How Community Nursing at Home Has Helped Mary*

How is it possible to give a family member the highly specialised medical care they require, when they need it? And when that loved one still has a passion for being an active part of their community – what is the alternative to a nursing home?

Mary is proof that specialised medical care can go hand in hand with family life and social involvement: We chatted with Advanced Community Care Nurse Helen* about service user Mary* and her journey with us…

Q. Set the scene for us, Helen – what brought Mary to the point where she met Resilience?
A. My Nurse Manager had first met Mary when her family were looking for care options and they got in touch with Resilience. Mary had been in hospital for quite a long time with respiratory complications. She had what we call Complex Care needs because she needed Continuous Positive Airway Pressure (CPAP) ventilation at night and through the day too.

I first met Mary with my Nurse Manager at a visit to the hospital. I introduced myself and spent some time chatting to Mary, explaining I would be her Nurse, providing care when she was discharged home. I also met members of her family.

Q. What was the family’s concern?
A. Mary didn’t want to move to a nursing home. She wanted to get home, to be with her husband and the things she loved. She was very independent and had led a busy life. She loved meeting up with friends for bingo and getting out with local walking groups. I could see that Mary was very much a ‘people person’. Her family knew she needed high-level care, but they didn’t want to see her give up the things she loved. She was still full of life.

Q. So, what was the first step?
A. Resilience through our Advanced Community Care division was the perfect fit for Mary – providing specialised nursing care at home. We had many family discussions and did several comprehensive assessments – then developed a Care Plan based on what Mary needed medically, and to suit her lifestyle. I would be part of her Adult nursing team, visiting her each day in her home. Mary is a private patient, so the plan was developed independently of the HSE.

Q. What was important in putting the plan together?
A. Obviously a really big thing was to make sure that the nursing team going into Mary’s home would be a good fit for her and her family. So, I spent a lot of time speaking with the family, understanding their daily way of life, and how I could work with and around this. I had to bear in mind too that it’s not easy for a family to suddenly have ‘staff’ coming into their home – so I spent a lot of time looking at how I could respect boundaries and family privacy.

Q. What practical requirements had to be considered for Mary’s care?
A. Mary’s family adapted their home and living space, to suit her. Stairs were a problem, so Mary moved to a downstairs bedroom. This level of complex support demands absolute quality care – and we worked hard to ensure Mary’s move from in-hospital care to at-home nursing was safe and that it met all requirements. As Mary’s Nurse, I was overseen by my experienced Nurse Manager who was always there to support and provide advice if I needed it. We also regularly updated Mary’s Care Plan to make sure we maintained the highest level of support.

Q. So, what was the result?
A. It was just amazing to see the positive outcome for Mary – and the feeling of bringing her back home to the life that really meant so much to her. She picked up her interests where she’d left off – enjoying her hobbies and passions and, above all, being with her friends and family. It also made a world of difference to Mary’s family’s peace of mind: they knew she knew she was happy doing the things she loved while her medical needs were being met.

Q. Were there any bumps along the road?
A. There are challenges of course – but I’ve learned to always focus on finding the solution. At the start, Mary wasn’t sure about accepting help at home – so I needed to be sensitive and compassionate. From the beginning, the team and I built a good therapeutic relationship with Mary. Making sure she always has the same, regular staff supporting her has also helped relieve Mary’s anxiety about having strangers in her home.

Mary is one example of how community nursing at home can strike the balance between the highest level of complex care and quality of life. It’s about the right care, by the right people, in the right place. You can find out more information on the benefits we bring, here.

*The names of the individuals concerned have been changed to protect their privacy.