If this is your first time joining this series, I would encourage you to visit the page dedicated to this series so you can start from the beginning. Please click anywhere in this paragraph to get full context.

I have been blogging for over 12 years over multiple web sites and a variety of subjects. My blog posts have always been about what I am currently learning, or what I have learned. This has been my strategy over the years to keep my readers from feeling like I’m talking down to them or lecturing them. For this series, I have deviated from that practice. Some readers have continued to embrace what I am sharing, and some readers have expressed concerns. Concerns that I am being condescending.

All I have to offer is this; I truly want to see everyone succeed at this work. It’s my heart’s passion. I have never felt so committed to a profession in my 30 years of employment. I hope every reader who joins this series can understand that I am desperate to help you. I want you to stay in hospice and love it as much as I do. Please continue to read. Contact me if you need help. I’m here for you!

Today I will address the biggest question that I have been getting throughout this series. Today we will engage how to manage our day-to-day activities with the goal to help us be done every day by 5pm with next to nothing left to do.

I do need to add a disclaimer. This could be said for every post. Maybe when I draw this series to an end, I will update every post with this disclaimer.

I do a lot of education at my current company. I start every training explaining my 90% principle. I explain that this stuff works 90% of the time. This means that there is always outlier situations that don’t fit in this nice little package I have created. Don’t let the 10% keep you from experiencing the 90%.

Okay, let’s get started!

Plan our work. Work our plan.

I mentioned in my first post the importance of intentionality. Intentionality is being proactive. No more letting our day happen to us. Today, we will focus on how we can happen to our day.

1. New schedule every week

Our weekly visit schedule is like our financial budget. No two months are alike. Every month our finances look different. Our electric bill changes based on the seasons. Birthdays come and go. Back to school shows up, and it is time to get new clothes and supplies.

It is the same with our visit schedule. No two weeks should look the exact same.

I’m not saying to totally revamp our schedule every week. The problem is that it gets really tempting to just keep our schedule the exact same every week. When someone dies, we just plug a new patient into that open spot. We do it without even considering time and distance. We have a caseload full of patients that are very used to specific days and, sometimes, specific times of the day. Now we are dragging ourselves all over our service area trying to get it all done. When we take a day off, some other poor nurse has to try to fill in and they crash trying to get it all done. Don’t be afraid to reach out to a patient/PCG and tell them, “Hey, I have to move you to Tuesday/Friday due to caseload changes. There is no reason to have a 10hr day Monday and a 6hr day Tuesday.

2. Start early

Over the years I have worked with multiple nurses who didn’t get to their first visit till 9:30am-10:00am. When I would quiz them about their start times, I would generally get the same response.

“It takes me a while to set up my day.”

“Set up your day? What is that?”

”Calling the pharmacy. Replying to text messages. Putting in orders.”

We cannot start today with finishing yesterday. Yesterday’s work must be done before starting today. Charting, phone calls, refills and emails from yesterday should all be done. You should be at your first visit according to company work hours. Our work hours are 8:30am-5:00pm. This means my nurses should be at their first visit by 8:30am. Showing up at 9:30am or 10:00am is a recipe for disaster. The most successful hospice nurses are finishing their second visit at 10:00am. Not strolling into their first visit.

3. Plan our day

We should not spend our entire day being surprised.

“Wow, I can’t believe how long that visit took!”

If we find this happening to us on a routine basis, there is a problem. When our day has 5-6 visits we need to have a plan.

Here is some self talk I would encourage all of us to engage in before the day even starts.

”I’ll be at Jones by 8:00am. Charting should be done and I’ll be in my car at 8:45am. Travel to Smith will be 20 minutes so that visit will be 9:05am-10:45am. Then I’ll head to Bubba who is 30 minutes away. I’ll be there from 11:15am-12:00pm.”

Visits for the day are half done, and it’s noon. Okay, one of those visits took a little long and it’s 12:30pm. Okay, it’s 1:00pm. Still, we have 4 hours to finish the rest of our visits. If we follow number 6 below we are through the toughest part of the day.

If most of our visits take 1.5-2.0 hours there is a problem. We should not be in and out of crises all day. I will address super long visits in a future post.

4. Everything at the bedside

I addressed this a little in my second post. I’m going to expand on it today. Even with a full day, we have got to make sure to do everything for the patient while we are with them, or in the car, but mostly with them.

Call the doctor while with the patient.

Call the pharmacy while with the patient.

Call the equipment company while with the patient.

Enter new meds in the EMR while with the patient.

Enter new visit frequencies while with the patient.

Eat lunch while with the patient. Okay, don’t do that, but you get the point.

This makes a big difference. We are less likely to forget stuff when we do it all while with the patient. The patient and caregiver know it was done as well. This provides them with peace of mind. They are less likely to call after hours wondering if something got done. They saw it get done!

5. Embrace the tension

This happens to all of us. It has been happening to me for years. The tension I’m talking about is this urge in our gut to get done with the current visit and leave for the next visit. It’s especially strong when we are making a lot of changes for our patient. We have to enter the meds, generate orders and write new HHA care plans. I know doing all this while with the patient sounds impossible. It’s not impossible.

The tension and pressure we are feeling in your gut can help us if we embrace it. It will push us to become faster with our EMR.

I’m on my 5th EMR in 6.5 years. I have used Suncoast, HCHB, CPC, Netsmart and Healthcare First. I have trained myself to do everything at the bedside for all of them. I pushed past that tension with every EMR until I got super fast at clicking all the boxes and locking everything. Three weeks ago I did 27 visits and charted everything at the bedside.

The tension is a great instructor. Let it make you fast!

6. Start with our sickest patient

Every day needs to begin with our sickest patients at the stroke of 8:00am. Our sickest patients take the longest. Patients who are transitioning or actively dying really need us early. Nobody in the home is sleeping. They have been waiting all night for us to show up. Waiting till later in the day to see these patients is a recipe for making our day too long and pushing us past 5pm. It’s also rude.

The rest of our caseload and everyone’s visit times are inconsequential when we have patients in crisis. We have to contact everyone the day before and update them on the schedule change. Reasonable people understand when we explain one of our patients are in a crisis and needs us first.

Do the hardest work first. It’s the best thing, and it is what our patients deserve.

7. Don’t waste waiting

We actually do a lot of waiting in hospice.

We wait for medications to take affect.

We wait for the funeral home to arrive.

We wait for the doctor to call us back.

We wait for someone to pass while we are with them.

We should spend our waiting getting something done. Last year I took call on Christmas Eve. One of my patients died, and I did the death visit. I was there from 11pm to 2am waiting for the funeral home to arrive. I found a quiet corner and worked on everything I could think of. I got all my IDT/IDG notes done for the following week. I wrote out a couple recertification notes. I got a lot done.

While we are waiting with our patient, we should stay busy! Don’t waste waiting! Step out and make a phone call. We should open our device and do something. Do anything! Just don’t waste waiting!

In closing I need to address how organizations get in the way of their nurses trying to integrate all of the above.

How about the beloved morning “stand up” call at 8:30am? I hate these things, but many organizations require them. If your organization requires a stand up or stand down call every day, you are forced to work around it. You may have to see your first patient at 7:45am so you have one visit out of the way. I don’t love this idea, but I would rather start earlier than work later. Starting early doesn’t interfere with my family life like starting late does. If your organization is giving you 8 or more visits a day, and telling you to chart at home, I don’t see how you can do much of the above. You are in an impossible situation.

I have integrated several ideas into one post here. Embracing the tension is probably the biggest take away. Let the tension force you to become fast on your EMR. Being quick with your documentation is essential in hospice care.

Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.

You are reading part 3 of my series, “Avoiding Hospice Burnout.” If this is your first time reading this series, please visit my first post by clicking HERE. This will help you get a quick overview and the foundation for this series.

Since the title of this blog is “Confessions of a Hospice Nurse,” I thought I would start this week’s post by making a confession.

I have a hero complex. I really do. I want to save everyone. Not from a medical or spiritual standpoint. I just want to be everyone’s hero. Hospice can really feed this desire. I get to show up to someone’s house and be the hero. I’m the center of attention when I walk into the room. I sit down. Everyone gets quiet, and they wait to hear what I have to say. A lot of the time, I have undivided attention. Everyone hangs on everything I say. They want to know how long their loved one has to live. They want to know what medications fix their issues. For a few short minutes I have all the answers to all the problems. I can even predict when someone is going to die.

I am powerful.

Replace Yourself

Nurses are natural caregivers. Hospice nurses are a whole new level of caregivers. We walk in to some of the most demanding and challenging situations. We feel it is our duty to help bridge any and all challenges we encounter. We trained for this. This is what we do. We look for the problems, and our brains start running at break-neck speed to find the solutions.

The desire to have all the answers and solve all the problems is a major contributor to hospice burnout among nurses. It causes us to attempt to fix too many problems and stay longer than we should. We become the center point. We become the one with all the answers. The home becomes dependent. They want our number. They want to call and text us after hours. They need us.

My first six months as a case manager in hospice were overwhelming. I felt responsible for everything that happened in the home when I was there and when I was not there. I felt responsible to be available around the clock as a resource to my families and patients. After all, I’m the hospice nurse. I know stuff!

Eventually I realized something. I am not the hero in everyone else’s story. That is not what hospice nursing is all about. Hospice is supplemental care. It is our job to empower our caregivers to be the hero in their own story. They are caring for someone who, at one point, probably cared for them. I have sat with more than one daughter, wife, husband and son, looked them in the eyes, and said, “You can do this. I believe in you.”

How do we achieve this in practice? Let me provide you with some solutions.

1. Never be critical of your caregiver. Nurses are critical thinkers by nature. Many caregivers are emotionally fragile. It’s a natural condition when caring for someone who is dying. We do this work all day long. This is usually their first time. If they have cared for someone at end of life before, it was probably a lot different, because no two deaths are alike. Even if your caregiver did make a big mistake, don’t focus on the mistake or be dramatic about it. Watch your facial expressions and your posture. It can send the wrong message.
2. Reinforce good behavior. Be sure to focus on all the great things your caregivers are doing. Even if they are struggling in many areas, point out how well they are doing in other areas. It’s okay to lie a little. They are doing the best they can given the situation. Remember, we are there for a few minutes a couple times a week. Our caregivers live this every day. They are tired and stressed. They need to know that they are awesome!
3. Turn off your work phone after hours. This is absolutely huge! We do not want our caregivers to become dependent on us. They should see us as part of a larger entity. They should believe that any nurse within our organization is capable of meeting their needs. They should expect and know to call “the main number” any time they have needs outside of regular business hours. Even if you use your own phone, do not reply after hours. I know it’s hard, but this is a must.

A few years ago I met the most amazing caregiver. He was adopted, and he never knew his birth father. One day he decided to try and find his dad. This amazing man learned his dad was living several states away, and he was homeless. He was able to get in touch with him, and he discovered his dad had terminal cancer. He had his dad transported back here to Kansas City to be his caregiver while on hospice. I cried at every visit because it was so beautiful. He cared for his father until he died.

Now that is a hero.

Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.

You are reading part 2 of my series, “Avoiding Hospice Burnout.” If this is your first time reading this series, please visit my first post by clicking HERE. This will help you get a quick overview and the foundation for this series.

Today, we will be discussing what is the single biggest thing that causes burnout in hospice. Many readers are coming here from the Hospice Nursing Support Group on Facebook. This series was motivated in large part by many posts from that group. There is not a day that goes by where this is lamented. Today, we will address this directly. Hold on to your nursing cap, this is gonna get real!

Chart at the bedside

Okay, I can hear the moaning from the back row. I considered saving this for the very last post. I’m worried about how many readers I will lose after just my second article in the series. For some inexplicable reason, this concept gets mountains of pushback. Why would someone want to intentionally wait till the end of the day to do all their charting? Do you hate yourself? Do you feel like you don’t deserve a personal life?

Maybe we can call it “field charting.” This seems to help it land a little softer to some people. This concept encourages charting to be done before showing up to your next visit. This means you chart in the driveway or around the corner. I still don’t like it, because it results in less time with your patient.

Let’s take a few minutes to debunk a few of the reasons I hear for not charting at the bedside.

1. “It’s rude to open my computer in front of my patients.” In my six years in hospice, I have been asked to not open my computer less than 5 times. Computers are a part of medicine now. They have been for 25 years now. I saw a cardiologist a few weeks ago. He had his computer out the whole time. Join the new millennium. Everyone else has.
2. “I don’t have the time to chart during the day.” This is the least believable of all the reasons. What takes you 10-20 minutes while you are with the patient will take you 30-45 minutes at home. Home can be a full-time job for many of us. Husbands, wives, kids, friends and responsibilities pull at us the second we walk into the house. Home is absolutely the worst place to do your documentation. Many nurses end up in bed and chart from 9pm-11pm every night. What a disservice to your patients! What a disservice to your family. What a disservice to yourself!
3. “This system is way too hard to use.” In my hospice career I have used 5 different EMRs. I have been able to successfully chart at the bedside with every single one of them including HCHB. This can be done on any system.

You’re here for help, and I want to help you. Let’s start by just being honest. In fact, you don’t have to even be honest with me. You don’t have to tell me the truth. You can lie to me all day long. Will you stop lying to yourself?

I have been in leadership for the last 4 years. I have ridden with many nurses, and I have watched them work up close. I have come to a simple conclusion. Nurses don’t chart at the bedside because they just don’t want to chart. There, I said it.

This honesty is your first step in overcoming this hurtle in your hospice career. Say it with me right now, will you? Are you ready?

“I’m not charting at the bedside because I just don’t want to chart.”

Look, I get it. None of us went to nursing school for the charting. None of us love it. Well, the crazy compliance nurses love it, but they are a different breed. Charting is a part of what we do, and hating it hasn’t got you very far, so it’s time to do something different.

Okay, now that we have that taken care of, let’s start anew. Remember when we talked about intentionality? This is where the work gets real. You have to become determined to be successful at this. You have to decide right now that you will make this a priority. If you want to avoid burnout, you have to start right here with charting at the bedside. This is step one.

Over the next few articles, I will address several ways to become successful at charting at the bedside. For now, I will leave you with one strategy that helps to address the first fear from above.

Many nurses when starting to chart at the bedside make the mistake of opening their computer the minute they walk into the home. They think to themselves, “I better get going on this right now, or I’ll never get good at charting with my patient.”

Don’t do this! Take the first 10-15 minutes of the visit to sit with your patient and their caregiver. Give them that undivided attention that we know they crave. It’s one of the reasons we got into this work. You will complete your assessment during this time. During conversation you will notice if they have a chronic cough or how short of air they get when talking. At some point, the conversation will become more technical. Use this moment as a reason to dig out your device and get started. If you have been using your system for any amount of time, you should be able to document a comprehensive assessment in 20 minutes and a focused assessment in 10 minutes.

As promised in my first article, here is how to identify if your organization is getting in the way. If your caseload is so large you have more than 6 visits in a day, your organization is in the way. If you have been trained to click and type in every single box for every assessment, your organization is in the way. Your comprehensive assessment should take 20 minutes and your focused assessment should take 10 minutes. Visits should last 40-50 minutes on average.

Feel free to comment and engage in conversation below in the comments. This is a robust concept, and it can’t be resolved with a single post. It takes time, effort and intentionality!

Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.

I have been in hospice a little over 6 years. I have held just about every position an RN can have. I started in case management, but I have also been an admissions nurse and have performed hundreds of admissions. I have hundreds of hours on-call both evenings and weekends. I have several years of clinical director experience and have held the position of administrator. I am currently a clinical team leader in the Kansas City area.

I have witnessed many great nurses burn out and give up on this work. In this series, I hope to present many ways in which this can be avoided. Today, I will start with the most basic skill needed to avoid suffering from burnout.

Be Intentional

For this series, I (currently) have 12 different things we can do to help protect ourselves from burnout. They all require intentionality. Each of these items require more than just a desire to not be burned out. None of us magically survived nursing school. We had to be intentional every single day. We got up at a specific time. We knew our schedules, and we took them seriously. In the same way, we won’t magically avoid burn out.

I tell my nurses, “Your day doesn’t happen to you. You happen to your day.” Yes, there will be surprises, but we can’t be surprised all day long. Much of our day is predictable. We shouldn’t be spending most of our day saying to ourselves, “Wow, I never thought that could happen.”

Abraham Lincoln once said, “You can have anything you want, if you want it badly enough.” I’ll ask you now, “How badly do you want this? How badly do you want to stay with hospice? How badly do you want to avoid burnout? Your level of intentionality is the answer to this question. How purposeful you are willing to be is how successful you will be.

The concept of intentionality will be woven into every article I write on this subject. It is the foundation required to pull this off. Many of these concepts may seem impossible or at least too difficult to really pull off. They may be foreign to you, or something you have been told to do many times, and you have not been able to do them. If you are someone who naturally focuses on how something can’t be done, none of this will be of benefit to you. If you are willing to push yourself beyond where you are now, you can do this.

There are two kinds of burnout in hospice. There is work burnout and organizational burnout. You can love your company, but be exhausted with hospice. Your days are crazy. You can’t get your charting done. Your patients are high acuity. Your caseload is too high. You do love the company you work for, they treat you well and you like your leadership.

How will you be able to tell the difference? As you work your way through all of my posts, you should be able to identify whether it is your company or your bad habits causing the burnout. For an example; If I’m talking about time management, and you are trying to carry a caseload of 25 patients, it’s pretty clear that you are suffering from organizational burnout. They have put you in a place where failure is the only likely result. Even if you have an LPN/LVN at your side, this is a no-win scenario. I will try to address this with each article. I’ll help you decide if the problem is the company or your habits.

In closing, these articles are time tested. I was trained this way when I started working in hospice. These concepts have helped me avoid burnout. Right now, hospice is as challenging for me as it has ever been. I’m as busy as I have ever been, but I’m also as happy as I’ve ever been.

Will you take this journey of discovery with me? Will you allow me to invest in you? Are you willing to wipe the slate clean and engage these articles with a new sense of wonder for this work? It is so important for you to stay in hospice. Your patients and their families need you. The hospice community needs you. Your neighbors, friends and city need you. You can do it, and I want to help you get there.

Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.