Guidelines for Public Health Nurses Working with Lay Home Visitors

Guidelines for Public Health Nurses Working with Lay Home Visitors

As Registered Nurses, you are professionally obligated to act as client advocates (College of Nurses of Ontario, Guidelines for Professional Behaviour, 1995). As client advocates, Public Health Nurses (PHNs) must inform their clients and families of the care they may receive by a Lay Home Visitor (LHV).

LHVs are not professionals and they are not bound to any professional standards to protect the public. As unregulated health care providers, LHVs are principally accountable to their employer and to the person to whom they provide care. Whereas, RNs, as professionals, have additional accountability to the College of Nurses of Ontario (CNO) through its professional and practice standards, and are held to a higher standard under the Regulated Health Professions Act (RHPA) and the Nursing Act.

As PHNs, you must inform your client - or if your client is incapable of giving consent, the Substitute Decision Maker - of the role and service provided by LHVs. You must then obtain consent for treatment from your client or Substitute Decision Maker. Failure to obtain consent where consent is required is professional misconduct (CNO, Guidelines for Professional Behaviour, Definitions of Professional Misconduct). Clients have the right to know who is providing their care and the right to choose their health care provider (CNO, Ethical Guidelines - Truthfulness, 1995 and RHPA, Section 3). If your client receives care from a LHV, document this in his/her chart and initiate a care plan which outlines the activities that the LHV will be performing and a mechanism whereby the PHN can evaluate the care. It is recommended you inform the client or Substitute Decision Maker that you, as a PHN, will be contacting him/her regularly to assess the effectiveness of the care provided. The PHN must perform random in-house inspections to evaluate the services provided by the LHV.

This care plan will act as proof of service provision as well as evidence of compliance with standards and guidelines from the CNO when the client is receiving care from the LHV. This care plan should include: services provided by the LHV; PHN responsibilities of teaching, supervising and evaluating; and the reporting mechanisms for all parties involved. Each care plan should be readily available for the PHN, the LHV and the client. If the client or Substitute Decision Maker does not wish to receive care from the unregulated care providers (LHVs), the client's wishes must prevail and this should be documented in his/her chart.

PHNs must determine the level of competency of the LHV before they can assign, monitor, supervise, direct performance and evaluate the care provided by LHVs. There must be mechanisms in place to allow the PHN to do so. All of these activities involve knowing what the LHV has been taught. ONA members cannot assume that the education received by LHVs has made them competent health care providers. Those of you working with LHVs must know what they can and cannot legally perform as requested by your employer. This also includes knowing the definition of routine activities of daily living and whether activities they are being asked to perform are controlled-act procedures as outlined in the RHPA. PHNs should be cautioned about delegating - that is, transferring authority to perform controlled acts outside those defined as routine activities of daily living. PHNs must determine the competency of the LHV before they can provide a health care service (CNO, Guidelines for RNs and RPNs Working With Unregulated Care Providers, 1996). An analogy of this is a person who has passed all requirements for a driver's license, but may not be a competent driver.

According to the CNO guidelines (CNO, Accountability of Public Health Nurses Supervising Lay Home Visitors, 1998), the nurse providing supervision is responsible for:

• Knowing that the LHV is competent to meet the needs of the family as assigned
• Checking that the LHV understands the parameters of his/her role (this includes knowing when and how to report outcomes and ask for assistance)
• Providing the appropriate degree of supervision, based on the family's needs, the nature of the care required and the degree of competence of the LHV
• Being prepared to intervene if necessary

Therefore, the employer must allow the PHN time and other resources to evaluate the service provided by the LHV. The time requirement should reflect a decreased workload, ability to travel to clients' homes and additional time to evaluate services and consultation with the LHVs.

According to the CNO Guidelines for Professional Behaviour, nurses who function in management positions need to provide a safe environment as well as sufficient resources to give safe, effective and ethical care. They are also to provide support and encouragement to their employees. There is a presumption in law, which is reflected in the CNO Guidelines for Professional Behaviour, that the employer, when hiring a professional, must ensure that professional meets his/her standards of practice. If the employer wants PHNs to teach, supervise and evaluate services provided by LHVs, that employer must accommodate the PHN by reducing workload and providing other resources.

If there are discrepancies between your professional nursing judgement and your employer, you must document your observations, assessments and concerns on the client's file. As well, complete ONA's Notification of Improper Work Assignment form to inform your employer of this unsafe situation. This will require an immediate response by your employer to rectify the situation and protect your client's well-being, as well as your own. By doing this, you will fulfill your legal obligations to inform your employer of unsafe client situations (CNO, Guidelines for Professional Behaviour).

Matching the health care needs and health status of the client with the skills and knowledge of the health care provider is essential (CNO, Safeguarding Care By Unregulated Health Care Providers, May 1995).

It is ONA's position that high-risk families are anything but predictable and, therefore, we recommend that all families who are assessed as high-risk receive care by a professional PHN. If your employer suggests that a LHV can perform routine activities of daily living, as a PHN you must determine if, in fact, these activities are routine and ask the following questions:

• Has the need for a specific procedure been identified?
• Has the frequency of performing the procedure been established?

   

• Does the person respond or react to the procedure in a consistently predictable way?
• Is the outcome of performing the procedure always the same?
• Is the specific procedure required indefinitely?

If you can answer "no" to any or all of the above, the procedure is most likely not a routine activity of daily living and, therefore, should not be assigned to an unregulated care provider - a LHV.

Ethically, a nurse must demonstrate a regard for client well-being by improving the level of health care in the community. This is accomplished by working with individuals, groups, other health professionals, and employers.

The Healthy Babies, Healthy Children Program involving LHVs presents a role conflict of new categories of staff. It could potentially take away the work of the bargaining unit - ONA members. This program should be constantly monitored to determine if it minimizes the professional work of PHNs. We can look to our counterparts in the hospital sector where unregulated workers, like LHVs, have been utilized with the resultant layoff of RNs.

To learn more about your professional and legal obligations, ONA offers the following workshops: CNO - Know Your Rights and Legal Issues for Nurses. If you have additional questions, contact ONA's Nursing Practice Department.