activities. Katz index for activities of daily living and Lawton index of Instrumental activities of daily living are few scales used routinely. Once we understand the level of care needed, you need to select the level of nursing care required. Hiring maid servant and expecting them to perform professional nursing care. A nurse manager from a reputed organisation can help you identify the nursing need and recommend appropriate nursing care.
Quality of Care
It is quintessential that the nurse you appoint is well trained and informed. A nurse manager will help to map the needs of the elder and the skill set of the home nurse. Such mapping greatly reduces future conflicts in quality of care given.
Home nursing cannot be treated as separate entity as an elder who needs nursing care would also require other health related help like physiotherapy, doctor consultation and allied health needs. All such care should be coordinated and performed meticulously.
Cost of good nursing service
Cost of home nursing is not regulated in India. While quality care comes with a cost, often elders and their families tend to settle for low cost nursing care. This is due to high financial burden it amounts to in the long run. Cost of hiring a stay home qualified nurse attender comes to around 1200-1400 for a day . Hiring a dedicated RN round the clock would cost 2200-2500 per day.
What constitutes good home nursing care?
1. Trained and skilled nursing personal
2. Availability of senior level nurses cadre for any clinical complications or emergencies
3. Professional HR management of home nurses including recruitment, prompt replacement of staff to ensure continuity of care.
4. Well groomed nurses with excellent communication skill.
5. Ability of the home care team to provide comprehensive care through a multi- disciplinary team
6. Cost effective Care
7. Employee wellness practices for home nurses including adequate time off service to relieve from care giver stress.
Author- Dr Rahul Padmanabhan, is pioneer in long term care of elders. He is the medical director of Dr Rahul's Elder Care with branches in Coimbatore, Cochin, Madurai and Chennai.