Hospice Nurses and Social Workers: Hand in Hand

I was relieved to see Helen's car behind me, inching along the gravel road toward our next admission's house. Already four miles in, we crunched along the uneven, one-lane surface back in the "hollers" (local word for deep valley) of our rural community. When the GPS confidently announced, "Arriving at your destination," I looked up to see several signs crowding a small sapling, including, "No trespassing. Trespassers will be prosecuted," and "Beware of the dog." Behind the signs was a steep driveway, full of crater-size potholes. Helen shouted out her window that we should ride up in her car, which had a higher clearance.

When we neared the top, we were met by deafening barking from what looked like dozens of dogs (and turned out to be 17), penned behind a feeble fence. We made our way in to what served as the kitchen where we perched out bags on a chair, with the dogs safely behind a fence between the kitchen and the other rooms of the house. A difficult conversation ensued almost immediately since the family couldn't understand why we were not able to see the patient back where the dogs were. Eventually they brought the elderly woman, via wheelchair, to the kitchen and our visit continued.

I looked gratefully to Helen, who with great finesse and love and true compassion, talked calmly with the family and the patient. She went on to tell them that she could be a resource in helping them obtain, by donation, some needed items to care for the patient, including a recliner and possibly a rollator walker.

In a difficult setting, where there is conflict about how to treat-or where to treat-patients, social workers are an invaluable asset. Always a team approach, hospice works best when all the team members respect one another, understand each other's roles and lean into one another's professional strengths. The medical social worker truly specializes in taking hospice from basic end of life physical care to the next level where it becomes a wholistic and comprehensive approach to the entire spectrum of death and dying. The social worker moves the care outward, beginning with advocacy for the patient to care for the family and the entire support system, and following up with bereavement care after the death.

As with any professional partnership, there are bound to be conflicts. When we dance so close together, invariably we step on each others' toes. Whether the nurse is offering advice that conflicts with the social worker's or the social worker is expounding on medical information that is more in the nurse's realm, these moments of tension can and do occur but are not insurmountable obstacles. An attitude of respect, cooperation and unfailing kindness toward one another and toward the patient can bring resolution to even the worse case of mashed toes!

Besides the social worker, the hospice team also involves the ministry of the chaplain and sometimes of volunteers. Many times people have ambivalent feelings about their higher power, not stopping during busy lives to assess where they stand. When death becomes more of a reality, urgency steps in and patients and their families often want help in discussing where they are on their journey and how they would like to move forward. The chaplain can also be helpful when there are broken relationships that need healing before death. He/she can be a great listener and ask questions that assist the transition from feeling out of control to taking some concrete action toward resolution. In their role of spiritual counselor, the chaplain works hard to non-judgmentally meet the person right where they are and to work toward goals that the patient and their family define.

In our hospice, we try to have a nurse and a social worker at every admission. Since we never know exactly what we will find, we try to make an assessment and then defer to one another based on the needs at hand. As the in the case described above, the patient's physical needs sometimes play a smaller role than environmental needs. When this is the case, the nurse naturally steps into the background while arrangements are discussed. However, at most admissions, the primary needs are related to symptom management. In this case, the nurse takes the lead and guides the conversation moving forward.

In both situations, it is critical for the nurse and the social worker to each understand and feel comfortable in their respective roles, deferring to one another and supporting each other through the entire length of the patient's stay in hospice.

Maybe you have had a great experience working with your social worker staff. Can you share a time when they have been particularly helpful? What are some of the challenges of working together when there are differences of opinion and role conflicts?

As we left the home that day and walked to the car, accompanied by a true cacophony of dogs barking, I smiled broadly at Helen and thanked her for a job well done. She kidded me, "Hey, you let me do all the talking!" I raised by eyebrows and smiled back, "Yep! You had all the right words, my friend. There was nothing I needed to say." As we rode back down the rutted driveway, we felt a sense of satisfaction at a job well done-together.