Company Dynamics, Family Dynamics, Burnout

[UpTheLadder12]

I'm an LVN, 2 1/2 years in hospice as a visiting nurse and continuous care nurse, and I also occasionally take the On Call phone on weekends. I'm finally morphing from the bright-eyed bushy tailed new nurse to Hospice Hulk. I'm really having trouble with some boundary setting with families, and I'm not sure if it's related to the lack of leadership and organization at the company I'm with, or if I just need to be firmer and/or meaner. but I'm losing the ability to have compassion and give good care to my patients due to manipulative and extremely needy caregivers.

the first company I was with was mid-sized, and very organized with an emphasis on training. Nurses were either full time in the field, on call after hours for distress calls, or CC with a set schedule.

the company I'm with now is smaller, the same general pool of nurses covers routine visits, distress calls and CC with a skin-of-the-teeth haphazard style of scheduling and organization. Payment for visits is per diem, CC by the hour, most field nurses are contractors (but paid by W-2 with taxes taken out), you can get overtime for CC beyond 8 hours but not if your visits and CC combined are over 8 hours, no paid breaks on CC. Basically the main advantage of working with this company is that I have never missed a single dance recital or sports game of my little one, because I can always turn down a shift and can usually reschedule visits.

However, I am finding that a lot of my routine pts have complicated family dynamics, and because this company assigns the same nurse to visit the pt 2-3 times per week on contract, and the Case Manager does not see the patient in person under most circumstances, the families and caregivers are relying too heavily on me instead of viewing their care as being provided by the company. and then most families are extremely picky and stubborn about visit times: they all want a visit between 11-2, they expect me to be able to come at EXACTLY 2pm (not gonna happen in LA traffic and a full day of visits) and then many of them are manipulative, tell different stories to me vs case manager. And both the families and case manager expect me to be available 24/7 for extra visits and distress calls for "my" patients. I finally blocked my cell number on outgoing calls because when I would call or text them they would get my number and then call ME at 3am Sunday for distress instead of the hotline, text me with supply orders,etc. just any time of day or night.

i often end up zig zagging around town instead of taking the direct routes from visit to visit, yanked in different directions by the needs of families and case managers. Because I'm payed per visit, sitting in extra traffic costs me sometimes half a day's pay, and disrupts my schedule enough that I might end up seeing pts all seven days of the week for a few hours a day instead of getting any 'real' days off, and I end up turning down CC shifts because of one or two rescheduled visits for that day.

How do you seasoned hospice visiting nurses manage families and keep your schedule under control? Am I being to soft with families that need to work with me on scheduling and communication, or do I need to find a company with better leadership where the patients understand that I am just one arm of the care team, not their personal concierge?

HELP!!!!

[UpTheLadder12]

I should add that we serve the greater Los Angeles area, my route averages 90 miles a day total driving, there is no "rush hour" here, freeways and major streets are jammed from 7am to 7pm and sometimes later, and finding parking for patients in apartment buildings or Assisted Living can take 15-20 minutes if parking lot not available.

[lifelearningrn, BSN, RN]

What exactly does the CM do? It seems to me that you're doing the job the case manager is getting paid to do. You're getting paid per visit. The crisis calls, supplies, etc., should be up to the case manager, imho.

[caliotter3]

Your scenario sounds a lot like what my visiting nurse acquaintance used to complain about doing visits. She told me that she set a two hour window and that was it. According to her, she rarely let the client dictate any timing changes to her. She told them when she was going to be there and that was that. In general, it sounds to me like you need to take charge of your situation so that it benefits you. Push back when dealing with 'not reasonable'. If you can not get the support that you feel you need, then perhaps it is time to visit another company. Not that there are not a lot of hospice companies in the LA area. Unfortunately, you will probably find the same attitude at the rest of them. That is the problem.

[Libby1987]

I'm HH and with the exception of medical need, it's "I'm calling re tomorrow's schedule, I will be in your area in the afternoon, would you like between 2 and 3 or 3 and 4?" Or whatever my window is.

"That doesn't work? I wish I had more flexibility but I will let your case manager know and get you on the schedule as soon as possible...Oh it will work? Okay great! I will see you this afternoon, talk to you soon!" Said with my smiling compassionate voice.

And they will get my darned best when I get there, with no residue resentment.

[Jack Hazz, BSN, RN]

Its time to look for another company. Getting burnt out will do you or your patients no good. I can only imagine what you are going through. We never give out our number to our pts or families. They have to call our office. I have a family member that got very upset when i told him its company policy not to give our numbers and just to call the office number. I just had to stand firm. At the end of the day, we can not effectively help our pts if we can not help ourselves, too.

[softrbreeze]

That sounds like rough working conditions. I'm unfamiliar with that type of set-up for pay but as for the caregivers calling/manipulating you- there could be something within company management contributing to that. A few years ago, I transferred to a nearby (closer to home) national home hospice agency with a similar census and was SHOCKED at the self-perceived neediness and frequent calls which contributed so greatly to my work hours- I went from working a 40-45 hr/work week to working 55-78 hrs/wk. A lot of it was unwillingness of management to answer any calls- they just forwarded all of my patient-related calls to me which slowed down my day considerably. They even had me trying to do things which would have been better accomplished by a social worker or supervisor- like setting up transportation for patients. In the end, only you can decide if the aggravation is worth the flexibility of schedule. Wishing you the best!

[toomuchbaloney]

In large part what you describe is/are boundary issues.

The hospice agency is violating your professional boundaries to meet their needs.

The family is violating boundaries to meet their needs.

It seems that the company you work for is not good at meeting the needs of any party engaged with them.

Turn your phone off at the end of your shift.

The message should clearly state that it is NOT an emergency number and that messages are checked once/24 hours.

The families should be given a written document which describes their communication tree for urgent needs. They should have no confusion about which number to call to acquire an urgent visit, additional equipment, or to change an appointment. Their documentation should clearly identify WHO the RN Case Manager is and it is not you. This is an agency failure and breach of protocol and boundaries if they are not promoting this.

DO NOT zig zag for less than emergent issues. You have a schedule and a plan for the care of patients which was designed to provide the biggest "bang" for the agency's and patients hospice buck. Tell the office that you will get to it at the end of your day. The patients that you have scheduled appointments with are ALSO important to the health of the agency. Those arrangements should be honored as a general practice.

My suspicion is that this agency is gonna give you some flack about protecting yourself.

Fearing that, I would be considering other options while I still had my physical and mental health intact because work conditions like you are describing will harm you, IMHO.

[caliotter3]

I could not agree more with toomuchbaloney's post above.

[TammyG]

The case manager seems to have a pretty limited role in managing the care of these patients, which seems to be contributing to the unwieldy nature of the care, the frequent calls from the family, and the difficulty in managing the schedule. The case manager should know the family best, should be able to anticipate needs, and plan for them in a reasonable fashion. In my company, the case manager is responsible for resolving all needs that arise between 830 – 5 PM. When there is no one managing the care, these types of frequent calls are more likely to arise.