For on-call how do you ....

Specialties Hospice

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Not sure there's an answer for this as all of my co-workers voice the same complaint. But how do you stay "on" for on-call without letting it consume your nerves? I love my job, the first time I can say that in nursing and I'll be here a year in June. I love my co-workers they are awesome. The only thing I don't like about my job is the on-call.

Right now I have the weekend which for us is Sat 8am to Mon 8am. There's a 12 hour nurse with me til 9p. We have an IPU that takes calls until 7am starting at 7pm and if there's an emergency I would need to go out. Because we are slow tonight, the 12 hour nurse has the phones, but quite often I would be triaging calls from 4p to 7p from answering service.

I had to go out earlier today with a foley not draining and it was no big deal. The pt was wearing briefs AND long pj bottoms so it was all twisted and an easy fix. But I guess I hate that unknown and not knowing what crisis it could be and other nurses voice the same.

We are blessed as we only have on call weekends approx every 6 weeks. However if you don't have a weekend that month you are generally scheduled for more overnights (for us that's 430pm to 8am) however we do have an evening nurse that works from 9p to 7am and for the most part we never go out after 9p as she catches it all for us. We do frequently have admissions though after work if we are on call or tuck ins, which can go until 10pm, so it's exhausting.

I just can't relax when I'm "on" I'm always on high alert, can't sleep etc... because you just never know I would rather have an assigned shift than this. I've gotten better for it not darkening my mood totally but I do find that I will sometimes be thinking about it the week before, dreading it's upcoming which is nuts because then I'm losing piece of mind on 2 weekends! Writing it out makes it sound nuts!

So how do you relax and just let what happens happen? I usually am v good about trusting God and his plan and any time I've been called out, it really does have his plan and purpose imprinted on the experience but I still don't like "not knowing" haha.

allnurses Guide

herring_RN, ASN, BSN

3,651 Posts

Specializes in Critical care, tele, Medical-Surgical.

I'm not a hospice nurse. My only on-call has been hospital work.

I know it is important to be rested and able to go at any time.

I understand the apprehension about an unknown situation. Probably your fellow hospice nurses will give good advice.

I think you will know what to do in most situations. There should be a physician to call for medical orders and/or questions. Check the policies and procedures.

Have you asked your coworkers about thei experiences with call?

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

It am sure it is nerve wracking,really difficult to relax...Going back to that foley Cath,are you permitted to do some trouble shooting over the phone?

Specializes in hospice, ortho,clinical review.

Thanks! That's just it, we have awesome doctors I mean doctors that I wouldn't hesitate to call, just fantastic human beings that never make you feel inferior, bad etc... I generally can figure what to do and so far it hasn't been extreme but I guess there's always that "chance" that gets me.

ktwlpn: To answer your question, yes/no! It depends on the situation and how comfortable the family is as well as what they've been taught. We do often say that we know we've done our job (teaching) when the families are okay and don't always need us and can do the care. This lady was a bundle of nerves, which oddly kept me calm because I had to be! Plus you can't fix a problem and worry, you just do it! But when she called in she just said it wasn't draining and the call to go came from my office (we have office people that triage from 8a to 4p on the weekends as well as 2 weekend nurses but we still can get called for back up emergencies, admissions) so I wasn't able to trouble shoot and I doubt she would have been able to fix it with her mindset. I did do teaching before I left, but IME if your anxious it's like hitting a brick wall and not much is retained. I did say SEVERAL times to keep the long pants off for the most part!

If it's the middle of the night, if they are not in pain and it's leaking we can try to walk them through removing it and padding the pt up until morning.

I had a call this morning on a pt who slept on their hand and family was concerned as it was swollen. I instructed to ice and elevate and and then she said mom didn't seem "right" as she wasn't readily speaking just staring etc...(I immediately thought CVA and offered a visit because that's happened) but then she said maybe it was how she slept last night and she wanted to wait a bit to see if she came around and so she declined the visit.

Even in a case where the family is freaking out we can offer for them to go to one of our IPU's if they are overwhelmed and we can even do this over the phone if it's bad enough and I'm pretty good at deciphering where family is on the spectrum of phone vs visit vs send pt to IPU!

I've walked in on a normal day for a COPD pt in respiratory crisis and that one after several tries with MSO4 and Lorazepam, family opted to call 911 because transport would take a few hours as it's never an emergency for hospice pts to get to an IPU (that's a whole other kettle of fish that I don't understand!)

My point with all this rambling (sorry I'm sleep deprived again as I just don't sleep well!) is I can usually figure it out or know where to go to get the info if I can't and like mentioned we have awesome back up. Right now I have my office nurse triaging, she is has our 2 weekend nurses out and will call me if needed. If not the phones will go to me starting at 4p until 7p (at 7p one of our IPU's rotates calls till 7am) If after 7p I get a call, that generally means I need to go out because the IPU can trouble shoot over the phone.

The last time that happened I got called for a pronouncement, I got there at 1030p and couldn't leave until 115am because the funeral home was from another state and was a 2 hour drive! She told me she understood if I needed to leave and I said "do YOU need me to stay, because I can" and she said she would feel so much better and that was it. She gave me ice water and reminisced on the wonderful life of her mom and it was a privilege to be included. The funeral home arrived and the thanks that we always receive is so humbling. My husband even didn't mind waiting in the car for 3 hour as he ate my snacks haha! (he likes to go with me on the night ones, so I'm blessed there too!)

So yeah, see? What is my problem? I think it's because I'm not an adrenaline junkie. In fact when the EMS showed up on my COPD pt and thought I was killing him with the measly 10mg of MSO4 SL and they were questioning me etc....I HATE that, I don't care for their over inflated egos (granted some do not, but many do, but I've run across some awesome friendly EMT's as well)

It's that fear of the unknown and even though logically I know that God doesn't give me something I can't handle, it's the waiting for the phone to ring and not knowing if it will and jumping when it does!

My co-workers express the same stress, the not knowing and not being able to relax. I just wondered if there's some tip we're missing! My husband says just go about your day and if it rings it rings! Great in theory but I can't really apply it! But then when it's over I usually think "ok that wasn't so bad"

I would just love to get past this. It's the one thing that nearly has me running and thinking I need to find another job! Especially with the 48 hour on calls But it's only 3x month if I have a weekend,(one weekend plus 1 week day night) or it's 4x month with no weekends on average. Otherwise I love this job! I love the flexibility the different days, (some days there are meetings, others, not) sometimes I will go on a 48hr follow up with my social worker and I love her because we get things done for people. I love the fact I can go in and fix a problem and leave! It really is the best job, so I get there's always going to be something you don't like about work, but when I'm in the midst of it my anxiety level rises and I write pages of nonsense! (I get how nuts this looks writing it out)

So I appreciate any/all feedback. Maybe just to commiserate!

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

I think you just need to adjust your mindset to "on call" = working....Easier said then done I know.I have a unique position now and I am theoretically on call all night and every weekend.Have not had to leave the house yet but have spoken to staff and family members a number of times.I can't rest if I don't have my cell within arms reach.I have had family members on hospice,not once did the case manager come out to pronounce and hold our hands until the undertaker came.Maybe it's the education that is lacking? Of course some family members are going to be high maintenance no matter what but isn't the hospice philosophy to provide education and support to the caregivers to enable them to do the heavy lifting?The family of your COPD pt really should have been prepared to consciously sedate for comfort at end of life.What did hospitalization mean for him and his goal of dying at home?Forget about EMS and their opinions,you and I know how much of that morphine is really absorbed,we also know we titrate to comfort with no max dose.These family members fear the unknown,I truly believe if an agency is fielding a lot of these calls after hours and on weekends they need to look at the regular staff and their teaching......

Specializes in School Nursing.

I honestly believe that all hospice companies should have separate on call staff. There is no excuse for the nurses who are responsible all day to do visit and field calls/admissions/emergencies to also have to take call all night and on weekends. I do not agree with "call" rotations for day staff. Nobody should have to be available to "drop and run" 24 hours a day. It's not safe and in the long run, is why burn out is so high.

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

I don't agree,I think on call staff doing admissions is a waste of time.In my experince the case manager never seems to catch up....and The on call as neededstaff never seem to know all the p and p.f

.When the regular staff take call daylights and on weekends they are given other time off so they can recharge.

Specializes in hospice, ortho,clinical review.

Newhospicern I agree! We've been saying that for awhile. Before though, I heard it was worse before we got our evening nurse so they're always telling us how lucky we are that she's there. And we are thankful as we usually don't have to go out, but it's there looming so... They also tell us they will get us a news crew (evenings weekends) as we grow, right now we have an average census of 190 spanning a few different counties.

ktwlpn- you are correct! I should make that my mindset but working =48 hours is what's mindblowing. Granted it's never actually that. DH thinks that someone else should cover the phone starting at midnight since I need to be ready to go tomorrow at 8am for my regular part.

Interesting your comment about not going for pronouncements as we have new guidance and we may be leaning that way, to have families call 911 to pronounce, others feel it's taking the heart out of hospice.

I don't often stay with a pronouncement as I usually don't know the family. We are told to use our judgement but if a family "wants" us to stay, as I specifically asked her as I could tell she was becoming anxious after we got her mom cleaned and dressed, then we stay. Was I thrilled? no, but if I could provide that comfort...then I don't take that lightly.

As far as using more MSO4, we teach patients that they can use 20mg q1h until comfort, if still not comfortable with that, then they need to go to IPU for IV symptom management. We do have CE's that tell the pt we can do everything they want which drives us crazy sometimes doing damage control when we case managers have to go in and burst bubbles but they are taught (our company standpoint at this time) if family is not comfortable at any time they can in their best interests revoke and seek aggressive care and call 911. Our job is to keep them comfortable at home but if family can't handle that....we do not just keep giving MSO4 in the home exceeding 20mg an hr. I usually don't have concerns in the home much with that. I have bigger ones in the facilities where they look at us like we're angels of death euthanizing people when we ask for morphine q3h routine as well as PRN doses. We have even done in services to educate staff and still there's resistance.

Frankly there needs to be more education on what hospice is and isn't. It's not the automatic death sentence that some think it is. I have seen a huge improvement in quality of life for a few patients in my care, some are even able to enjoy some fresh air for who knows how much longer...but it's brought back their joy for the time. So not all our destined to come through our doors and pass in days but we have many of those as well.

I know we're different than a lot of our competition for hospices. Our reputation has spread because of our faith based principles and so much of our "business" right now is word of mouth and families stating over again how impressed they were when "John Doe" was on our service and the difference it made for them and how wonderful the care was and that's why they chose us. And we don't want to lose the core of who we are or how we got here.

I was in the hospital Friday doing a eval for our IPU and this mega hospital actually has their own hospice. One of the nurses came up to me and couldn't say enough about the care her family member got and how much she loves us! Many love our particular serene setting for one of our 3 hospice houses. Most everyone that has seen it has remarked in awe how this should be how everyone dies, it's just that peaceful.

I agree though, it is to empower the caregivers, that's us doing our job. We always enjoy the ones that think there's a "poop squad" that will come and clean up their loved one after hours and then we have to explain they need to hire extra caregivers for that kind of care.

Specializes in hospice, ortho,clinical review.
I don't agree,I think on call staff doing admissions is a waste of time.In my experince the case manager never seems to catch up....and The on call as neededstaff never seem to know all the p and p.f

.When the regular staff take call daylights and on weekends they are given other time off so they can recharge.

We don't get extra time off for taking call. Technically if we are out all night, we can come in later but then lose money which for us it's time and a half and we do feel, if you're having us go out for all this extra stuff then you're paying us. Same if we have an admission after work, it's exhausting but it's all overtime. We totally need more admission nurses, right now we have 2 twelve hour nurses and it's still not enough, if we are on call especially a Friday it's near guaranteed we'll have to go out and do one.

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

Most clients of hospices in this area are instructed to call the undertaker at TOD,the hospice physician signs the death certificate later.Most casemanagers in this area are given a day off before they take call for the weekend,granted these are large companies.If you could you would do 1-1 at the bedside during end of life few but it's not possible.That's why the education is so important

Specializes in hospice, ortho,clinical review.
Most clients of hospices in this area are instructed to call the undertaker at TOD,the hospice physician signs the death certificate later.Most casemanagers in this area are given a day off before they take call for the weekend,granted these are large companies.If you could you would do 1-1 at the bedside during end of life few but it's not possible.That's why the education is so important

Wow! I feel like I fell down the rabbit hole! That really does make sense and I do wonder if we are leaning that way but because it's new leadership they don't want to rock the boat too much, too fast. As it is there have been many changes due to CAHPS etc...Even our tracking method is going to change. But calling the undertaker makes total sense. Calling 911 (that's what another nurse said was the possible plan) does not.

I do wonder about your hospice's policy to titrate to comfort no matter the amount. We definitely do not do that, and I wonder why?

Oh! And we are not allowed to take a Monday or Friday off around on call. Which is the other reason we just say "pay us then". Tired...forgot to mention that. So I can go in later tomorrow in theory only if I've out half the night and am really unsafe to work. We can take a Friday off but pre-planned. Another words bc I worked on call, this Friday is IDG meeting, I can't say I want to leave early as it likely won't be approved since Fridays are so busy (to use over time time) if I want to use it in advance PTO that's okay.

caliotter3

38,333 Posts

I have found that the only way I can relax when anticipating anything about the job is when I sleep at night before getting up in the morning to go to work for a day shift. Otherwise, I am always anxious to some extent about a job. And for those nights when I might dream about work, I wake up exhausted. Just a way that work holds us hostage and adversely affects our health, at least for some. I've never figured out a fix for this work anxiety.

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