What does it mean when a preacher says, “In closing?”
Absolutely nothing!
What does it mean when a blogger says, “In closing?”
About the same!
In Closing
What I originally thought would be 12-15 articles appears to be 10 articles. Many of my ideas have been combined in more than one article. It has played out well, and it has generated some quality conversations both public and private. I appreciate everyone who has take then time to follow this series to its end. I especially appreciate all the feedback I have received. Some of it has been negative, and some of it has been positive. I welcome both responses when given politely, which is what I feel has happened in most cases. I have learned a lot just writing this series. I hope you have as well.
Today, I want to finish this series with a couple straggling thoughts. Just some simple observations that I feel will bookend this series, but don’t really warrant additional articles.
1. Help each other
I had not even considered this as a subject until yesterday. I had just spent the previous 10 days on a much needed vacation. I have spent most of the last year carrying a caseload and training new nurses. We intentionally go overboard when training new staff. Most new nurses with us get 2-4 weeks of in-the-field training with me.
Well, I had completely forgotten one of my nurses had vacation starting this Wednesday through next Wednesday. She called to let me know that she had already reach out to her follow case managers for help. All of her visits were already covered. My role calls for me to pick up the slack, and she only needs me to make 2 visits while she’s out. All of her teammates had already picked up the needed visits.
Not all nurses have this kind of support. I have worked with more than one nurse who just wanted to get done with their day and head home. There was no interest in checking with their coworkers to see if they need help. This is the most impressive group of nurses I have ever worked with. A couple of them are very new to hospice, and yet they are still reaching out to me on slow days to see who they can help.
They have developed a culture that says, “Why should I go home at 2pm when I have a teammate who may not get done till late tonight. They reach out to each other to see what help they can provide. What a healthy culture to be a part of!
If you are struggling to get help, I would recommend you find another nurse in your organization who is willing to team up with you and be your backup. Maybe the two of you can be the change in your company you want to see. Others will follow your lead. I promise. I have watched it happen here in my own company.
2. The 90/10 rule
This is something I really should have shared at the beginning of this series. I have two classes I teach at my current place of employment. At some point in each one I share this rule.
I believe that the content of this series can be executed successfully at least 90 percent of the time. There will always be the unplanned and unexpected 10 percent. Those who see the world of hospice as 100 percent one way or the other are doomed to struggle. This includes your humble servant, James. I have to remember that my material doesn’t work 100 percent of the time for 100 percent of nurses.
It’s also not the 10/90 rule that says all this material can only be done 10 percent of the time. If you want to argue 80/20 with me, I can entertain that. What is most important is our ability to examine our own ideas objectively. If you want to fiercely object to something in these articles, then I have achieved my goal. I have got you to think it all over. That’s progress! That’s good for you and me!
So, before just rejecting any of this series, ask yourself if what I suggest can be done at least 80-90 percent of the time. Maybe it will help you! Why not try it?
Most of what I teach is based on my own experience. By its very nature this means that I am biased. All of these articles can really be boiled down to just my opinion. It’s not like there is some kind of comprehensive hospice nurse textbook that a reader can just pull out to verify my claims.
What I do know is what I have done to survive six-and-a-half years of hospice working for (an embarrassing) 5 companies. I have just now found my forever hospice home. I’ve never been so happy to do this work as I am right here and right now.
Have you found your forever hospice home?
Are you with a company that you love, but it just seems impossible to get everything done and still have a personal life? Are you willing to get out a calendar right now, look forward 6 months and place an “X” on that date. Are you willing to say to yourself, “For the next six months, starting tomorrow, I’m going to put my full effort into this entire series. I’m not going to pressure myself to do it all at 100 percent. I’m going to shoot for 90 percent and see what happens.”
I think you will find this series has the potential to completely change your level of success in the specialty of hospice nursing. You wouldn’t even be reading this series if you didn’t hold out some amount of hope that you can be successful at hospice without constant fatigue and stress.
Don’t let your current habits or situation be the end of your hospice career. Try something completely different, and maybe this can be a new beginning for you. You can avoid hospice burnout, and this series can help you get there.
I have spent more time contemplating this article than all the others in this series combined. I have even considered skipping this section of the series completely. After much thought, I have decided to include this subject before closing the series.
If you feel like you are in the throws of hospice burnout, then this article may be more pertinent to you than any of the others in this series.
Is it time for you to leave hospice?
I don’t desire for anyone to leave hospice. This specialty is absolutely desperate for high-quality nurses. It’s hard work. Maybe the hardest in all of medicine. I haven’t worked them all, but I have experienced enough other specialties to see the unique challenges that come with caring for the dying.
My first job out of nursing school included some ER work. I really expected to love it. I thought I would enjoy the action and adventure I heard so many nurses rave about. One evening we had someone come in who attempted to complete suicide. He had cut his arms from elbow to wrist with a blade. he didn’t even come close to death, but he had long cuts on both of his arms that needed to be sewed up. I stood by his bed as I watched one of the ER physicians repair his wounds. I got light headed and almost passed out. I learned real quickly that any type of nursing that involved sutures and stitching was not going to be for me. It made me nauseous. Over the years I found other areas of nursing that were a better fit. Ultimately I landed here in hospice care.
Below I have come up with a series of questions you should ask yourself in determining if you should continue with hospice as a profession, and find a better fit for yourself.
1. Am I waiting for hospice to become easier?
Waiting for hospice work to get easier is an exercise in futility. Difficult patients, family members and caregivers are all a part of hospice work. If I wake up each day asking myself, “Maybe today will be much easier,” my expectations are unrealistic. There is always a challenging situation awaiting our intervention. There will always be difficult symptoms to manage. There will always be patients who either challenge our ability to remain calm or become almost like family and leave a hole in our lives when they die.
If the only reason you are still working in hospice is anticipation of this work getting easier, it may be time to change specialty.
2. Am I unwilling to work an 8 hour day?
This work cannot generally be done working less than a full day. We need to be willing to arrive at our first visit by start of day and leave our last visit at end of day. Business hours vary among organizations. They tend to be 8.5 hours and start at 8:00am and end at 4:30pm. Not every work day needs to be this strict, but if we develop a routine that has us showing up to our first visit at 9am or 10am and trying to end our day by 3pm we are setting ourselves up for frustration.
No other area of nursing allows its staff to just wander in and out whenever they feel like it. Just because we can start our day late and leave early doesn’t mean we should. This is a recipe for lots of working from home. What takes you 10 minutes out in the field will take you 30 minutes at home.
If you are unwilling or unable to get out of your home timely, it might be time to change specialty.
3. Do I struggle with autonomy?
The autonomy that comes with hospice nursing may be one of the biggest reasons it draws in staff. It may be the same way with home health. It’s nice to be able to swing by the grocery store in the middle of the day and grab something for dinner. You can stop in and have lunch with your kindergartener as well.
The difficult side of autonomy is that there isn’t someone in the back seat of your car reminding you of the work you still need to get done for the day. A quick stop at a big box store can turn into an hour or two of the day lost real quick. Nobody is calling at you from the garage reminding you to get out the door by 7:30am so you can be to your first patient by 8am. You only have the still small voice in your head, and we are all great at shutting that voice down.
There is very little direct supervision in hospice. Many hours of the day can be lost or mismanaged easily resulting in a lot of work that goes unfinished. Management is plenty busy getting their work done. They aren’t calling all day long to make sure patients are being seen timely.
If you struggle with managing all the time away from supervision, it might be time to change specialty.
4. Am I unwilling to turn off my work phone?
When we are off work, we need to turn off our work phone. Leaving our work phone on is a recipe for constant reminders of the work we do. As many times as we remind our patients and caregivers that we don’t work after hours, they still cannot resist the temptation to send us notes or trying to call during our off hours. We end up answering those calls and messages, and we end up trading in our personal time by working for free. We have on-call services for a reason. The only way we can get our patients and caregivers to become dependent on the whole team, is to be sure we cannot be reached after hours.
If you struggle with the “not knowing” part of being a hospice nurse, it might be time to change specialty.
5. Am I unwilling to learn to chart at the bedside?
Cal it what you want. The general idea is your charting for patient A is done before you see patient B. All my charting happens while I am with my patients. Nobody calls me rude or says anything about it.
I addressed this issue in depth during Part 2 of this series. If you have been reading this series as I have been releasing each article, you should be making progress in this area. If you continue to do a lot of charting at home in the evenings, I highly encourage you to read Part 2 again and get working on this.
There is absolutely no reason for you to spend your evenings charting. No reason at all. None. Zero. Zilch.
Don’t chart at home. Ever. Have I been clear?
If you have decided charting at the bedside is not appropriate or impossible, it might be time to change specialty.
6. Do I have to always be right?
Our medical brains are full of very useful information. The unfortunate reality is that not all patients and caregivers want to access that information. Many of them have their own thoughts and ideas on what is best medically. As frustrating as it is to see them choose WebMD over hospice best practice, we have to be willing to accept that not all of our advice will be implemented.
When we push and push we just find ourselves in constant conflict with patients and their caregivers. We cause ourselves and our clients undue and unneeded stress and anxiety. We go home frustrated because we feel unsuccessful from the day. That one difficult patient wears on our mind. We spend countless hours away from work trying to figure out how to convince them to start or stop certain behaviors.
If you just can’t handle watching others make bad decisions, it might be time to change specialty.
7. Do I have to fix every problem?
In general, hospice professionals operate in very imperfect environments. Our patients are dehydrated and malnourished. Often they are bed bound, or they have severe dementia. They have wounds, shortness of air and pain. There can be fighting among family members in our very presence. Sometimes everyone wants our help with these problems, and sometimes they just want to handle it all themselves.
We are in homes with bugs, cigarette smoke so thick you can hardly see and spoiled trash in the corners. At times it can overwhelm the mind and the senses. The patient or family may point out just one problem that is important to them. We look around and see ten problems that need to be solved. Maybe the one problem they want fixed is something that cannot be fixed. Now we are struggling with helping the family come to terms with the dramatic changes they see in the one they love more than anything on this earth.
We have to come to terms with the realization that we can’t fix everything. This is end of life care. Our patients’ bodies and minds are failing them.
If you find yourself having really long visits and getting caught up in family drama, it mightI be time to change specialty.
Organizations do contribute to burnout. I have mentioned it a few times during this series. Generally speaking, I believe organizations play a small part in hospice burnout. Much of what causes burnout can be found in bad behaviors and practices by staff. The short list above is my own observation of the biggest contributors. You have to master all of the above to make it.
Still, there are bad organizations or offices out there. Maybe the company philosophy of care is just too much on the staff. Maybe they have caseloads or travel times just too high.
I am limited in my ability to assist you with finding the right organization. I only know my region and how hospice care is delivered here. We have more than one organization in this area that pushes staff too far.
I can only offer this simple advice.
Don’t leave hospice before making sure it is you, and not the organization you are working for. Start by having a good one-on-one conversation with your direct supervisor. Ask lots of questions. Treat the meeting like you are interviewing the company to make sure they are worthy of your continued involvement in the organization.
Don’t stay with an organization or specialty that makes you miserable. Life is too short.
Today we will discuss the most important thing in hospice. We are going to address what can possibly be the biggest cause of burnout among all hospice staff. Nobody can escape this dilemma. No matter what role you have in hospice, today’s subject will affect you. This is by far the biggest challenge. This can make hospice amazing or absolutely miserable.
Today we discuss our coworkers.
Workplace Conflict
This series cannot reach completion without discussing the relationship hospice professionals have with each other. This work is incredibly stressful. Working in hospice forces medical professionals to work with patients and families at the peak of their vulnerability. We are providing medical care while death is invading their lives. They are going to lose someone close to them forever. The sheer gravity of the situation has the ability to overwhelm anyone.
Something as simple as running out of disposable diapers can become a crisis. Someone is getting a phone call, and the person on the other end may be angry because the nurse forgot to leave supplies. To the hospice professional, this may seem trivial. To the family member, it means a late night trip to the store to purchase something hospice was supposed to provide. Now they have to find someone to sit with their loved one while they make a run to the store. It is even more likely that the after-hours nurse will have to make an emergent delivery and get an earful while they are there. They will spend thirty minutes taking the blame from someone they have never even met. If you are an on-call nurse, you have experienced this more than once.
This is just one simple example of how difficult this work can be. We can NEVER blame the family when we don’t meet their expectations. Doing so will heap more stress on them. As a result, we end up taking it out on our teammates. The stress of this work has to find an outlet. Unfortunately, it often results in conflict between hospice professionals. We feel pressure to lay blame, and we turn on each other.
1. Assume Positive Intent
A lot can be found online regarding this topic. Rather than regurgitate what I have read elsewhere, I will address this based on my own experience. This is something I have witnessed throughout my hospice career.
So, what does it mean to “assume positive intent?” It means to assume the other person’s intentions are honest. It is to assume your teammate has everyone’s best interest in mind.
This sounds easy enough, but it really is not very easy at all. We all bring our personal experiences to work with us. We have all had bad experiences in the past with relationships. We have been lied to, or we have been cheated on. We have watched coworkers at previous jobs steal from the company, or make up all kinds of fake excuses for their behaviors. We drag these experiences from one job to the other, and it causes us to judge our current coworkers based on previous experiences.
This is especially true when a decision impacts us in a negative way. It is easy to assume the move was made to intentionally cause us harm. We also tend to judge someone else’s mistakes differently than we judge our own mistakes. We can explain our own mistakes away because we know our intentions.
The next time one of your coworkers does something that confuses you or impacts your happiness, assume positive intent before calling them up to tell them how you feel about their decision. Chances are they really weren’t trying to make your life harder.
2. Listen – Validate – Communicate
Conflict is inevitable when dealing with people. It will find its way into our relationships at work. Let me share with you a strategy I have been using for years to help deescalate conflict. I use this in every area of my life. I use it with family, friends, my children, coworkers and patients.
Listen: I start by making sure the other person is heard. Sometimes, I’ll just ask, “Are you okay” to start the conversation. Most people just want someone to listen and understand where they are coming from. The more they are able to explain the situation, the more they will calm down. As we listen to them, we also begin to understand what is at the core of the problem.
Validate: Once I have listened well, I will validate their fears and concerns. This shows the other person they have been heard. Most of the time I am able to really connect with the other person after I have heard all their concerns. Listening well also may change my own perception of the situation. I can also learn how someone thinks or what causes them distress. That is valuable information to understand the person behind the frustration.
Communicate: After having listened and validated, this is my opportunity to share my own feelings or thoughts. For patients, I educate. For staff, this is my chance to work towards a resolution. I have found most people are a lot more receptive if we save the rules and correction for the end of the conversation.
The next time you find yourself in conflict with a coworker, would you consider trying this strategy? I think you will find some amazing success. You may even discover the two of you aren’t as far apart as it seems.
3. The Speed of Trust
A few years ago I read the amazing book, “The Speed of Trust.” The main theme of the book explains that the more you are able to trust those around you, the faster the work will get done. If you struggle to trust your teammates, you may want to pick up this book. Also, if you are not very trustworthy, you should pick up this book.
It hurts my soul to watch two people, whom I believe love this work, fight with each other. I catch myself trying to find ways to help them see how awesome the other person is. I’m not very sneaky, so everyone knows what I’m up to. I’ll say to myself, “I can’t believe these two people are fighting. They are both so awesome! They both love our patients. They both want to provide amazing care for our patients. Why are they fighting like this?”
I observe how miserable they both are due to being so untrusting of the other person. I watch this mistrust turn into a cancer between two amazing people. We should all be working towards building a culture of trust inside of our businesses. We can’t spend time pointing at everyone else. True change starts with us. Let’s all be the change we want to see in others. Let’s trust early and often.
4. Getting Burned
I’m a naturally trusting person. I spend most of my day assuming the people around me are working hard and being honest. I realize this is very high risk on my part. I have paid the price in the past for being overly trusting. I have found myself working harder and longer because I was assuming things that just were not true.
I refuse to become jaded and change my strategy. I watch others who are looking for work-place conspiracy under every bedpan, and I will just not live this way. If I get burned, I can still sleep well at night.
I have never been a very good desk jockey. Even when I was a hospice administrator, I found ways to help in the field and still see patients. One day I was out seeing a patient for one of my nurses. After the visit I called her to provide an update. When she answered I could hear her doing the dishes. I was out seeing one of her patients because she was so swamped for the day, and she’s at home!
The weight of this type of behavior is on that nurse. It is never my fault because someone was dishonest with me. It’s not my fault because I opened myself up to being treated poorly. The weight of bad behavior is on the person who is misbehaving.
5. Gossip is Poison
This section can be nice and short. If you like to talk about everyone to everyone, you are poisonous to your organization. If you run around and complain about your company to your peers, you are poisonous to your organization. Pot stirrers have no place in hospice. Complaining should always go up the ladder. It should never go down or laterally. You know it’s being done wrong if the person you are complaining to is powerless to make the changes you desire.
Hospice is a very complex and stressful area of medicine. Our most valuable resource is our teammates. Every one of use has a specific purpose and has equal value. There may be hierarchy in a technical sense, but not in a practical sense. All members of the team should be treated with equal respect and equal value. The home health aide is not “just an aide.” The office manager is not “just a secretary.” We all have to work together in unison for our patients to get the absolute best care possible.
Let’s be the kind of professionals who contribute to a healthy work environment. We can only do this by being intentional about how we conduct ourselves and how we interact with those around us. Let’s trust each other every chance we get. Let’s be willing to sit down with those we struggle to understand. Let’s assume everyone has the same goals for our patients. Let’s stop the gossip and negative talk. Let’s all take ownership of our company, and be the change we want to see in others.
Over the last year I have learned that, not only am I passionate about taking great care of hospice patients, but I have developed a strong passion to help nurses avoid burnout when doing this work.
To every hospice nurse reading this blog I say to you, “I believe in you! You can do this! You can be a great hospice nurse, take excellent care of your patients and still have great work/life balance.” I believe this with all my heart, and I have dedicated this blog to helping you get there.
There are two major themes throughout this series that I believe are paramount to avoiding burnout. Those themes are maintaining work/life balance and using bedside charting to help accomplish this. I believe both of these items are essential in avoiding burnout.
Failure is a great instructor
Last Monday, before I went to bed, I had my Tuesday completely planned out. I knew what time I needed to make my first visit, and I knew what time I needed to arrive at my last visit. I had five visits on my plate, and there would be a lot of driving.
I got up Tuesday morning like usual. I had my coffee and turned on my work phone just like I usually do. I discovered that my last visit of the day really wanted me to be there an hour earlier than we had planned. Rather than maintaining healthy boundaries, I agreed to move up the visit. Due to this change, I also decided to move a visit from Wednesday to Tuesday. Now I had 6 visits, but I was convinced this was a great idea.
My clinical director even offered to get someone to see one of my visits. I was almost indignant! I remember messaging her and explaining that I could get this done on my own, and I even mentioned I just wanted the mileage back home anyway.
By the end of the day I had pulled it all off. I was done by five-thirty and all charting was completed. It was a thing of beauty, but I wasn’t done there. In a stroke of absolute bafoonery, I took my schedule from the day and posted it on the nurses support group I am a member of on Facebook.
I was proud! Let the accolades begin. Now everyone can see how 6 visits can be done in a single day, and all charting done as well. This will convince even more nurses to read my blog and get the help they need! And everyone will think I’m awesome!
Okay, I do get delusions of grandeur at times. Anyway, here is what I posted for all to see.
My schedule today and charting.
6 patients who will be known as 1-6 All Charting completed at the bedside.
Patient 1 – 8:00am – 8:45am (no new orders) Travel 43 miles Patient 2 – 9:30am – 10:30am (Actively dying) Travel 30 miles Patient 3 – 11:15am – 12:00pm (pillbox) Travel 0 (same building) Patient 4 – 12:00pm – 1:00pm (pillbox) Travel 25 miles Patient 5 – 1:30pm – 2:30pm (new orders) Travel 23 miles Patient 6 – 3:00pm – 4:00pm (no new orders)
Drive 5 miles to where my daughter works to pick her up since her car is in the shop. She gets off at 5:30pm.
Worked from 4:00pm-5:30pm to do Recert notes on patients 5 and 6 above. Also completed IDT notes on 3 patients for a nurse who is out sick.
Start nice and early. Chart at the bedside. Be intentional!
You may be reading this so far thinking, “Okay, what’s the big deal, James? This looks like amazing time-management skills to me?”
Maybe instead you’re thinking, “Geez, that just seems very impersonal. And who lives like that? This guy didn’t take any breaks or even eat lunch!”
This pretty much sums up many of the responses I got on facebook. After over 100 comments and twice as many reactions, I began to wonder if I achieved my intended goal. I even remember seeing a couple members say, “This isn’t an example to follow.”
Now, in a group that big, there will be a wide variety of responses. I should not take anything too personal. I got plenty of positive responses and accolades. I probably shouldn’t take the negative feedback to personal. The thing is, I’m just not wired that way. I easily take everything personally. It’s just who I am and how I’m made.
To help clear things up, I started to reach out to a few people whose opinion I trust and know their feedback will be honest no matter how much it might hurt.
So, with this in mind, I started with my administrator. She will tell it straight.
”James, you came across as a little arrogant and kind of like a showoff.”
Well, that felt good, but she was right. I was showing off a little.
Next I decided to message another member of the group who had contacted me a while back. She had thanked me for this series. She is an administrator as well.
”I think people do need a break but that’s how I do it. I started early and charted at bedside. But maybe 9.5 hrs is too much.”
She was totally right. In my excitement to share my day, I never even bothered to look at my schedule objectively. It was 9.5 hours of constant movement. No stops to take lunch. No stops to catch my breath. I completely did it to myself, and I was proud of it.
I have been doing this to the nurses I have been training as well. In fact, I’ve developed a reputation of not taking bathroom breaks or stopping for lunch.
Here I am trying to write an entire series on work/life balance, and I can’t even stop long enough to let someone riding with me to eat or get a bathroom break.
The second administrator also said something else to me that gave me pause.
“Those yellows and greens hate it…reds and blues love it.”
I had no clue what she was talking about. After some web searches I discovered she was referencing personality types.
As I looked over the 4 personality types, and her point sunk in. The green and yellow personality types are more emotional about their activities, while the blue and red are more analytical.
I have always viewed hospice through a more psychosocial standpoint. I love the relationship building part of the services that hospice provides. I have an entire training program built around the psychosocial needs of hospice patients and caregivers. I almost yelled out loud, “I’m not red or blue! I’m yellow and green!”
The fact is it takes all 4 colors to be successful in hospice. It’s when we try to live in any individual color that we get into trouble.
For an entire day I operated in red and green only. Good care at 100 miles per hour. I traveled Kansas City from East to North to back East to South, and then back East again. I took no breaks. I didn’t stop to eat. I went non-stop for 9.5 hours. My patients got good care, but I didn’t. Then I posted my spectacular achievement on Facebook for all the world to see.
They big takeaway from this experience? We all have to work our way to the center of the color wheel above. We need to do it right. We need to do it now. We need to do it in a caring way. We need to do it together.
When we depend on a certain color, or fail to see the value in all the colors, that is when we get lost, and we find ourselves working towards burnout.
In light of this new information, here are some questions we should ask ourselves every day.
1. Am I operating in a caring way?
None of us would be in this work if we didn’t feel like we operate in a caring way. We still need to make sure our visits are patient centric. All of my visits on Tuesday were forty-five minutes to one hour long. I believe I was caring towards my patients. It could have easily become something else. I just got lucky.
2. Am I allowing others to help me?
My supervisor tried to get me some help. I declined that help. I should not have needed help at all. If you remember from above, one of the visits I imposed on myself. I could have easily left that visit for the following day.
Do any of you find yourself doing this same thing? I did six visits on Tuesday, and only 2 visits on Wednesday. I made Tuesday hard on myself for no reason whatsoever.
3. Am I doing it right?
This is imperative. There are right and wrong ways to do this work. As much as compliance can be boring and tedious, we still have rules and regulations to follow. There is best practice for visit frequencies and end of life care. We have deadlines for payroll and documentation. Leadership has expectations of us, and we have to step up to meet the challenge.
4. Am I doing it now?
Much of the debate in the nurses group had to do with how many hours I worked on Tuesday. There was some legitimate concern. I worked 9.5 hours without a real break. Do 9.5 hour days happen to us sometimes? Yes they do! Should we do them to ourselves? No we should not!
I did this to myself! I added a visit that didn’t need to be added. Then I ignored pleads from my team to help me. We all need to be smart enough to move visits around to make our days easier, not harder.
I will stand by one of my decisions from that day: I was at my first visit by start of day.
Whatever your company’s business hours are, that is the time you should be at the office or your fist visit. If you worked at a clinic from 8:00-4:30 daily, you wouldn’t wait till 8:00am to leave your home. You would leave your home early enough to be at work by your scheduled start time. Nobody gets paid for their commute to work. It’s the same in Hospice. I didn’t somehow work ten or eleven hours because I left my house early enough to be at my first visit by start of the business day. Even if my first patient was an hour from my house, I would leave early enough to see them by start of business day. That’s what “do it now really means.” Starting early is huge in hospice. Our day can get away from us quickly. We can’t be running out of our house at 9:00am in the morning and expect to have a successful day. Especially if we are going to mismanage our schedule the way I did on Tuesday.
Let’s end this weeks post by engaging in some self reflection.
As you review the color wheel above, do you find yourself operating in one color more than the other three?
Do you often find yourself ignoring the yellow color and trying to do everything yourself?
Are you so obsessed with compliance, that you forget about the heart of what hospice is all about?
Are you in a big rush like I was last Tuesday, and you forget to take care of yourself?
Are your visits all about the relationship you have with your patients, and you neglect charting and collaboration with your teammates?
The hardest thing any of us will ever do is engage the person in the mirror. I was forced to do some self reflection this week. I hope you will join me in the experience. I believe it will serve you as well as it has me.
This week we will address a topic that I get the most questions about. Charting at the bedside is most important thing, and maintaining boundaries is the second most important. This week’s issue can easily find itself in third place on the burnout scale.
Visit Times
I see a lot of debate among hospice providers regarding the subject of visit times. I will address this based on our organizational philosophy and strategy. I do believe we have the best understanding of this, but I may be a little biased.
Let’s address a few things before I get into the details. This cause of burnout generally happens with the most passionate nurses. Super passionate nurses tend to get “stuck” in a lot of visits. They are there for 2-3 hours. Nurses who perform “drive-by” visits don’t generally have issues here. They are in and out of the home in 20-30 minutes. If you are one of those “drive-by” visitors, please stay tuned. I can help you here. You should go back and read Part 2 right now to help you start doing this hospice thing a little more appropriately. You’ll be glad you did.
1. See all your patients at least twice a week
Does it seem strange to start this article with this piece of advice? What does visit frequency have to do with how long a visit takes? I’m glad you asked! The more you know about your patient, the easier your visits will become. I’m amazed at the amount of nurses I have worked with who will change a patient to one time per week after the first visit. They look at the patient and say to themselves, “Well, she looks okay. She’s not in a crisis, and she’s not transitioning yet. I’ll just change her to once a week, and when she gets worse, I’ll increase my visits.”
This is a guaranteed way to have lots of really long visits down the road. When we see a patient once a week, we completely miss those little changes. We get caught off guard when we show up after not seeing someone for a whole week, and now they are in a state of transition. Many times the family is completely oblivious to the changes that have happened in the last week. The nurse is stuck there for an extended period of time trying to fill in all the blanks.
If you are reading this, and most of your caseload is only being seen once a week, you need to change it today!
2. Understand the two types of visits/assessments
There are two types of case manager assessments in hospice. There is the comprehensive assessment and the focused assessment. Simply put, one assessment is a review of the whole person, and the other assessment is more of a follow-up assessment on immediate needs.
So let’s combine point 1 and point 2 from above.
Make your first visit of the week your comprehensive assessment. The second visit of the week is the more focused and simple assessment. My first visit of the week almost always takes an hour. Since I chart at the bedside 100% of the time, the comprehensive assessment does take a while. I also complete my HHA and LPN supervisory visit during that first visit each week.
This creates a situation where Thursday and Friday visits are completed in quick order. You have already addressed anything that happened over the weekend, so now it’s a quick follow-up visit for each patient. These visits are easily 30 minutes or less including charting.
Quick Tip: If my patient is actively dying, I will save the comprehensive assessment for the end of the week. The patient is likely to pass before the end of the week, and I can spend my visit educating and supporting the family.
3. Bring the calm with you
No matter how bad things look, be the calmest one in the room. I cannot express this enough.
A few years ago I received a call from one of my nurses, and she was in a panic. We will call her Jennifer. Jennifer was working an on-call shift, and we had an admission. Our patient was being discharged from a local hospital, and they were going to call us once she arrived home. The family called Jennifer in a panic. The patient was discharged earlier than planned, and none of the equipment had arrived yet. She was on oxygen, and she was bed bound. The family was distraught. Jennifer arrived to find EMS in the house with the patient on the gurney in the living room.
”James, this is a mess! The family is so angry with us! This lady is on the gurney and there is nowhere to put her! She can’t even go into a chair, because the oxygen isn’t here! What do I do?”
”Jennifer, I need you to take a few deep breaths for me, please. Do not get caught up in the emotion of the moment. Be the calm in the room. You are the nurse. You got this.”
“Okay, James, what do I do now?”
”Walk over to the medics and thank them for waiting like this. Call the equipment company from inside the house and see where the equipment is. You want the family to see you do this. You need to show them that you have this well in hand, and you are on the job.”
She followed my instructions, and the equipment was only 30 minutes away. EMS was more than happy to just hang out for a few extra minutes while they all waited together.
This was a completely new situation for Jennifer. Honestly, it was new for all of us. This is a rarity in hospice. Hospitals generally never discharge patients early. Usually the equipment is in the house for hours before the patient arrives. We had everything scheduled out perfectly. The hospital just discharged early.
Even if we are coming apart on the inside, the family and patient need to have the impression that we are cool, calm and collected.
4. Avoid power struggles
This may be the greatest piece of advice I received in my first two years as a hospice nurse. We nurses are fix-it machines. We find problems, and we fix the problems we find. If a patient or family member wants to get in the way we end up spending extra time trying to convince them of our preferred solution.
All we end up doing is spending more time in the home, and we drive a wedge between ourselves and the patient.
Quick Tip: If it is important to the patient, it is important to you. If it is not important to the patient, it is not important to you.
This quick tip applies to EVERYTHING once you walk in the door of the house. If it looks like the patient is crazy uncomfortable, but the family tells you they don’t want mom to get anything, and they say she is going to die a “natural death.” It’s your job to find out what they do want from you and accomplish that.
As long as grandma isn’t being physically abused, there is no reason to impose our will on patients and their families. It is not a violation of someone’s constitutional rights if they get no drugs at end of life. They can huff and puff themselves right through the pearly gates if that is what the family wants. We are not here to change someone’s belief systems.
5. No triangles
We recently experienced this with one of our patients. The DPOA lived out of town, and she was trying to direct care. She wanted us to use all the comfort meds to keep her mom from experiencing distress. Unfortunately, there were multiple family members locally who did not share the same opinions. Even though the DPOA has the legal authority, these family members were not about to let us give any medications.
One of my nurses got stuck at the house for hours while the family fought and argued over the medications. My nurse was trying to support the DPOA, but the longer she was there, the more heated things became. Not because of anything she was doing.
We cannot resolve decades of disfunction in the middle of a crisis. It is perfectly acceptable to call the room to order, remind them of the medications that are available and how to use them. We can then announce that we are leaving, and they can reach out to use with assistance if needed.
We are hospice nurses, not family therapists. It’s okay to abandon them to their own dysfunction.
6. Don’t invent problems
There are no perfect patients, families or environments. Houses have mold. Mice are in the attic. Beds have bugs. People lack hygiene. Family members get all their info from WebMD or some neighbor who doesn’t trust doctors. People feed food to dying family members.
We don’t need to find and fix every problem in the house. We don’t need to spend hours convincing family members that gramma ins’t comfortable enough. If they think she’s comfortable, she’s comfortable.
Even if we are just supply and medication dealers, get them what they want and move on.
7. Know your patient
This relates directly to point 1 above. Nurses who see their patients a lot have a deeper knowledge of what to expect when death is near.
Not everyone dies the same. Not all symptoms are the same for all patients. Not all needs are the same for all patients. Hospice is individualized care. Nobody lives the same. Nobody dies the same.
Recently I was case managing a patient with end stage COPD. Pursed lip breathing was her normal. Her respirations were always around 25-28 per minute. She denied shortness of air all the time when I visited her. She would take some lorazepam every now and then to help her relax. This was her normal.
I kept in close contact with her daughter as her health declined. Her daughter started providing 24 hour care about 2 days before she died.
There is this idea among hospice nurses that respirations at end of life should be less than 22-25 breaths per minute. Anything above 22 breaths per minute is a sign of discomfort or pain. While this may be the case for some patients, it is not the case for all patients. Can you imagine what I would have had to give this patient if I wanted to get her to breathe only 22 breaths a minute when she hasn’t breathed like that in years? I would have spent hours trying to give copious amounts of medications.
This is a great way to have long visits that accomplish nothing. I helped this daughter understand what she was seeing is very normal for her mom, and this will be her “comfortable.” I was able to have very normal visits that lasted about an hour while this patient was actively dying. I did not spend hours trying to manage a symptom that was already normal.
8. Chart at the bedside
I’ll keep this short. Everyone reading this series knows how passionate I am about bedside charting. I’ll never understand how a nurse can be in a visit for 1-2 hours and have no charting done. Seems to be that someone has wasted waiting.
You can really use bedside charting to end a visit. Get that device out, and start smacking down on those keys. This will really help wind down your visit. The room will get quiet. Bedside charting can send this big message that you are wrapping things up by getting your documentation done.
Nothing sends a stronger message that the visit is over than closing up your laptop/tablet, placing it in your bag and standing up to make your exit.
Visit times is a very complex subject. I’m sure I could write on this for many more hours. There are so many variables that can contribute to visits that just last too long. Long visits here and there are perfectly normal. Challenging symptoms and diverse family dynamics play a large role in dragging out visits.
Don’t be afraid to take control of the room, calm everyone down, and help bring focus to the situation. If focus cannot be established due to poor family dynamics, abandon them to their own devices and head to a patient who really wants your help. You’ll be glad you did.
Late Edit 8/31/21
I decided to add to this article details from my Tuesday following the original release. This is my attempt to give my readers a glimpse into one of my days. I hope it helps you!
My schedule today and charting.
6 patients who will be known as 1-6 All Charting completed at the bedside.
Patient 1 – 8:00am – 8:45am (no new orders) Travel 43 miles to Patient 2 Patient 2 – 9:30am – 10:30am (Actively dying) Travel 30 miles to Patient 3 Patient 3 – 11:15am – 12:00pm (pillbox) Travel 0 (same building) Patient 4 – 12:00pm – 1:00pm (pillbox) Travel 25 miles to Patient 5 Patient 5 – 1:30pm – 2:30pm (new orders) Travel 23 miles to Patient 6 Patient 6 – 3:00pm – 4:00pm (no new orders)
Drive 5 miles to where my daughter works to pick her up since her car is in the shop. She gets off at 5:30pm.
Worked from 4:00pm-5:30pm to do Recert notes on patients 5 and 6 above. Also completed IDT notes on 3 patients for a nurse who is out sick.
Start nice and early. Chart at the bedside. Be intentional!
I really try to keep these articles short enough to be read in 3-5 minutes. My readers are busy, and they work a lot of hours. Today’s subject will challenge my desire for brief yet helpful material. I can bloviate with the best of them. In college I was able to take the simplest of subjects and write page after page of (mostly boring) material. Simply put, I am an expert on my own opinion, and I like sharing it with anyone who will listen.
Boundaries
Only charting at the bedside stands above boundaries when it comes to the big challenges for hospice nurses. A lack of maintaining healthy boundaries with patients and caregivers will destroy a hospice nurse.
1. Turn off your phone
Recently I decided to address this with all my staff. I called the meeting to order, and I instructed everyone to hand me their name badges. I promised everyone they were not getting fired. Then I looked at everyone with a big grin on my face and said, “Okay, you are all now unemployed.” After a few seconds of awkward silence I continued.
”We happen to have two openings here at Interim. Actually, we have six openings now that none of you work here. We have five RNCM openings and one on-call opening.”
I told everyone in the room I was going to offer them a job, and there better not be any surprises with the answers. I then grabbed a name badge one-by-one from the pile and started calling out names.
”Mike, which position do you want? RNCM or on-call nurse?”
Mike: “Case manager please.”
”Jennifer, which position do you want? RNCM or on-call nurse?”
Jennifer: “Case manager please.”
I continued this way until all five positions were refilled. We had a good laugh at how absurd the whole thing was, but my point was made with a little humor. I then addressed the issues we had been having with our cell phones. I’m going to have the same talk with my readers now.
On call exists for a reason. It is there to provide relief to the staff. Regardless of how your organization is set up, there are times you are supposed to be off work. Your work phone should be turned off within an hour of the end of your shift, and an hour prior to the beginning of your shift. Our patients or their caregivers should not expect to be able to reach us around the clock.
”James, can I get your cell phone number so I can call you if I need something?”
”I can give you my number, but please understand I work 8:30am-5:00pm and you will need to call our main number outside of those hours for urgent needs. I will get your messages, but I can’t guarantee you how quickly I can return your call.”
Even when I’m on call, I do not answer patient calls or texts after hours. This is an important boundary I have set for myself. Patients calling me directly also circumvents the system. Their issues and concerns after hours do get logged into the system as an on-call need.
We have to train ourselves to be really good at this boundary. Do whatever it takes. If your company won’t give you a phone, get a cheap pay-as-you-go phone from walmart. Download the Google Voice app and use it for a second number on your phone. Do something. Do anything. Just don’t turn yourself into a 24 hour resource for your patients. It’s not healthy for you and your personal life. It trains our patients and caregivers to rely on just one person. It’s also against Part 3 of this series.
2. Read something that will help with boundaries
A few years ago I discovered this amazing, and short, book by Andy Stanley. It’s an important reminder on the importance of family over work. You can also check out something my wife told me a few weeks ago. Go back and read Part 3 of this series. Are you becoming too much of the centerpiece for your patients? Consider this fantastic book by Henry Cloud and John Townsend on the subject of boundaries.
3. Don’t have favorites
Now this is super hard. We all have patients we enjoy over others. It’s human nature. We have those patients who we feel like we can relax around them. Maybe we have something in common with them. I personally love my military men. My father-in-law is a Vietnam combat Marine veteran. I feel a deep sense of responsibility when I find out one of my patients served in the armed forces.
Becoming too invested emotionally with our patients can have dire consequences. Our visits start to get too long. We start trying to do things beyond the real reason we are there. We are cleaning the bathroom, or joining the family for meals. We are doing grocery shopping, or picking up snacks on our way over to the house.
We are not there to replace family and friends. We will move through their lives over a period of a few short months, and then we are gone. Eventually, we may not even remember their names. This is a harsh truth of what we do.
We are representatives of the federal government. What we do at each visit is actually regulated by CMS. We need to ask ourselves this question: “What is Medicare paying me to do here?” This will help us clarify what our goal is for each visit. This doesn’t mean we can’t enjoy our patients. This doesn’t mean they can’t enjoy us. It means we are constantly aware of our place and how much of ourselves we are giving away.
We must provide equal and same care to all of our patients regardless of where they live, how cute they are, how clean they are or how nice they are.
4. Hospice is not about me
I have to remind myself of this all the time. This is the patient’s care plan, not mine. These visits aren’t about me. I can fall into this trap so easily. I love to be fun. I want to entertain everyone. In another life, I would love to be a stand-up comedian. I can generally get any room laughing. I have the kind of personality that wants to take over a room the minute I walk in. I want to be close friends with everyone. If I find out someone doesn’t like me, I’m flabbergasted.
“What? They don’t like me? That’s crazy! Everyone likes me. Just come and hang out with me for a few minutes. You will like me. I promise. Something is wrong with that lady. She doesn’t seem to like me.”
Hospice is not about us. Not ever. It’s about someone’s mom or dad or brother or sister who is in the last months of their lives. We should not interject ourselves in a way that we become the center point of the experience. We are one member of a larger organization with the singular goal of providing end-of-life care. This isn’t a chance for us to gain a new friend. This isn’t a chance for us to find a new mentor. This isn’t a chance for us to prove ourselves. This is a chance for us to bring the gift of hospice to the community.
Be friendly. Be encouraging. Be uplifting. Be fun if that is what your patient wants. Smile when they smile. Cry when they cry. Talk about sports, or the weather. Find things in common. All of these are fun and enjoyable, but when it moves to the point that we are starting to be treated as immediate family, it is time to take a step back and reconsider the situation.
We do not want to get so close to our patients and families, that when we are no longer there, more loss is experienced. Eventually we will have to pull ourselves away. When we do, the connection should not be so strong that someone gets hurt. That someone could be us, and that will contribute to hospice burnout.
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.
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.
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.
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!
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.
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.
“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.
“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!
“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!
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.
