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

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

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

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

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

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

Okay, let’s get started!

Plan our work. Work our plan.

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

1. New schedule every week

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

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

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

2. Start early

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

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

“Set up your day? What is that?”

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

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

3. Plan our day

We should not spend our entire day being surprised.

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

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

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

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

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

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

4. Everything at the bedside

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

Call the doctor while with the patient.

Call the pharmacy while with the patient.

Call the equipment company while with the patient.

Enter new meds in the EMR while with the patient.

Enter new visit frequencies while with the patient.

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

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

5. Embrace the tension

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

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

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

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

6. Start with our sickest patient

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

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

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

7. Don’t waste waiting

We actually do a lot of waiting in hospice.

We wait for medications to take affect.

We wait for the funeral home to arrive.

We wait for the doctor to call us back.

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

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

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

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

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

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

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

James

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.