frustrated and overwhelmed

mtnmom · Mar 2, 2006

I am just finishing my first month in hospice and my experience has not been much different. Very little orientation and what I got was very fragmented. One of the nurses that oriented me for 3 days got fired 2 weeks ago so of course I am wondering what kind of bad habits I picked up from her. Our office is larger than yours...but there is a great deal of turnover. Our DON is very sweet and knowledgeable but is extremely disorganized which makes all of our lives more stressful.

I don't know...I really enjoy the type of work but am wondering if I made the right choice. I am not sleeping from the stress. Plus since my hire I found out that nurses are expected to work 50-60 hours a week if that is what is needed with all the call and caseload. I just cannot do that for several reasons, although I know the money would be nice.

Yes, I would also like to know how other hospices orient their people.

bay bay · Mar 2, 2006

Hi, and welcome. I can relate to your story because I too, am new to hospice.(3 months) I recently posted about the heavy focus on recerts, paperwork etc, at the end of my "angry patient" thread. Yesterday, as a matter of fact, I went to my director, and told her how much I loved my job, and let the point be known to please be patient with me because I really like what I'm doing, and want to do well. I was starting to lose focus on my patient goals because of all the "policies and procedures" we are faced with learning. I empathize with you, and understand where you are coming from. With all the stress you are enduring right now, I pray you will be blessed by a patient with whom YOU have made a difference, and places a gentle reminder in your heart that are in the right field. Best of luck

req_read · Mar 2, 2006

Wow! It amazes and saddens me how nursing in general and hospice in particular have evolved. As an ‘old’ nurse (no longer practicing in a traditional setting ) it is disturbing to hear what y’all have to endure. Small wonder there is a nursing shortage when for so many managers the MO seems to be: Get a new nurse, burn her up and throw her out, then go get another new nurse.

Sadly, some nurses play into this by bragging up their ‘workaholism’ as though it were some sort of merit badge… which only adds fuel to the fire.

If nothing else you can wait until your next JCAHO visit and when you are asked what kind of orientation you were given you can say, “Basically, none.” When your response is compared to what your P & P says about orientation, your agency may have to rethink how they do business.

doodlemom · Mar 3, 2006

It makes me sorry to hear that you all are going through this. There really are some good hospices out there. Are the hospices you work for older, established agencies that have a name in the community? If they are not, then I would search for a job in that direction. I have found better luck working for agencies that have been in the community for 15 or more years. If you really want to do this work, please don't give up!

aimeee, BSN, RN · Mar 4, 2006

I am sorry to hear that you are struggling so. I raised an eyebrow when you first reported that you already been given a patient load but I didn't want to say anything at the time that would undermine your confidence.

We would have a minimum of 2-3 weeks orientation for even an experienced hospice nurse. Nurses who are "green" to hospice would have more like 6 weeks and then be started with 4-6 patients and then be given more based on their performance. Nurse managers try to be available for lots of mentoring during the first 6 months or so.

Being the only nurse except for your supervisor sounds like a difficult way to learn a specialty field. Who is there for you to fall back on? What happens if you are sick? Who sees patients then? You mention paper notes AND computer entry. Are you doing double documentation?

silverwillow · Mar 5, 2006

Okay, Ive been doing hospice now for a little over 2 mths, I had very little orientation and Ive had a case load of 9 pts since the first week and now Ive got 12 and I fill like Im drowning, Im behind on my paperwork and I have 3 recerts due next week. Im doing about 16 visits a week and traveling about 300 miles a week

Sorry to hear that you had so little orientation. If they are so busy there, they should have just let you do revisits for awhile to let you get ahold of the hospice philosophy, which as you know is alot to learn in itself. Gaining confidence about decisions you make is important, and your agency should be allowing you to focus on symptom management, etc before throwing the heavy things like recerts at you.

jerseyRN · Mar 6, 2006

I've been a hospice nurse for four years and things have changed so much since I started. Everyone is expected to do more (higher census) with less (reduced staff) and the bottom line is, as a case manager I work way more hours than I can bill for. I keep doing it because that's what it takes to get the job done the way I want to do it.... but we keep hiring nurses and nobody stays very long... wonder why??

req_read · Mar 6, 2006

No doubt that when you complain to administration about not having sufficient staff they come back with remarks about rising costs… right?

It is true that the percentage of total hospice revenues going to nursing and meds have risen since hospice’s early days. However, per diems (income) have risen about 1/3 in the last eight years and hospice income has been shown to exceed hospice expenses by 10-12 percent.

Having run a hospice myself I am aware that breaking even should not be a problem. Getting rich is something else again. Hospice was not designed to be a “cash cow,” although some have tried turning it into one.

If your agency suffers from chronic understaffing then there are 2 possible causes; 1- administrative/managerial ineptitude, or 2- plain old-fashioned greed.

kelluvanurse · Mar 8, 2006

Hey, I finally found time to respond. Thanks everyone who replied, we are up to 14 pts now and Im still the only case manager. I told them last week if they did not get me any help that I would probabley be leaving because I cannot handle the pressure. So they have asked our oncall nurses to help out with some visits so that will help some, I asked for another case manager but they said they just couldnt do that right now. Im really thinking about throwing in the towel because when I get home Im stressed out and I have 3 school aged children and we are very active and I just cant deal with all of this. Weve been slammed with admits this last week, my supervisor has been helping with that but its just not enough. I have a daily dressing change on a elderly man with malignant melonoma and she's having a fit because we have been doing dailys she said we should have never started that and now she wants the aide to learn how to do it and now the wife is very upset. Oh well, maybe things will look better tomorrow. Oh, this company has been around for 10 yrs but a little less than a year in our community. thanks again everyone for the replies.

req_read · Mar 8, 2006

If you have a patient who needs a daily dressing change then you should be doing a daily dressing change… it’s that simple.

If your manager suggested that you should not be meeting your patient’s needs because it does not meet her needs then she is a darned poor excuse for a manager… or even a person for that matter (and if she is a nurse I am truly appalled!)

As I said, I used to run a hospice and therefore have some understanding of how the financials work. A census of 14 patients generates about 47 thousand dollars of income per month. If your agency cannot figure out how to secure sufficient nursing coverage on that kind of income then I repeat; they are either inept or greedy (only now I’m mad, so I would say they are either idiots or rip-off artists.)

Plus, from a business perspective, if your agency is ten years old then their pockets should be deep enough to get a new hospice (yours) through its start-up period. If they do not have the capitol to start up a new hospice then they must truly be incompetent. And if they do have the capitol but are not willing to use it, well, I am running out of terms sufficiently derogatory to describe their behavior.

The world of hospice does not need agencies like this.

My advice to you would be to, (if at all possible) get out ASAP… before something really bad happens and your career is jeopardized more than it already is.

kelluvanurse · Mar 12, 2006

Hey Reg Read, thanks for your post. 47,000 per month wow thats alot. When I told my administrator that the wife was very upset and had commented on how much they get paid per month based on what she has recieved in the mail she says "people just dont have any ideal how much money it takes to run a business". But anyway, I have finally convienced them that a nurse needs to to it, after the aide saw the tumor undressed she was really stressed about doing it so I will continue to do it daily and the oncall nurse will do it on the weekend. But, Im looking into working for another hospice but all they have is part time right now but I know a nurse there that I have worked with and trust and she recieved a very lengthy orientation and is very happy there. Right now they are so busy she said that I could probabley just about get enough hours just not benefits but that is okay with me. Hey how does oncall usually work. Our nurses get a flat oncall pay of 50.00 per day and nothing extra if they have to go out and they get 175.00 for the whole weekend starting at friday evening until monday morning. Does that sound about right? Oh, what is the average pay per hour or per visit because right now Im on salary?Thanks for your post because I was kinda feeling that way about my administrator, she is all about the numbers and not very good at patient care. We have a pt on marinol and is doing very well on it and she has been wanting us to wean her off of it and try something else that is just as effective but more cost effective, yeah right, I told her that I just couldnt take it away from her and that I would discuss it with the physician but of course I havent and Im not going to. I have sort of just forgot about it. There is no way that megace and compazine are going to provide the same relief that marinol has and who cares if she is addicted at least she can go about her day without pucking her guts out. Oh dont get me started on my soap box!