James worked on-and-off as an LPN for over 20 years. In 2014 he completed a bridge program and became an RN. James became a hospice nurse in January 2015. He lives in the Kansas City area with his wife of over 30 years, 4 daughters and 2 sons in law.
The first time I met Melvin he was sitting at his dining rom table putting together a puzzle.
”Hi Melvin, my name is James.”
He didn’t look up at me or acknowledge my presence.
“He can’t hear you.” His wife explained.
I raised my voice significantly to announce myself. “Hi Melvin, my name is James. how are you doing?”
”James, he can’t hear anything.” She explained. “He’s totally deaf.”
She touched him on the shoulder, and he looked up at us. He smiled at me, and then he smiled at her. He reached up with his hand and caressed her face for a few seconds. He smiled at her, gave her a kiss on the opposite cheek from his hand, and then he returned to his puzzle.
Melvin didn’t start out his life as a deaf man. He just experienced comlete hearing loss as he aged. Over the 2-3 month period of time that I was his nurse, I never heard him say a single word. Every visit was the same. I would perform my assessment, and ask his wife all the questions. He was always engaged in some activity. He would look at me and just smile.
I learned a lot about Melvin from his wife. They had only been married a few years. She told me stories about his travels around the world. He had visited almost every continent. He had been in most of the major cities in Europe. According to his wife, he had even scaled Mount Everest. Most of this had happened before they ever got married. I don’t honestly remember what he actually did for a living. I think he was a college professor or something of the sort.
Most hospice patients end up on some type of symptom management medication as the end of life nears. Usually it’s more than one medication. We have medications for pain, shortness of air, anxiety, hallucinations, nausea and vomiting. Most patients end up on several medications at end of life. Most commonly they end up on something for pain and hallucinations. Melvin sticks out in my mind because he took almost no medications while he was dying.
I remember visiting one day, and he was lying in his hospital bed. His wife was sitting at the head of his bed holding his hand. He was looking up at her with his usual smile. He was cupping her cheek in his hand.
”How has he been acting?” I asked.
“He hasn’t eaten or drank anything since yesterday morning.” She said.
Sitting next to her I asked. ”He doesn’t appear to be in any distress to me. What do you think?”
She looked at him and looked at me.
”He’s never had any chronic pain issues, and he seems to understand what is happening.”
“What is happening?” I asked her.
”He’s dying, and I think he knows it.”
I visited them every day that week. Every visit was exactly the same. She would be sitting at the head of his bed, and he would be holding her face with his hand. He had the same simple smile on his face. Most visits I would see him pull her close and give her a soft kiss on the opposite cheek he was touching. There was never a sound from him. Not a moan, or a groan. No coughing or attempts to speak any words. Just a smile and a kiss.
I remember the day he died. I had received an email from our secretary, Kay. It was a simple email like all of her emails.
“Please call Joanne, she is pretty sure Melvin has passed.”
I replied “Okay” to her email like I always did. After calling Joanne, I drove over to their house. She let me in and lead me to the living room where he was lying. I put my stethascope on his chest and listed for a heartbeat. There was none. I looked at my watch and gave the time of death to her.
While we waited for the funeral home to get there, we talked about the last 24 hours.
“James, it was the strangest thing. Every couple hours he would wake up, look at me, smile, lift his head, give me a kiss on the cheek and lie back down. All night long it was the same. Every couple hours. Wake up. Smile. Kiss on the cheek. Lie back down. Right before I called your office, he did the exact same thing, but this final time, he stopped breathing after the kiss.”
I have never seen anything like it since that day. I have never had a patient who remained that lucid until their final breath. Most patients are unresponsive for days leading up to the end. Not Melvin. He was awake till almost the last minute.
Melvin had a lot of adventures over his lifetime. He had been everywhere, and he had seen everything. When he was close to the end, the only thing that mattered to him was Joanne. He couldn’t communicate with his voice, because he couldn’t hear. What he could do was communicate with his face and hands.
At the end of his life Melvin made sure Joanne knew exactly how he felt about her. A touch and a kiss was all she needed to understand.
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 can’t reminisce about the Kansas City Royals winning the 2015 World Series without remembering Randy.
He was only about 10 years older than me. He was a tall strong looking man. He had severe respiratory disease, and he couldn’t walk 10 feet without becoming so short of air he had to sit down. Even during conversation he couldn’t complete full sentences without stopping half way to catch his breath. Our visits always took place at the dining room table. He had a pill box that I kept filled up for him.
The Kansas City Royals were making their second trip to the World Series. They had a heart-breaking loss to the San Francisco Giants. The name of the Giant’s pitcher who beat us is banned across the region. The mere mention of his name could cause a fist fight between the closest of friends.
Randy and I managed to watch most of the series with the Astros together. We would scream and yell at the screen in unison. When the Royals were down 6-2 in the bottom of the 7th in game 4, we were in the middle of a joint visit with the social worker. We turned the game off in frustration to resume our meeting. We knew the season was over.
About 10 minutes later I pulled out my phone and checked Twitter. I’m a socially challenged rule breaker like that. I was shocked to see that the royals had the bases loaded with no outs! I stood up and crashed the meeting. I looked at the social worker and said, “I’m really sorry to end the meeting so soon, but the Royals are in the middle of an epic comeback!” The social worker laughed out loud, and we turned the TV back on. Randy and I watched as the Royals performed one of the greatest comebacks in franchise playoff history! Ultimately, we celebrated Kansas City’s second world championship in 30 years.
Over the next couple of months Randy’s health continued to decline. During one of my visits his girlfriend was out of the house.
”James, please make sure that I don’t end up on a ventilator again.”
Before Randy came on hospice he had a horrific hospitalization. He was on a ventilator for over a week. It was a miracle he ever came off the device.
“James, being on a ventilator was a traumatic experience for me. I don’t ever want to experience that again. I just want you to keep me comfortable. I want to stay right here at home for the end of my life.”
“Does Amy know this is what you want”?”
”Yes, I have told her many times, but I worry she will panic at the end.”
”Okay, I promise to help her remember when the time comes.”
It wasn’t too may weeks later that I got a message from the office to call Amy. The message said that Randy was having a hard time breathing, and Amy wanted me to go and check on him.
I walked into the house and Randy was sitting in his favorite recliner. He was leaning forward with elbows on his knees; A common position for people who struggle to breathe. He was very lethargic and was barely able to make eye contact. I called our equipment company and had a hospital bed delivered STAT. While we waited for the bed, I administered a high dose of medication to help him relax.
After the bed was setup, I helped Randy get in. Since that day I have helped do this many times. When someone looks this sick, I know they will never got out of bed under their own power again.
Randy’s girlfriend watched from across the room while all this was taking place. She was calm. She was too calm. I could tell she didn’t have full understanding of what was happening. She thought this would be temporary.
“Amy, come over here and sit down with me?”
She sat on the sofa with me. Next to us was the hospital bed with Randy in it. I put her hands in mine and looked her in the eyes.
”Amy, his lungs are failing him. He is going to die in the next few days.”
She stood up in shock!
”What? No! James, he can’t die! We need to call 911 right now!”
”Amy, hold on a second.” I said calmly. “Sit back down with me.”
She reluctantly complied.
”Randy has discussed this with you, hasn’t he?”
She paused for a minute trying to clear her thoughts.
”Yes, we talked about it.” She finally answered.
”What did he tell you was his wishes after he was on the ventilator last time?”
”He told me he never wanted to experience that again.”
”Amy, if we call 911 right now. They will come and get him and take him back to the hospital. He will end up on a ventilator again. Is that what he wants?”
”No, he doesn’t want that.”
”Okay, he has made this decision for you. He has taken this situation out of your hands. Now it is your job to make sure his wishes are honored. You have the power to grant this wish for him. Keep him here, at home, where he wants to be. Don’t let him wake up at the hospital with tubes in him. It is not what he wants.”
She felt empowered. This gave her a sense of purpose in this sad situation. She was going to lose the man she loved, but she was also going to be his guardian till the end.
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.
When I first got into hospice, I really thought I would have memory of every patient I cared for. I was so excited to work in hospice that I told my mentor during orientation I would want to attend the death of all my patients day or night. He smiled at me and explained how impossible that would be. I didn’t realize how many people I would care for.
I have been in hospice for just under 7 years. I can say, without fear of contradiction, I have cared for hundreds of dying people. It is impossible to remember everyone. The sheer numbers alone make it difficult. Still, some patients remain a part of my memory forever.
I will never forget Angie. She lived in a rural area of Kansas City in her daughter’s basement. Every time I would visit she would be pulled up to her computer reading Facebook. She was almost completely blind, so she used a large TV screen for her monitor, and everything was blown up to about 200 percent. She would look at the screen from about 6 inches away. Any time I visited she would just wave me into the room without making eye contact.
”I’m working on FarmVille, James. I’ll be right with you.”
I would just sit by her hospital bed and wait patiently. Eventually, she would push herself away, apologize and let me perform my assessment. She was a cute little short lady with heart failure. Over the next several months her health continued to decline. She was not a candidate for any type of aggressive care. We addressed any out-of-control symptoms as they would arise. I would call her cardiologist and get new orders to treat extra fluid and chest pain.
It is normal for all hospice patients to begin to lose their appetite. The body is slowly failing, and the desire for food begins to subside. As the caloric intake declines, weakness and lethargy take over. This isn’t painful at all. It is a normal part of the dying process. Eventually, everyone becomes too weak to get out of bed. Angie was no different.
One day I made a visit and, for the first time, she was not sitting in front of FarmVille. She was lying in her hospital bed. Her daughter was sitting in the other half of the room as I sat down next to Angie’s bed.
”I’m too tired to get out of bed, James.”
”I know.” Was all I could get out.
I sat there in the quiet for a few minutes. I could tell her daughter knew things were getting closer to the end. She understood.
I looked back at Angie and said, “Your heart is failing you.”
She looked back at me and said, “You mean I’m not going to make it?”
I got goosebumps. I looked at her daughter. Her daughter looked back at me and gave the slightest nod.
I looked back at Angie and managed to say, “No, you are not going to make it.”
Angie cried.
After a few minutes, she gathered herself. I pointed to a ledge on the basement wall where she had at least a dozen Bible based figurines. She had the entire Christmas Nativity set up on the wall. I looked at Angie and asked her what I was looking at.
”That is Jesus, Mary and Joseph. I also have some of the saints up there. Peter is there and so is James and John.”
”So, do you believe you will go be with Jesus when this life is over?”
”Yes, I get to go be with him.”
“Will it help you to think of them every day when you wake up?”
”Yes it will help a lot, James.”
Her daughter looked at me in approval. Over the next few weeks Angie moved from this world to the next. With every visit we looked at her figurines on the wall and discussed what awaited her. Eventually, she went home to be with her Savior, Jesus.
I will never forget Angie.
I remember her, because she was the first person I ever told they were going to die.
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 never know what your first visit with a patient will be like. I’ll never forget my first visit with Earl. He was living with his wife in downtown Kansas City. They had lived in that house for over 50 years. Most of the houses around them were either vacant or in complete disrepair. Walking in the front door was like traveling back into the 1960s.
I don’t think he really wanted to be on hospice. I think he did it because that’s what his wife wanted.
”How is he doing?” I asked her.
”Oh, I don’t think he’s doing very well, but I better stay out of it.” She replied.
I performed my assessment. I asked if he had pain. He said yes. I offered medications. He said no. It went on like this for the first 2 weeks. We spent most of our visits watching TV. It was either a Royals game or poker on ESPN. Always sports. After a few weeks we started making commentary on what we were watching. Nothing deep or specific. Just a couple guys watching TV. I can still hear his voice in my head. He sounded like Lewis from Christmas Vacation when he was telling Bethany to “say the blessing.”
”Who do you think is going to win?” I would ask.
”I don’t know, James. This is some really bad baseball.” He would respond.
After a couple months he started agreeing to my suggestions. I’d spend the first 30 minutes just watching ESPN with him. At some point I would start with my assessment. He was getting weaker, and I think he knew it. One day I asked him if I could get something delivered to truly address his pain.
”Whatever you say, James.” Became his response.
Each visit I would address something new, and his response became standard.
”Whatever you say, James.”
”Your blood pressure is getting low. I think we need to decrease your medicine.”
”Whatever you say, James.”
“I think you need to take your pain medicine twice a day.”
”Whatever you say, James.”
One day his wife caught me on the front step of their home before I went in. She told me that he had fallen several times since my last visit. She explained that, since his last fall, she had been pushing him around the house on his seated walker.
”Don’t let him know I told you. He would be so embarrassed.”
I sat down next to him. His color was different. He was so pale.
”You don’t look so good, my friend.”
”I don’t feel so good.” He replied.
”Listen, let me get you a hospital bed in here. That way you can relax while we watch ESPN together.”
”Whatever you say, James.”
I had the hospital bed delivered that evening, but it just sat there the rest of the week. The following week I got a call from his wife.
”You better come early this week, James. I can’t get him out of his chair. He’s been in it all day.”
I shuffled some visits around and made my way to their house. He was very drowsy, and I knew we were getting close to the end. I walked over to him and sat down.
”How are you feeling today?”
”Not very good, James.”
“Can I help you get into bed?”
“Whatever you say, James.”
I helped him get into his wheelchair and pushed him over to the hospital bed set up in his living room. I lifted him into the bed and helped him get situated. His wife smiled at me in approval.
He died later that week.
Hospice is a heart job. I think sometimes we complicate things. Not everyone wants deep and complicated medical care. Not everyone wants a complex assessment with lots of big words and fancy solutions. Sometimes, our patients just want to feel normal.
Earl was really sick, and he knew he was sick. He didn’t want a nurse who was also his friend. He wanted a friend who was also a nurse. For Earl, friendship had to come first. I joined in on what he found important, and that gave me influence with him. I built trust, and he needed to trust someone before he would let them help him.
Eventually, I was able to give him and his wife what they needed through hospice care. I just needed to be patient and find out what Earl needed from me first.
I became the friend Earl wanted, so I could become the nurse he needed.
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!
