Advice on hospice social worker role

[Spidey's mom]

Good morning - I need some advice but I'll give you the scenario first.

I opened a new patient two days ago. The social worker always goes with the nurse so we get everything done on the first visit. We are also a small rural hospice with 3 nurses and at the most 12 patients. We only have 3 right now.

This patient is over 400 pounds, with weeping edema to his legs, groin, abd. After the social worker did her thing, I began my physical assessment. Part of the assessment was to take the blanket off (he was naked due to the fluid running off his body). I asked him first, was it ok if the social worker stayed during the assessment. He said ok. As I moved in front of him I was between the sw and the patient and said with a smile, "I'll be blocking most of the view".

Today, the social worker and the manager talked to me about the sw being a team member and it was ok if she helped with patient care. My response was that was fine but I was going to ask the patient's permission first. I'm the patient advocate and my role is to protect his privacy. The sw continued the conversation saying I shouldn't have said I would be blocking the view as that hurt her feelings, since the patient had ok'd her being there.

Now, I've never had a person have their feelings get hurt because my goal was to protect the privacy of the patient.

Do your social workers help with patient care? (I'm actually ok with that as long as the patient is ok).

Did I do anything wrong to the social worker?

steph

[Maryann RN]

I guess I am playing devils advocate here but I'm really not understanding where most of you are coming from. My experience has been that ALL hospice team members are patient advocates and protect patient privacy. As the nurse/case manager I know that I am responsible for the team but have never considered my role more important than anyone elses. In the case mentioned, once the patient agreed to have the SW present it was a done deal. I never totally uncover a patient even when I am alone with them. We need to protect their dignity and modesty. We should all have been taught this in nursing 101. I can do a complete assessment, bathe a patient and keep them covered the whole time. You only uncover the part of the body you are working with at any given time. Part of the role of a SW is to be able to identify pain, depression, anxiety, delirium and mobility when with a patient. I frequently get calls from the SW, who is with a patient, describing what they are seeing. they have called me about new skin tears, possible pain, anxiety etc. with the patient. Our aides and chaplains do the same thing. Of course they are not medical and do not do a medical assessment but know enough to call the nurse. I do feel the SW in this situation should have discussed her feelings with the nurse after the visit was over. If they could not have resolved it then they both together, should have taken it to a higher level for help in rsolving this. Hospice nursing is challenging enough without having the stress of internal team conflicts. I hope you can resolve this and let it go. Take care of yourself and appreciate that what you do can be difficult, Your team needs to be there to support each other.

[jerseyRN]

My guess is your boss is not a nurse. She places both you and the sw in the uncomfortable position of exceeding/ignoring your scopes of practice. Yes, in hospice we work as a team, and there have been a few times when I've needed a sw to take the other side of the draw sheet and help me lift someone in bed, or order the 02 concentrator. But in the circumstance you were dealing with, the sw's I know would have had the good sense to excuse themselves and leave the room, or at minimum, turn away and use that time to offer support to family members while the nurse did her thing.

[Spidey's mom, ADN, BSN, RN]

Mary Ann - I appreciate your take as we are a very small rural hospice and the sw has at times helped with the patient.

I think where I'm coming from mostly is the social worker being upset that I asked the patient if it was ok for her to stay during the assessment. Her thoughts are that I don't need to ask, that hospice is different than acute nursing when it comes to questions like this and that I didn't need to ask the patient if it was ok for her to stay.

Actually my first open with her I decided to give the patient a bed bath and back rub. The family left and she helped me.

My major beef is with her not understanding the true role of a nurse regarding advocacy and privacy and saying hospice is different for RN's.

The other thing is, I never expected this issue to even pop up and was surprised at her bringing it up after she had discussed it with our boss (who is an RN too).

I meant absolutely nothing personal towards her when I asked the patient. She took it very personally.

That is the crux of the issue.

I really appreciate everyone hashing this out with me by the way. :flowersfo

And we are the only local hospice where the nurses can wear scrubs - all home health care and hospice nurses in the surrounding areas wear street clothes.

steph

[Maryann RN]

It has been interesting reading all the responses you have gotten. It just bothered me to hear the anger and vindictiveness in some of the e-mails. As I said before, hospice is difficult and challenging enough with patients and families without having conflicts with team membrs. I had a MAJOR disagreement with a SW a few months ago. It caused me alot of stress. the next day we went to lunch together and were able to talk about it. It wasn't easy but it was resolved and we didn't have to involve anyone else. We have a great working relationship and the incident has not been mentioned since. I hope for your sake that you are able to put this behind you. It can be challenging working with a team, lots of different personalities, beliefs systems, roles. Hope you have received some good feedback and positive support.

Maryann

[tencat]

The hospice team is one of the wonderful things about hospice. No one is more 'important' than anyone else, and everyone has a specific role to play. I help the aides give baths and do personal care, I pray with the chaplain when he prays with patients, I gather information for social work. I also appreciate it when they call me and say, "Mr. X is in pain and he was wondering if he could take his meds now?" or call me with any other information. The patients often tell the aides things they don't tell anyone else on the team, and I encourage that relationship.

I stink at giving baths, I am not an authority on religion, and I don't know much about what is available for ancillary services in the community for our patients. Aides, the chaplains, and social work are the experts in these areas. I would not presume to give pointers to the aides on baths as they've been giving them longer than I've been alive, I would not tell the chaplain he's not praying right, and I wouldn't tell a social worker that he/she isn't doing his/her job right. I sure as heck wouldn't get my 'feelings' hurt if I got kicked out of the room while patient had a bath or prayed, or whatever. There are times when I need to step back and let the specialist take the lead. There are times when the other members of the team have to do this, as well. It boils down to trusting the others on the team. When a new person is added to the mix, then I think the best approach is to let them use their professional judgement and withhold comment until or unless something happens to prove their judgement isn't so hot. I don't feel like I'm in charge of the team as such. I'm kind of the jumping-off point, a centralized location to organize and communicate to the team what the patient might need.

[jnette, ASN, EMT-I]

Well, from everything I've read here, Steph, I believe you were correct in your judgement and it should never have been taken "personally". I have never worked hospice, and I agree, they are a wonderful breed unto themselves, and may well do things a bit differently, and certainly do consider themselves a team. But I would have done the same as you, certainly, and I think your SW allowed herself to feel "left out" for some odd reason... don't quite understand her reaction... but I feel you did exactly right. :)

[Spidey's mom, ADN, BSN, RN]

I didn't have time this morning to thank you jnette and tencat. You both gave me a lot to think about.

Thank you.

steph

[marachne]

I mentioned that and she came back with "This is not acute care - this is hospice and it is different". And since she has more training than I do, I don't know what I'm talking about.

steph

Not been around this place (or anywhere in the social media for a while) but this caught my eye.

Anytime someone uses their experience as a cudgel it puts up warning flags for me. (I'm assuming the part about you don't know what you're talking about came from her). It also seems that being part of a team doesn't mean that you try and ride roughshod over someone trying to do their job, or that a SW, who should be good at interpersonal relations shouldn't be getting her feelings so hurt when you are talking about a exchange of perspectives among colleagues (and team mates).

One aspect that bothers me is that of role confusion for the patient -- it's hard enough for pts and families to know who is the best person to ask about "X" but when the professionals are making the lines even more blurry, it's worse. As others said, it sounds like a power trip to me, to at least some degree.

I don't think that "being a patient advocate" is solely the nurse's purview, but overall assessment and developing an appropriate approach to care IS.

Good luck with it all. Small communities/organizations can be particularly tricky to navigate -- you do need to depend across disciplines more, and it can become insular and claustrophobic. That said, using "hospice is different" as a trump card is B.S. Hospice is patient centered and family focused. You asking the patient for their OK was EXACTLY WHAT YOU SHOULD BE DOING -- you are giving the patient's needs and desires primacy.

You are still professionals with different scopes of practice, and different places where you are, and should be in control of the proceedings.

[Spidey's mom, ADN, BSN, RN]

not been around this place (or anywhere in the social media for a while) but this caught my eye.

thanks for joining in - i do really appreciate your perspective.

anytime someone uses their experience as a cudgel it puts up warning flags for me. (i'm assuming the part about you don't know what you're talking about came from her). it also seems that being part of a team doesn't mean that you try and ride roughshod over someone trying to do their job, or that a sw, who should be good at interpersonal relations shouldn't be getting her feelings so hurt when you are talking about a exchange of perspectives among colleagues (and team mates).

she does actually have more experience in hospice - i've been there a little over a year. but i agree that using your experience as a cudgel (love that word) is not a healthy way to communicate. i did have a long conversation with another team member who has long experience with her and while we love her, she does struggle with esteem issues and does not excel at interpersonal relations where she feels (rightly or wrongly) threatened. i also spoke with a mentor who used to work hospice and does not know her. she says the manager is partly at fault here and needs to draw some firm lines which should be followed or the sw should be fired. all of us agree that we enable this behavior because we don't confront it because she gets so darn defensive. she starts her msw program soon and i wonder if they have classes on this issue.

one aspect that bothers me is that of role confusion for the patient -- it's hard enough for pts and families to know who is the best person to ask about "x" but when the professionals are making the lines even more blurry, it's worse. as others said, it sounds like a power trip to me, to at least some degree.

i don't think that "being a patient advocate" is solely the nurse's purview, but overall assessment and developing an appropriate approach to care is.

i completely agree that i'm not the only advocate - i was simply trying to get her to understand that my role as a nurse supercedes my role as her teammate.

good luck with it all. small communities/organizations can be particularly tricky to navigate -- you do need to depend across disciplines more, and it can become insular and claustrophobic. that said, using "hospice is different" as a trump card is b.s. hospice is patient centered and family focused. you asking the patient for their ok was exactly what you should be doing -- you are giving the patient's needs and desires primacy.

i think being rural and small is central to this all. plus, we do socialize together - every other month we have dinner at a member's home. we see plays together. we help the sw with her role as drama coach for the local high school.

you are still professionals with different scopes of practice, and different places where you are, and should be in control of the proceedings.

the member i spoke with recommends calmly not allowing her to do this and not backing down - it has happened a couple of times in our weekly meetings since this incident although not related to me. :-)

i dunno . . .we shall see.

thanks for the input.

steph