Guidelines

International Guidelines for Home Health Nursing

The International Guidelines for Home Health Nursing Practice are guiding principles for nurses who aspire to provide excellent care to patients in their homes. Developed by home health nurses for home health nurses, their purpose is to provide guidance to nurses around the globe who seek to develop their professional home healthcare practice and performance.

Although home health care is different in various countries (subject to differing resources, regulations and cultural expectations), these guidelines outline steps professional home health nurses can take to provide the best care possible to home health patients. They are based on evidence and consensus about the elements of excellent home health nursing practice and performance. This document is not meant as “standards” that must be met, but as goals nurses seek in their pursuit of excellence in home health nursing.

Home health nurses everywhere are encouraged to use and comment upon these guidelines. Updates are anticipated based on developments in practice and comments from nurses about the needs in their countries. Contact us for questions, concerns or recommendations for future updates.

  • Standard 1: Assessment

    Guideline

    The home health nurse performs a comprehensive assessment of the patient, collecting data that affects the patient’s health and well-being.

    Interpretative Statements

    Home health nurses are frequently the sole health care provider in the patient’s home. Patients in home care are dependent on nurses to identify all the factors that could affect their health outcomes/goals. Nurses must assess the patient’s health status and needs holistically using a systematic and ongoing process.

    Depending on the patient’s unique situation, this comprehensive assessment may include physical, functional, nutritional, psychosocial, emotional, behavioral, cognitive, sexual, and spiritual assessments. The nurse may also need to evaluate the patient’s medication plan, learning needs, cultural preferences, caregiver needs, financial needs, home environment and community resources that may affect the care plan.

  • Standard 2: Diagnosis

    Guideline

    The home health nurse analyzes the assessment data to determine the patient’s problems and needs.

    Interpretative Statements

    The patient’s home health problems and needs are based on the patient’s medical diagnoses and other factors identified during the assessment that could affect the patient’s health and well-being. (Examples of other factors include insufficient funds for medications and symptoms that are bothersome to the patient, such as trouble sleeping.) The nurse develops a list of problems and needs, which are sometimes identified as “actual or potential problems” or “nursing diagnoses.”

  • Standard 3: Goal Identification

    Guideline

    The home health nurse identifies desired care goals individualized to the patient.

    Interpretative Statements

    Once problems and needs are identified, the nurse discusses them with the patient, family, and other caregivers. Together, they should determine goals that honor the patient’s desires, priorities and preferences. (Goals are also known as “expected outcomes.”) Each goal should be SMART (specific, measurable, achievable, relevant and time-defined).

  • Standard 4: Planning

    Guideline

    The home health nurse develops a plan that prescribes strategies and interventions to attain the desired goals.

    Interpretative Statements

    Knowing the patient’s current status and health goals, the nurse identifies best-practice and evidence-based interventions that will help the patient attain the desired goals. This plan should be developed in collaboration with the patient, and others as indicated, such as the patient’s physician/healthcare provider and family/caregivers.

    The nurse may plan for other interdisciplinary or community services, if they are available and affordable, such as social workers, rehabilitation therapists, dietitians, pastoral counselors or social service/government programs. Strategies may include ongoing assessments, teaching interventions, administering medications and treatments, coordinating care and transitions of care, and other interventions.

  • Standard 5: Implementation

    Guideline

    The home health nurse implements the individualized patient plan of care.

    Interpretative Statements

    While implementing the plan, the nurse demonstrates kind and caring behaviors, facilitates patient engagement and self- management, promotes patient safety (e.g. implementing infection control principles) and works collaboratively with physicians/healthcare providers and the interdisciplinary team. The nurse prioritizes the strategies implemented per the patient’s needs and preferences and delivers care in a safe, efficient and effective manner.

  • Standard 6: Evaluation

    Guideline

    The home health nurse evaluates the patient’s progress toward the desired goals.

    Interpretative Statements

    In consultation with the patient and the interdisciplinary team, the nurse provides ongoing evaluation of the patient’s progress towards the goals and expected outcomes.

    Evaluation requires re-assessment and if the plan is not working, the nurse needs to revise the plan with new strategies that are more likely to be effective. Once the patient’s home health goals for care are achieved, the nurse facilitates an effective transition of care for management after discharge.

  • Standard 7: Ethics

    Guideline

    The home health nurse practices ethically.

    Interpretative Statements

    Nurses must value and protect each patient’s inherent dignity and rights to self-determination, privacy and confidentiality. Nurses provide compassionate caring, characterized by keeping patient interests paramount, forming therapeutic relationships, adapting care to meet patient’s needs and preferences, and maintaining professional boundaries. Nurses must be honest, enabling patients and others to trust what they say and document. They must advocate for the patient and the patient’s rights and priorities, especially when they are threatened. Nurses must adhere to professional and governmental practice regulations.

  • Standard 8: Education

    Guideline

    The home health nurse seeks the knowledge and skills needed for providing excellent care to patients in their homes.

    Interpretative Statements

    Home health nursing is a specialized area of nursing practice, requiring specialized knowledge and skills beyond basic/generic nursing knowledge and skills. Although the agencies that employ home health nurses have an obligation to provide education that promotes effective home health nursing care, nurses must be committed to lifelong and self-initiated learning. Thus, home health nurses need to determine their educational needs and seek formal and informal opportunities to develop their knowledge and skills so they can provide excellent home health nursing services.

    Additional knowledge and skills may be needed in patient/ community assessment, teaching to promote patient/family self-management, effective use of technology, case management, care coordination, advances in care practices based on new research and leadership skills, among others. Opportunities for education may be provided by orientation programs, inservices, preceptors, professional journals and books, consultations, or formal college/university educational programs.

  • Standard 9: Evidence-Based Practice/Research

    Guideline

    The home health nurse integrates evidence and research findings into practice.

    Interpretative Statements

    Nursing care is grounded in science, evidence and research to the extent possible. Nurses have the obligation of staying up-to-date with the latest evidence and guidelines that enhance the services that nurses to provide to home health patients. Home health agencies and government programs should support the dissemination of research and evidence-based guidelines to the nurses who provide home care.

  • Standard 10: Quality of Practice

    Guideline

    The home health nurse contributes to quality nursing practice.

    Interpretative Statements

    Home health nurses must be committed to providing quality nursing services. Quality care is safe, effective, equitable, patient-centered, cost-efficient, and timely.

    Home health nurses should help develop and implement policies and procedures that promote quality care. For instance, to promote safe care, home health nurses can develop and implement infection prevention policies that protect patients from infections through rigorous infection control procedures. To promote effective care, nurses might advocate for electronic health records that facilitate the nursing process, standardized terminologies, and communication across settings. Home health nurses can advocate for and participate in continuous quality improvement programs.

  • Standard 11: Communication

    Guideline

    The home health nurse communicates effectively.

    Interpretative Statements

    Home health nurses communicate effectively with patients, families, caregivers, physicians, interprofessional care team members, and others as needed to promote effective patient care. They communicate effectively orally, in writing or electronically, while always protecting patient privacy and confidentiality.

    Effective communication skills are crucial to patient assessment, teaching, case management, care coordination and documentation. To promote good communication with patients, nurses assess patients’ language and health literacy, adapting care plans to promote effective communication and patient teaching.

  • Standard 12: Leadership

    Guideline

    The home health nurse demonstrates leadership.

    Interpretative Statements

    The nurse’s leadership responsibilities are intrinsic to the nurse’s professional responsibilities. The home health nurse leads by example, such as when the nurse collaborates, solves problems, manages conflicts, promotes quality care, advocates for the patient and in many other ways. Nurses lead whenever they manage care, develop care plans or supervise non-professional/non-licensed care providers.

  • Standard 13: Collaboration

    Guideline

    The home health nurse collaborates with the patient’s physician/ healthcare provider, other healthcare team members and with the patient/ family/caregivers.

    Interpretative Statements

    Collaboration is grounded in cooperative communication that recognizes the unique and important perspective everyone involved in a patient’s care brings to achieving the best outcomes for the patient. Nurses see all professionals and paraprofessionals caring for a patient as crucial members of the patient’s team.

    Nurses work collaboratively with patients by discovering, respecting, honoring and facilitating their patients’ values and goals. They work collaboratively with physicians/healthcare providers to provide patient-centered care by voicing their unique perspective about the patient’s status, goals, barriers/facilitators to care, and the care plan interventions that they believe will best help the patient achieve the desired health and well-being outcomes.

    Nurses also collaborate with families, caregivers, other team members, payers and anyone else involved with the patient’s care through cooperative communication, characterized by courtesy, respect for alternative perspectives, and mutual problem-solving strategies.

  • Standard 14: Professional Practice Evaluation

    Guideline

    The home health nurse evaluates one’s own practice in relation to standards, guidelines, statutes and regulations.

    Interpretative Statements

    One of the hallmarks of a profession is that professionals determine the scope, standards and guidelines under which they practice. Thus, home health nurses are responsible for their own practice and may need to actively advocate for public policy changes that allow home health nurses to exercise their professionalism. Home health nurses are accountable to their professional practice standards, such as the guidelines identified in this document, or other documents they choose to guide their practice.

    Home health nurses are also accountable to any governmental statutes or regulations that govern their practice. Patients, peers and professional colleagues should participate in evaluating the nurse’s practice. When nurses find they are not meeting their professional standards or other regulations, nurses have the responsibility to resolve the deficit.

  • Standard 15: Resource Utilization

    Guideline

    The home health nurse uses resources to plan and provide safe, effective and financially responsible nursing services.

    Interpretative Statements

    In developing their patient care plans, nurses need to be fiscally responsible. The nurse needs to balance the resources allotted to the patient’s care with the resources (including financial resources) available to provide the care. The nurse focuses on the right care, at the right time, with the right provider, in the right place, at the right cost. The goal is the most safe and effective care for the least cost.

  • Standard 16: Environmental Health

    Guideline

    The home health nurse practices in an environmentally safe and healthy manner.

    Interpretative Statements

    The waste products of healthcare in the home – needles, syringes, drugs, medications, supplies contaminated with blood and bodily fluids, and other medical/plastic waste products – can pose infection and contamination risks to people and the environment. New technologies and research are needed to determine better ways to protect the environment we all share.

    In the meantime, the best way to dispose of these products varies depending on the geographic locale and the resources available for disposing of medical wastes. Home health nurses must adhere to any local regulations that govern medical waste disposal, while determining environmentally-friendly ways, that pose the least risk of spreading infection or causing harm, for their disposal.

  • Standard 17: Cultural Competence

    Guideline

    The home health nurse practices in a manner that is congruent with cultural and inclusion principles.

    Interpretative Statements

    Home health nurses treat all people equitably, regardless of race, ethnicity, religion, socioeconomic status, sexual orientation, gender identification or any other diversity issue that tends to marginalize people. They provide compassionate care to all people, assessing their cultural/religious/other diversity needs and preferences so they can adapt care to meet their patients’ diverse beliefs, values and practice.


Adapted with publisher’s permission from American Nurses Association (2014). Home Health Nursing: Scope and Standards of Practice