All posts by 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.
Avoiding Hospice Burnout

Avoiding Hospice Burnout: Part 1

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

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

Be Intentional

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

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

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

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

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

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

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

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

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

General

Home is your first job

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Work-life balance is one of the biggest challenges for hospice nurses. It’s so incredibly hard to turn it off when you get home.

I spend a lot of time trying to help my staff develop good habits. I try to explain to them the importance of turning off the work phone at the end of the day. I explain that we have on-call staff for a reason. I tell them, “Educate your families on calling the main number after hours. Teach them that you are not available in the evenings or on the weekends to field their questions.”

The absolute biggest key to having a work-life balance is completing everything you can while with the patient. This includes entering orders, calling the pharmacy, updating the care plan, writing IDT notes and absolutely charting and locking the visit.

I tell them, “When you get home, be with your family. Don’t be working! Your family needs you. Be there for them!”

My wife and I have been getting a lot done around the house this year. A lot of it we have contracted out. We got the HVAC replaced. We got two new garage doors put in, and we are about to get the house painted. There has been a lot to do. When I got home today, she had a short list of items for me to complete. After a couple busy hours, the work was done. I was ready to come inside and get cleaned up.

As I walked through the living room headed to the shower I told her everything was done for the evening. She said, “You can relax now. Your work is finished.” I looked at her and said, “I’m glad my second job is complete.” Without missing a beat she said, “Home is your first job.”

General

To those who work the hardest

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My mother-in-law worked as a Certified Nursing Assistant for almost forty years. She retired about three years ago. Her last fifteen of those years was out in the community with Visiting Nurses. She loved her patients like they were her own family. When asked if she was going to become a nurse, she would just smile and say, “I want to be with my patients. Not spend all day doing paperwork.”

For forty years that is what she did. Rain or shine. Snowstorms and blistering hot summers. She was as reliable and hard working as anyone I have ever known. Her patients got the best care she could possibly give them. Any weekend we visited her; she would tell us stories of her patients. She would give them gifts, and they were always giving her gifts. She was their family, and they were her family.

Being a nurse’s aide can be a very thankless job. They don’t get the same accolades and praise the RNs, LPNs and Physicians get. They receive no recognition publicly for what they do. It’s just not glamorous work. 

What I have learned in my twenty-seven years of nursing is that nurse’s aides don’t even want that stuff anyway. It’s not why they do what they do. They just love the people they take care of. They see most of their patients like a mother or father. They see them like a brother or a sister. Someone who just needs their help, and they are eager to provide that help. Even if most of the rest of us find it either too physically demanding or just gross. They do it every day. All day long. Without complaint.

To all the nurse’s aides, thank you. Thank you for being the backbone of healthcare. Thank you for doing the dirty work and loving it. Thank you for rolling up your sleeves every day and making sure all our patients get personal hygiene care. Care that brings relief no medication can ever match.

Please join me in celebrating nursing assistants all over America during National Nursing Assistants Week.

General

It’s okay to die on Thanksgiving

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Photo Credit: Laura D’Alessandro

This was the first time everyone was up. Usually, the grandson is asleep at ten in the morning. He worked the night shift at a local factory, and his wife spent the daytime with Mary. We usually started the day with simple conversation. Nothing serious really. Just a few minutes of acting normal. Something all of my patients seem to enjoy. They want a friend who is a nurse. Not a nurse who is a friend.

Today was different. I could tell our conversation would move straight to business. Observation is the best tool a hospice nurse possesses. She was a little more short of air than usual. Maybe she was anxious about the subject at hand. Her legs and ankles were as swollen as ever. There was no way she was walking very well these days.

I sat down and simply asked, “What’s up?”
She looked at her grandson and his wife. Then she turned her gaze to me and said, “I’m worried about something.”

“What are you worried about?” I asked her.

“It’s getting close to the holidays. I’m scared that I’m going to ruin everything for them.” She looked at her family and paused for a moment. “I’m afraid I’ll die on Thanksgiving, and the rest of them will be ruined forever.”

“Is it really that bad?” I asked her.

“What?” She responded.

“Is it really that bad? If every Thanksgiving for the rest of their lives they take a few minutes to remember the love they have for you. If every Thanksgiving for the rest of their lives, they take a few minutes to remember how much you loved them. Is that such a terrible thing?”

Her grandson and his wife had smiles on their faces. Mary looked at them and asked, “What?”

Her grandson spoke up. “Grandma, you don’t need that kind of stress right now. We love you very much. We don’t care when you die. We don’t want you to worry about when you die. We are going to think of you every holiday anyway. You have been such an important part of my life for so many years. We just want your final months to be as enjoyable as possible.”

“Listen,” I interjected, “Your grandson and his wife will be just fine no matter when you pass. Enjoy the time you have together, and don’t let the thought of passing on a holiday steal the joy of the moments you have between now and then.”

I finished the rest of my visit. She didn’t like taking medications, so we didn’t change a thing. Our visits were always more social than anything else. That’s what was most important to her.

Before I left that day, I reassured her that everyone would be just fine if she died on Thanksgiving, and that’s exactly what she did.

Building Rapport

Building Rapport: All the time in the world

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I thought it would be fun to do a series that teases out my strategies for building rapport with my patients and caregivers.

It’s easy to think of my job as a medical job. Legally, it is a medical job. The reality is that being an RN Case Manager is more about interpersonal communication than medicine. Most of my patients come into service with a lot of misconceptions regarding end of life care. They don’t understand the services provided by the Medicare hospice benefit. They don’t understand the medications we use. They don’t understand what to expect at end of life. This isn’t anyone’s fault. Most people just don’t have much experience with death and dying.

I discovered that if I don’t build rapport with my patients and caregivers quickly, I become frustrated when I’m met with resistance as I introduce new concepts.

For my first installment, I want to talk about “time.”

For the purposes of these posts, the words “patient” and “caregiver” are interchangeable.

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Time Machine
Time Machine

Imagine for a moment that you are a patient. Your nurse sees you one-to-two times per week. You are stable, but your doctor has put you on hospice. Your nurse calls you on the phone and tells you, “I’ll be there in twenty minutes to see how you are doing.”

It’s been two weeks since you started service with hospice. You like your nurse. He’s friendly and polite. He always greets your pets and takes a minute to show them some attention. He just always seems to be in a hurry. He barely gets to a chair before he pulls out his computer, stethoscope, blood pressure cuff and oxygen saturation monitor. He asks a few questions from his computer, the same questions he has asked every other visit. He attaches the battery-powered blood pressure cuff to your wrist, puts the oxygen monitor on your finger and listens to your lungs, heart and abdomen all at the same time. He types for a few minutes longer, but as soon as the room gets a little too quiet, he asks if you have any questions, excuses himself and goes out to the car where he spends another 20 minutes doing whatever it is hospice nurses do in their car.

That is how I did my visits in my second month in the field. My first month was the polar opposite. I would spend two hours at each visit trying to fix every single problem I could find. It was exhausting. I changed to the above strategy when I realized that I can’t fix every single problem during every single visit. The fast visit is very time efficient. I can make lots of visits in a single day. The problem was that when my patient began to decline, I had no relationship so they were still struggling to trust me. It was when I began to move into the third month of work that I learned my first strategy for building rapport with my patients.

Act like you have all the time in the world.

I know it sounds silly and maybe even impossible, but it is a powerful tool in building rapport with your patient. After I enter the home, and greet the pets, I find a place to sit. I put down my bag and just relax with my patient for a few minutes. My goal is ten minutes without doing anything medical. I allow the patient to direct the conversation. Sometimes they go straight to the medical issues at hand. Sometimes they want to tell stories about their life. Sometimes they don’t want to talk about anything, they just like the companionship. The point is to give them the assurance that you have time for them. You want to give them the feeling that you could be there all day if required.

Compared to your patient, you do have all the time in the world. The average time that a person is on hospice is less than two weeks. This means that most of our patients will die within the first few weeks of coming on service. Most of them can feel how little time they have left. The biggest compliant that I have heard about other hospice organizations is that the patient felt like their nurse was always in a hurry. Being in a hurry is just plain insulting. It’s like saying, “Yeah, I know you’re dying, but I have stuff to do.”

Generally, as those ten minutes come to an end, my patient will give me an opportunity to start my assessment. They will come up with an issue or concern that will allow me to address the items on my check list. If they don’t bring up any issues at the end of the ten minutes, I can easily start a conversation based on what I have observed so far. Maybe they have been arching their back frequently during the visit. Maybe they have been coughing a lot. Maybe they have been pursed-lip breathing throughout the first ten minutes. By mentioning what I have seen so far, I am sending the message that I am engaged in the conversation, and I am paying attention. I have been assessing my patient for ten minutes and never said a word.

Now I have thirty minutes to address their concerns and do my charting. Like I mentioned in my story, I used to do a lot of charting in the car once the awkward silence crept into the room. I have found that I was the one who felt awkward. I think my patients like it when I stay in the home and finish my charting. I’ve never had someone ask me to leave. I think they like having the extra time with a medical professional who actually has time for them. They have felt like cattle being herded by an angry dog for so many years. No doctor office or hospital has had much time for them.

Isn’t it the right thing to do, at the end of their life, to give them the gift of your time?

General

The weight of information

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Photo Credit: Peter Dondel
Photo Credit: Peter Dondel
A hospice nurse has a lot of information bouncing around in their head.

During my first two months of field work I can use the word “bombarded” to describe what it was like. I was bombarded with a lot of end of life experience. Certainly, end of life is what hospice is all about, but not all patients have a quick decline. When I look at my caseload now, there are only a couple of names I recognize from my first couple of weeks. This means that I have had a lot of experience with patients who are in a steep decline. It has been good for me because it has caused me to learn symptom management early in my hospice career.

It is a cliché, but with great knowledge comes great responsibility. With my increased experience it will be really tempting to walk into a home and try to pour out all the information I can in one sitting. I’m learning very quickly that the information I have in my head caries a lot of weight with it. I have already seen the look on the faces of a few caregivers who were given too much information in one visit. They just stare at me with a blank look on their face. They have been taken to a place where no information given them is being retained. A lot happens in the hours and days leading up to death. A lot of changes can occur with the human body. There are a lot of different things that can happen, but none of those changes are guaranteed. If I’m not careful, I will provide everyone with more scenarios than they can even begin to process. It’s my job to make sure that I don’t try to saddle my patient and their caregiver with too much information at once. It’s my job to give out the information I have in measured doses.

End of life is heavy. The information I carry around in my head is heavy too. My patients, and their loved ones, need a nurse who hasn’t turned his job into a collection of algorithms he applies to treat everything that can happen in someone’s last few hours on earth.

I need to be sure to stay in touch with the human side of what I do, or I will take an event that can be smooth and make it really complicated.

General

My first week as a hospice nurse

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Photo Credit: Kevin Harber
Photo Credit: Kevin Harber
Last Monday I took my first position as a Registered Nurse. I started at NorthCare Hospice and Palliative Care.

I have had a lot of different jobs in my lifetime. Half of them are in the medical field, and the other half are spread across construction, printing, self employment and retail. At no time during the last 24 years did I feel like any of those jobs had any spiritual significance until last week.

Hospice was on my list for a couple of reasons. The first reason was simply the schedule. I’m a family man, and I have no desire for rotating twelve-hour shifts like nurses work in the hospital. The second reason was because I was really interested in work that was more relational in nature. So many nursing jobs are too fast paced. The goal is to get the patient in and out as quickly as possible. Certainly, there is nothing wrong with this type of medical career. Short hospital stays are an essential component to healthcare. I had decided that I just wanted something different.

Over the last few months I have shared my interest in hospice nursing with friends, family and coworkers. I have received a wide variety of responses. People who have no experience with hospice just say that it sounds like emotionally draining work. When I talk to someone who has first-hand experience with hospice they usually get emotional, start crying and share about family or friends who received services from hospice. When I talk to someone who works in hospice they get a smile on their face and simply say, “Hospice is more than a job. It’s a calling.”

After a week of orientation at NorthCare Hospice I understand the designation, “Calling.” Before last Monday I understood hospice to involve helping people die as comfortably as possible. After a week of general orientation I understand that hospice is so much more than that. Hospice doesn’t just focus on keeping patients comfortable, even though that is an important aspect of hospice care. No, hospice isn’t only about death. Hospice is also about life. Hospice is about helping patients function at the highest possible level during their last months of life. Hospice is about empowering people to identify what is most important to them and helping them engage their last days in a way that is the most fulfilling to them.

Hospice is a calling because I will be a pivotal figure in the final chapter of someone’s life. I will manage their overall care. I’m responsible to make sure that my clients are equipped with everything they need to live their final days with dignity. I will be a central figure in the lives of immediate family as well. I will have at my disposal a team of professionals whose only concern is the care and comfort of my client. We will leave no stone unturned to make sure that our clients and their immediate families feel the support they need to manage the most challenging time of their life.

I have had a lot of jobs that I didn’t feel really mattered beyond providing for my family. For the first time in my life I feel like I will be doing something professionally that really makes a difference. For the first time in my life I feel like I will have a job that God has called me to do.