Although the Federal government originally predicted the nursing shortage wouldn't start until 2007, it's now clear that shortage is already here- and it's going to get worse before getting better. The National Sample Survey of RNs 2002 indicates in 2000 6.5% of all full-time RNs worked in home health. Predictions are that by 2020 8.9% of all full-time working nurses will be employed in our special setting.

I'm having trouble filling today's visits and client orders.

Where am I going to find additional nurses?

In rushing to create adequate home care professionals I want to be sure we don't lose sight of what it takes to be a productive home health nurse. We don't do just hospital nursing in the home, but home care is a career choice that requires a specialized body of knowledge and caring about the patients we serve.

Home care is a specialty practice certified by the American Nurses Credentialing Center; however, this nursing specialty doesn't suit everyone. The best nurses can juggle patient care, documentation, reimbursement, and independent practice, and are extremely flexible. They have been nurtured through the learning process so they don't bolt in the beginning when everything feels overwhelming. The ones who don't make it either don't have a natural home health instinct or were hired on a Tuesday, received a skimpy orientation on Wednesday (asked to review the admission packet), and were seeing patients on Thursday.

I can't just give them the comfort level they need to be a generalist in a patient's home. It takes courage and confidence to provide patient care in an environment where there's no next shift to spot what was missed or physician reading your notes looking for significant symptoms.

Home care nurses must be good at diagnosing, documenting, communicating, and be highly organized. Understanding the myriad of governmental and organizational paperwork required before the care is officially "done" is critically important. None of this can be accomplished simply by nurturing. I may be able to turn a poor home care nurse into a fair one, but I cannot turn this person into a consistently good nurse. Nurses who come to home care should be consistently good from the start, because from there some of them will become great.

But is it nature or nurture that makes a nurse start at "good"?

I think I can start with nature by taking the time and energy to pick the right nurse. That means that during the interview process I ask probing questions to weed out those nurses who, by their nature, are not suited to the autonomy, organization skills, and critical thinking needed for the diverse patient load they will be expected to manage.

After choosing nurses for these characteristics I can continue mentoring them by nurturing them. I can make more time and energy to provide the best possible orientation. Then invest in them by providing ongoing education and opportunities to have open dialogues on the processes that affect their work. This is the only way to solve the recruitment and retention problem in the long-term.

What I don't want to do is be so desperate to get a nurse seeing patients that I forget what I've learned from over 20 years in home care. I know what a poorly trained, ill-suited to home health nurse can do- and none of us wants that.

The best nurses have been nurtured through the learning process so they don't bolt in the beginning when everything feels overwhelming.

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