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!
Visit The Hospice Nursing Community for more assistance in avoiding hospice burnout.
So all your parts so far I agree w except this one . When you say if the family doesn’t want mom to have medication or if they think mom is comfortable then she is. If mom is uncomfortable and family doesn’t see this week letting mom suffer cause if what the family wants I’ve experienced this pt very uncomfortable grimacing restless family doesn’t want to medicate they want mom awake they don’t want to miss memories .my first obligation is too my pt 2nd the family I’ll educate them and usually they come around I’m not about to let my pt suffer because of what family wants .
Thank you for joining the conversation on this one!
I’m not suggesting at all that we don’t work with our families to help them recognize pain and other symptoms.
I’m referring to those family members who have been educated, and they continue to decline pharmacological intervention. We cannot impose our will on others. I’ve watched too many nurses fight and argue with caregivers at end of life. They accomplish nothing with all the fighting.
I don’t think you and I are on different pages with this one. I probably didn’t make myself very clear. I could edit this article to be more articulate.
Wow, this was great article.
First, I am new to CM, first 6 months, and new to hospice. My manager criticized the 2x weekly visits. Wondering when once weekly is appropriate? She states there needs to be nursing interventions or education documented for each visit, if not, should only be weekly. I feel that even with stable patients, I can document nursing education at the very least. Thoughts?
Your discussion on “Don’t fix it” is pretty powerful. After being a nurse for 20+ years, switching to “facilitator” not “fixer” is often easier said than done. Still a work in progress and starting to recognize when I am starting to go into “fix it” mode. It has been a bigger challenge than I thought it would be.
I have been amazed at what caregivers actually do at home, what true hero’s these people are. I always recognize what a gift they are providing to their loved one, to be at home surrounded by family, familiar sounds and smells etc. No matter how much they are struggling I find this makes them feel proud and their efforts worth every minute.
Thanks for this series.
You are spot on with your assessment for every visit being an opportunity to provide education.
I would (politely) disagree with your supervisor. What the nurses provide to our patients is much more broad than just symptoms and education.
In my experience, organizations that don’t have some kind of expectation around 2x per week visits by the RNCM experience much higher rates of revocations and return trips to the hospital. This is because their nurses have not developed a deep relationship with their patients.
I am also seeing higher caseloads with these types of organizations. They don’t push 2x per week visits because they want to be able to load up their nurses with 18-20 patients.
You do so much more with your patients than just tell them they are dying and manage symptoms.
Your goal is to build influence and trust with them, so they will believe you will be there for them when things get rough.
It is okay to place patients on 1x per week visits, but I don’t believe it is good to do that in the first 90 days of service. Of course some patients want 1x per week right out of the gate. Maybe because they are more higher functioning than some patients, and they have come on service earlier.
Regardless, I believe we have the most success with our patients when we try to keep as many of them on 2x per week as possible. I’ve just seen too many organizations with a 40%-50% live discharge rate because the nurses don’t see the patients enough.
I hope this helps you.
I came here and I appreciate the time you took to write this. I saw 9 patients today which is unreal but my thing is many of my patients have wounds. One patient I saw today has 4. How do you rush through that and chart too? And she’s severely contracted and bed bound. I get measurements on wounds too. I know 9 is too many and I’m severely over loaded but I don’t understand the skin inspections and charting in one hour. Many patients are bed bound
Mysti, thank you for reading my articles. I’ll start by agreeing with you that 9 visits in a day is way too much. To do 9 visits and bedside chart would take 12 hours. That just isn’t feasible.
Otherwise, if you were doing only 5-6 visits a day, you should be able to do your nursing care and chart in 60 minutes. If you have a patient with extensive wounds, those visits could be more than an hour. Maybe significantly more.
I can’t imagine every visit has wound care? Some of your visits should be 60 minutes or maybe a little less if there isn’t a lot of issues and problems.
My concern is always this. If EVERY visit is taking up to 90 minutes, then something is going wrong in the visits. What might be going wrong I can’t necessarily say, but something isn’t right if all visits are 90 minutes to 2 hours.