The stories of Mrs. Tindell, Mr. Smith, Mrs. Kay, and Mr. Dee that occur in a day in the life of Mrs. Jean Lowe may appear unreal or overly drastic; however, they are real—snapshots of the reality of home care nursing. The current trends in health care delivery that promote short hospital stays to reduce costs, merge health care organizations, and restrict information, set the stage for days in which providing home care is frustrating, fragmented, and wrought with multiple opportunities for adverse events. Although Jean was well educated and an experienced nurse, it was necessary for her to continuously compensate for problems resulting from lack of communication among health care personnel and insurance providers.
Jean had to troubleshoot many factors associated with the planning and implementation of patient care, often spending an inordinate amount of time coordinating efforts to obtain home equipment and facilitating communication between and among various health care providers, insurance companies, and paramedical groups. Jean had minimal information about the patients—only their name, diagnosis, and discharge date—prior to entering the home, yet she was responsible and accountable for providing comprehensive nursing care. Jean was familiar with the home environment; she had provided nursing care in the home as a home health aide for more than 3 years and she had the knowledge of a baccalaureate education. Although her intentions were to complete care for all her assigned patients, she was constantly delayed by spending more time per patient than she intended trying to deal with factors from dysfunctional health care services.
Jean was a victim of a complex assortment of health care services that lacks the infrastructure necessary to provide continuity of care for patients from the time they are hospitalized until they have recovered at home or have an established health care regimen for a chronic condition. Sooner or later, Jean could be held accountable and possibly sued because she was not able to reach a patient's home to provide care in a timely fashion. Family members of home health patients tend to be so distressed by the demands and frustrations of trying to provide adequate care that by the time a nurse reaches them, they are grateful for someone to help, so litigation cases against nurses in home health nursing remain low. What is most upsetting in the stories of Mrs. Tindell, Mr. Smith, Mrs. Kay, and Mr. Dee is the fact that Jean, a competent and caring home health nurse, will become burned out and eventually change to another type of nursing specialty or leave.
Of the 2.4 million nurses available to work in the United States, more than half of them change careers, enter new careers, or elect not to work (ANA, 1999). This is a sad commentary for a nation whose population is aging and whose need for home health care services is expanding. Jean has been a nurse for only 1 year; eventually she will become frustrated from her daily work as she encounters more and more problems with the health services. She may not encourage—indeed may even discourage—others who are considering entering the nurse workforce.
Nurses are aware of all aspects of health care because they are responsible for the 24-hour monitoring of patient care; no other health care professional is involved in solving the myriad of problems related to 24-hour care. Others are aware only of their aspect of health care and as such are not affected by the fragmentation of routine patient care activities. All too often, home care nurses leave the profession or change careers within nursing because they feel helpless in an archaic system. Jean continued working for the home health care agency immersed in the daily frustration of working among factors that thwart her best efforts to provide home health care—factors that contribute to, if not induce, error.
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