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.

What does it mean when a preacher says, “In closing?”

Absolutely nothing!

What does it mean when a blogger says, “In closing?”

About the same!

In Closing

What I originally thought would be 12-15 articles appears to be 10 articles. Many of my ideas have been combined in more than one article. It has played out well, and it has generated some quality conversations both public and private. I appreciate everyone who has take then time to follow this series to its end. I especially appreciate all the feedback I have received. Some of it has been negative, and some of it has been positive. I welcome both responses when given politely, which is what I feel has happened in most cases. I have learned a lot just writing this series. I hope you have as well.

Today, I want to finish this series with a couple straggling thoughts. Just some simple observations that I feel will bookend this series, but don’t really warrant additional articles.

1. Help each other

I had not even considered this as a subject until yesterday. I had just spent the previous 10 days on a much needed vacation. I have spent most of the last year carrying a caseload and training new nurses. We intentionally go overboard when training new staff. Most new nurses with us get 2-4 weeks of in-the-field training with me.

Well, I had completely forgotten one of my nurses had vacation starting this Wednesday through next Wednesday. She called to let me know that she had already reach out to her follow case managers for help. All of her visits were already covered. My role calls for me to pick up the slack, and she only needs me to make 2 visits while she’s out. All of her teammates had already picked up the needed visits.

Not all nurses have this kind of support. I have worked with more than one nurse who just wanted to get done with their day and head home. There was no interest in checking with their coworkers to see if they need help. This is the most impressive group of nurses I have ever worked with. A couple of them are very new to hospice, and yet they are still reaching out to me on slow days to see who they can help.

They have developed a culture that says, “Why should I go home at 2pm when I have a teammate who may not get done till late tonight. They reach out to each other to see what help they can provide. What a healthy culture to be a part of!

If you are struggling to get help, I would recommend you find another nurse in your organization who is willing to team up with you and be your backup. Maybe the two of you can be the change in your company you want to see. Others will follow your lead. I promise. I have watched it happen here in my own company.

2. The 90/10 rule

This is something I really should have shared at the beginning of this series. I have two classes I teach at my current place of employment. At some point in each one I share this rule.

I believe that the content of this series can be executed successfully at least 90 percent of the time. There will always be the unplanned and unexpected 10 percent. Those who see the world of hospice as 100 percent one way or the other are doomed to struggle. This includes your humble servant, James. I have to remember that my material doesn’t work 100 percent of the time for 100 percent of nurses.

It’s also not the 10/90 rule that says all this material can only be done 10 percent of the time. If you want to argue 80/20 with me, I can entertain that. What is most important is our ability to examine our own ideas objectively. If you want to fiercely object to something in these articles, then I have achieved my goal. I have got you to think it all over. That’s progress! That’s good for you and me!

So, before just rejecting any of this series, ask yourself if what I suggest can be done at least 80-90 percent of the time. Maybe it will help you! Why not try it?

Most of what I teach is based on my own experience. By its very nature this means that I am biased. All of these articles can really be boiled down to just my opinion. It’s not like there is some kind of comprehensive hospice nurse textbook that a reader can just pull out to verify my claims.

What I do know is what I have done to survive six-and-a-half years of hospice working for (an embarrassing) 5 companies. I have just now found my forever hospice home. I’ve never been so happy to do this work as I am right here and right now.

Have you found your forever hospice home?

Are you with a company that you love, but it just seems impossible to get everything done and still have a personal life? Are you willing to get out a calendar right now, look forward 6 months and place an “X” on that date. Are you willing to say to yourself, “For the next six months, starting tomorrow, I’m going to put my full effort into this entire series. I’m not going to pressure myself to do it all at 100 percent. I’m going to shoot for 90 percent and see what happens.”

I think you will find this series has the potential to completely change your level of success in the specialty of hospice nursing. You wouldn’t even be reading this series if you didn’t hold out some amount of hope that you can be successful at hospice without constant fatigue and stress.

Don’t let your current habits or situation be the end of your hospice career. Try something completely different, and maybe this can be a new beginning for you. You can avoid hospice burnout, and this series can help you get there.

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

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 spent more time contemplating this article than all the others in this series combined. I have even considered skipping this section of the series completely. After much thought, I have decided to include this subject before closing the series.

If you feel like you are in the throws of hospice burnout, then this article may be more pertinent to you than any of the others in this series.

Is it time for you to leave hospice?

I don’t desire for anyone to leave hospice. This specialty is absolutely desperate for high-quality nurses. It’s hard work. Maybe the hardest in all of medicine. I haven’t worked them all, but I have experienced enough other specialties to see the unique challenges that come with caring for the dying.

My first job out of nursing school included some ER work. I really expected to love it. I thought I would enjoy the action and adventure I heard so many nurses rave about. One evening we had someone come in who attempted to complete suicide. He had cut his arms from elbow to wrist with a blade. he didn’t even come close to death, but he had long cuts on both of his arms that needed to be sewed up. I stood by his bed as I watched one of the ER physicians repair his wounds. I got light headed and almost passed out. I learned real quickly that any type of nursing that involved sutures and stitching was not going to be for me. It made me nauseous. Over the years I found other areas of nursing that were a better fit. Ultimately I landed here in hospice care.

Below I have come up with a series of questions you should ask yourself in determining if you should continue with hospice as a profession, and find a better fit for yourself.

1. Am I waiting for hospice to become easier?

Waiting for hospice work to get easier is an exercise in futility. Difficult patients, family members and caregivers are all a part of hospice work. If I wake up each day asking myself, “Maybe today will be much easier,” my expectations are unrealistic. There is always a challenging situation awaiting our intervention. There will always be difficult symptoms to manage. There will always be patients who either challenge our ability to remain calm or become almost like family and leave a hole in our lives when they die.

If the only reason you are still working in hospice is anticipation of this work getting easier, it may be time to change specialty.

2. Am I unwilling to work an 8 hour day?

This work cannot generally be done working less than a full day. We need to be willing to arrive at our first visit by start of day and leave our last visit at end of day. Business hours vary among organizations. They tend to be 8.5 hours and start at 8:00am and end at 4:30pm. Not every work day needs to be this strict, but if we develop a routine that has us showing up to our first visit at 9am or 10am and trying to end our day by 3pm we are setting ourselves up for frustration.

No other area of nursing allows its staff to just wander in and out whenever they feel like it. Just because we can start our day late and leave early doesn’t mean we should. This is a recipe for lots of working from home. What takes you 10 minutes out in the field will take you 30 minutes at home.

If you are unwilling or unable to get out of your home timely, it might be time to change specialty.

3. Do I struggle with autonomy?

The autonomy that comes with hospice nursing may be one of the biggest reasons it draws in staff. It may be the same way with home health. It’s nice to be able to swing by the grocery store in the middle of the day and grab something for dinner. You can stop in and have lunch with your kindergartener as well.

The difficult side of autonomy is that there isn’t someone in the back seat of your car reminding you of the work you still need to get done for the day. A quick stop at a big box store can turn into an hour or two of the day lost real quick. Nobody is calling at you from the garage reminding you to get out the door by 7:30am so you can be to your first patient by 8am. You only have the still small voice in your head, and we are all great at shutting that voice down.

There is very little direct supervision in hospice. Many hours of the day can be lost or mismanaged easily resulting in a lot of work that goes unfinished. Management is plenty busy getting their work done. They aren’t calling all day long to make sure patients are being seen timely.

If you struggle with managing all the time away from supervision, it might be time to change specialty.

4. Am I unwilling to turn off my work phone?

When we are off work, we need to turn off our work phone. Leaving our work phone on is a recipe for constant reminders of the work we do. As many times as we remind our patients and caregivers that we don’t work after hours, they still cannot resist the temptation to send us notes or trying to call during our off hours. We end up answering those calls and messages, and we end up trading in our personal time by working for free. We have on-call services for a reason. The only way we can get our patients and caregivers to become dependent on the whole team, is to be sure we cannot be reached after hours.

If you struggle with the “not knowing” part of being a hospice nurse, it might be time to change specialty.

5. Am I unwilling to learn to chart at the bedside?

Cal it what you want. The general idea is your charting for patient A is done before you see patient B. All my charting happens while I am with my patients. Nobody calls me rude or says anything about it.

I addressed this issue in depth during Part 2 of this series. If you have been reading this series as I have been releasing each article, you should be making progress in this area. If you continue to do a lot of charting at home in the evenings, I highly encourage you to read Part 2 again and get working on this.

There is absolutely no reason for you to spend your evenings charting. No reason at all. None. Zero. Zilch.

Don’t chart at home. Ever. Have I been clear?

If you have decided charting at the bedside is not appropriate or impossible, it might be time to change specialty.

6. Do I have to always be right?

Our medical brains are full of very useful information. The unfortunate reality is that not all patients and caregivers want to access that information. Many of them have their own thoughts and ideas on what is best medically. As frustrating as it is to see them choose WebMD over hospice best practice, we have to be willing to accept that not all of our advice will be implemented.

When we push and push we just find ourselves in constant conflict with patients and their caregivers. We cause ourselves and our clients undue and unneeded stress and anxiety. We go home frustrated because we feel unsuccessful from the day. That one difficult patient wears on our mind. We spend countless hours away from work trying to figure out how to convince them to start or stop certain behaviors.

If you just can’t handle watching others make bad decisions, it might be time to change specialty.

7. Do I have to fix every problem?

In general, hospice professionals operate in very imperfect environments. Our patients are dehydrated and malnourished. Often they are bed bound, or they have severe dementia. They have wounds, shortness of air and pain. There can be fighting among family members in our very presence. Sometimes everyone wants our help with these problems, and sometimes they just want to handle it all themselves.

We are in homes with bugs, cigarette smoke so thick you can hardly see and spoiled trash in the corners. At times it can overwhelm the mind and the senses. The patient or family may point out just one problem that is important to them. We look around and see ten problems that need to be solved. Maybe the one problem they want fixed is something that cannot be fixed. Now we are struggling with helping the family come to terms with the dramatic changes they see in the one they love more than anything on this earth.

We have to come to terms with the realization that we can’t fix everything. This is end of life care. Our patients’ bodies and minds are failing them.

If you find yourself having really long visits and getting caught up in family drama, it mightI be time to change specialty.

Organizations do contribute to burnout. I have mentioned it a few times during this series. Generally speaking, I believe organizations play a small part in hospice burnout. Much of what causes burnout can be found in bad behaviors and practices by staff. The short list above is my own observation of the biggest contributors. You have to master all of the above to make it.

Still, there are bad organizations or offices out there. Maybe the company philosophy of care is just too much on the staff. Maybe they have caseloads or travel times just too high.

I am limited in my ability to assist you with finding the right organization. I only know my region and how hospice care is delivered here. We have more than one organization in this area that pushes staff too far.

I can only offer this simple advice.

Don’t leave hospice before making sure it is you, and not the organization you are working for. Start by having a good one-on-one conversation with your direct supervisor. Ask lots of questions. Treat the meeting like you are interviewing the company to make sure they are worthy of your continued involvement in the organization.

Don’t stay with an organization or specialty that makes you miserable. Life is too short.

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

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.

Today we will discuss the most important thing in hospice. We are going to address what can possibly be the biggest cause of burnout among all hospice staff. Nobody can escape this dilemma. No matter what role you have in hospice, today’s subject will affect you. This is by far the biggest challenge. This can make hospice amazing or absolutely miserable.

Today we discuss our coworkers.

Workplace Conflict

This series cannot reach completion without discussing the relationship hospice professionals have with each other. This work is incredibly stressful. Working in hospice forces medical professionals to work with patients and families at the peak of their vulnerability. We are providing medical care while death is invading their lives. They are going to lose someone close to them forever. The sheer gravity of the situation has the ability to overwhelm anyone.

Something as simple as running out of disposable diapers can become a crisis. Someone is getting a phone call, and the person on the other end may be angry because the nurse forgot to leave supplies. To the hospice professional, this may seem trivial. To the family member, it means a late night trip to the store to purchase something hospice was supposed to provide. Now they have to find someone to sit with their loved one while they make a run to the store. It is even more likely that the after-hours nurse will have to make an emergent delivery and get an earful while they are there. They will spend thirty minutes taking the blame from someone they have never even met. If you are an on-call nurse, you have experienced this more than once.

This is just one simple example of how difficult this work can be. We can NEVER blame the family when we don’t meet their expectations. Doing so will heap more stress on them. As a result, we end up taking it out on our teammates. The stress of this work has to find an outlet. Unfortunately, it often results in conflict between hospice professionals. We feel pressure to lay blame, and we turn on each other.

1. Assume Positive Intent

A lot can be found online regarding this topic. Rather than regurgitate what I have read elsewhere, I will address this based on my own experience. This is something I have witnessed throughout my hospice career.

So, what does it mean to “assume positive intent?” It means to assume the other person’s intentions are honest. It is to assume your teammate has everyone’s best interest in mind.

This sounds easy enough, but it really is not very easy at all. We all bring our personal experiences to work with us. We have all had bad experiences in the past with relationships. We have been lied to, or we have been cheated on. We have watched coworkers at previous jobs steal from the company, or make up all kinds of fake excuses for their behaviors. We drag these experiences from one job to the other, and it causes us to judge our current coworkers based on previous experiences.

This is especially true when a decision impacts us in a negative way. It is easy to assume the move was made to intentionally cause us harm. We also tend to judge someone else’s mistakes differently than we judge our own mistakes. We can explain our own mistakes away because we know our intentions.

The next time one of your coworkers does something that confuses you or impacts your happiness, assume positive intent before calling them up to tell them how you feel about their decision. Chances are they really weren’t trying to make your life harder.

2. Listen – Validate – Communicate

Conflict is inevitable when dealing with people. It will find its way into our relationships at work. Let me share with you a strategy I have been using for years to help deescalate conflict. I use this in every area of my life. I use it with family, friends, my children, coworkers and patients.

Listen: I start by making sure the other person is heard. Sometimes, I’ll just ask, “Are you okay” to start the conversation. Most people just want someone to listen and understand where they are coming from. The more they are able to explain the situation, the more they will calm down. As we listen to them, we also begin to understand what is at the core of the problem.

Validate: Once I have listened well, I will validate their fears and concerns. This shows the other person they have been heard. Most of the time I am able to really connect with the other person after I have heard all their concerns. Listening well also may change my own perception of the situation. I can also learn how someone thinks or what causes them distress. That is valuable information to understand the person behind the frustration.

Communicate: After having listened and validated, this is my opportunity to share my own feelings or thoughts. For patients, I educate. For staff, this is my chance to work towards a resolution. I have found most people are a lot more receptive if we save the rules and correction for the end of the conversation.

The next time you find yourself in conflict with a coworker, would you consider trying this strategy? I think you will find some amazing success. You may even discover the two of you aren’t as far apart as it seems.

3. The Speed of Trust

A few years ago I read the amazing book, “The Speed of Trust.” The main theme of the book explains that the more you are able to trust those around you, the faster the work will get done. If you struggle to trust your teammates, you may want to pick up this book. Also, if you are not very trustworthy, you should pick up this book.

It hurts my soul to watch two people, whom I believe love this work, fight with each other. I catch myself trying to find ways to help them see how awesome the other person is. I’m not very sneaky, so everyone knows what I’m up to. I’ll say to myself, “I can’t believe these two people are fighting. They are both so awesome! They both love our patients. They both want to provide amazing care for our patients. Why are they fighting like this?”

I observe how miserable they both are due to being so untrusting of the other person. I watch this mistrust turn into a cancer between two amazing people. We should all be working towards building a culture of trust inside of our businesses. We can’t spend time pointing at everyone else. True change starts with us. Let’s all be the change we want to see in others. Let’s trust early and often.

4. Getting Burned

I’m a naturally trusting person. I spend most of my day assuming the people around me are working hard and being honest. I realize this is very high risk on my part. I have paid the price in the past for being overly trusting. I have found myself working harder and longer because I was assuming things that just were not true.

I refuse to become jaded and change my strategy. I watch others who are looking for work-place conspiracy under every bedpan, and I will just not live this way. If I get burned, I can still sleep well at night.

I have never been a very good desk jockey. Even when I was a hospice administrator, I found ways to help in the field and still see patients. One day I was out seeing a patient for one of my nurses. After the visit I called her to provide an update. When she answered I could hear her doing the dishes. I was out seeing one of her patients because she was so swamped for the day, and she’s at home!

The weight of this type of behavior is on that nurse. It is never my fault because someone was dishonest with me. It’s not my fault because I opened myself up to being treated poorly. The weight of bad behavior is on the person who is misbehaving.

5. Gossip is Poison

This section can be nice and short. If you like to talk about everyone to everyone, you are poisonous to your organization. If you run around and complain about your company to your peers, you are poisonous to your organization. Pot stirrers have no place in hospice. Complaining should always go up the ladder. It should never go down or laterally. You know it’s being done wrong if the person you are complaining to is powerless to make the changes you desire.

Hospice is a very complex and stressful area of medicine. Our most valuable resource is our teammates. Every one of use has a specific purpose and has equal value. There may be hierarchy in a technical sense, but not in a practical sense. All members of the team should be treated with equal respect and equal value. The home health aide is not “just an aide.” The office manager is not “just a secretary.” We all have to work together in unison for our patients to get the absolute best care possible.

Let’s be the kind of professionals who contribute to a healthy work environment. We can only do this by being intentional about how we conduct ourselves and how we interact with those around us. Let’s trust each other every chance we get. Let’s be willing to sit down with those we struggle to understand. Let’s assume everyone has the same goals for our patients. Let’s stop the gossip and negative talk. Let’s all take ownership of our company, and be the change we want to see in others.

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