Did I simply shadow a lazy Hospice RN during clinical?

[SNB1014, RN]

Hi all,

I am an RN student and we had 2 days in hospice care to shadow an RN. I simply adore the concept of Hospice, but after this week's shadowing, I have a sour taste about it. Please let me know if this is "typical" or simply a bad nurse?

My nurse went to a chain drugstore, to pick up "discounted v-day chocolates", and spent 30mins there. she did this both days. When visiting pts, the only remotely medical skills she used were auscultating the heart and lungs (barely?!?) and BP (although i caught her 2x inflating only to 80....then telling the pt he had a 120/XX bp). she asked when the last BM was, and general "how are you feeling?". with every pt, she either proceeded to play with their pets, chit chat about vacations/ small talk with the family, and shoot-the-breeze with her pts.

Granted, I am thankful that none of the pts were in such a sickly state that I had to witness anything truly heartbreaking, but WHAT WAS THE POINT OF HER VISIT?

I truly didnt see her document even one BP. No medications were administered, no general physical assessment (edema, pressure ulcers, etc). If i was medicare/family paying for this service, i would be ticked.

The nurse seemed to truly adore her patients and was very kind, but can someone please explain to me if this is standard hospice care?

[leslie :-D]

not seeing her as "lazy".

when i shadowed a hospice nurse as a student, my hospice nurse pretty much acted the same way.

when you say she "barely" auscultated heart/lungs...i wouldn't be so judgmental just yet.

actually, i'd withhold being judgmental at all.

if a pt isn't in crisis, often we'll do a quick listen, just to compare to baseline.

even when chatting, we are still assessing our pts.

and as a couple of pts told my hospice nurse, "i don't feel like i have cancer".

not all hospice pts are going to require acute intervention.

we are the pt's lifeline...for their physical, emotional, spiritual needs.

believe me, when the pt starts deteriorating...the (experienced) hospice nurse will pick up on the most subtle signs and intervene accordingly.

so...to answer your question, NO, you did not shadow a "lazy hospice rn".

more realistic, is that none of the pts had any needs that necessitated concern from the nurse.

leslie

[tewdles, RN]

Hospice nurses are not driven by the need to accomplish tasks. We are not the caregivers. Hospice nurses are visiting the patient and carrying out a nursing plan of care. You visited 2 days with a nurse who will visit those same dying people many times over weeks to months. What you missed was that it is her job to have a trusting relationship with these people...in the good days...so that in the not so good days they will listen to her, and believe what she says, and seek her counsel.

That means that sometimes we visit and a big portion of the visit is social...heck I had game dates with one old gal. She routinely beat me at dominoes. She trusted me and I helped her have a peaceful death in the room her mother had birthed her. I visited another woman who bred and raised a particular breed of dogs. Her female had whelped about 2 weeks before I met her. She took great joy in the fact that I love dogs, was not afraid of hers, and didn't mind if the puppies chewed on my shoes a bit. We watched those pups grow together and when the last one was sold she was done...she died within the week.

I am sure that a student might have wondered, at some of those visits, what the heck I was offering these patients. It is unfortunate that she apparently did not talk to you about hospice, tell you the importance of relationships, the focus on life and comfort and seeing the joys in everyday things.

Frankly, many acute care nurses long for the autonomy to have the ability to walk through a store during your shift, or gasp...schedule an afternoon DDS appt for your kid.

Personally, I do not feel a compulsion to check VS every time I visit a patient. It really depends upon the patient and the POC. If I need the data I collect it, if I don't need it I don't. It does trouble me that the nurse was not, by your observation, honest with the patient about VS.

Primarily I would like you to consider that you saw a VERY small slice of hospice nursing and really gained no appreciation for what it actually encompasses.

[SoCalRN1970]

I agree with the ladies above. My current agency requires vs on every visit.. But I worked at one agency that did not. I would only take vital signs if there was a change in status! That is how that agency worked. I had one agency that only required us to measure wounds monthly! One that requires weekly!! So, saying that some habits may have formed on the nurse you were out with as well.

I have been doing this 8 years. I have found that yes.. as far as physical assessment I may just breeze through it. I know my patients.. and about 20% of any of my visits is clinical. The other 80% is psych soc.

If this is something that is a turn off to you.. I would like to see you in the feild after a few years... you will see what I mean. 80% of what we do is psych social.. the other 20% is clinical for sure.

[caliotter3]

I read the visit notes of a HHA who did hospice visits and wrote "socialization" as the purpose of her visits. I did not form the opinion that she was a lazy HHA, but that she was following the plan of care. Sometimes we get caught up in a task orientation view.

[ErinS, BSN, RN]

You pretty much described the way many of my visits go (but in a more negative light than I view them). Hospice is a different point of view. These clients invite me into their home. They invite me into their entire lives- I often know most of the dirty laundry, their pets, their kids, their neighbors, their church members. I see them over and over and over during the course of weeks to months. I chat with them and hope I brighten their day with some laughter. During this time I assess color, circulation, pain, dyspnea, anxiety, confusion, agitation, caregiver fatigue, weight loss, ability to complete adls. Vital signs are generally over rated in a long term situation, and a quick listen to the heart and lungs is often enough to detect new crackles, a new murmur, wheezing.

Also, my job is extremely stressful a lot of the time. But when it is not stressful, and everyone is managed through my hard work and foresight of potential problems, it is almost easy. And flexible. And sometimes I stop in the middle of my day to buy some chocolates. Sometimes I even share them with my patients! Hope this helps.

[SNB1014, RN]

thank you to all the hospice RNs who answered me questions. I apologize if I came off like I was demeaning the specialty. I suppose after the many hospital clinical days, I was surprised by the huge change. Thanks for clearing it up!

[Whispera, MSN, RN]

I agree with everything everyone said, but I'd like to be the devil's advocate here too.

Let's say the nurse you followed was incompetent, lazy, or having a couple of bad days. I hope you wouldn't judge a whole area of specialization by a less-than-satisfying observation of one bad apple. I'm so glad you came here to ask about your impressions.

[tencat]

Hospice is probably the most misunderstood niche of nursing there is, at least in my experience. Either people are terrified of it (I can't watch a patient die!) or they are suspicious of it (Morphine??? Are you crazy???? He'll quit breathing!) and most other medical people I've run into don't take the time to understand it.

Psychosocial stuff is a HUGE part of what we do (I sit and watch Judge Judy with one of my patients as a large part of our visit because that's what he likes to do and he's lonely. I really don't LIKE her, but it makes him happy). Do I check vitals? Yes, I find them to be valuable to me as they can show me when a patient might be making a turn for the worse, especially if they can't tell me what's going on for whatever reason. Usually we've worked with our patients for a long enough period of time that we know what's going on with them without a detailed assessment every time we visit. Ask your clinical nurse about what she does when her clients become more unstable, maybe request she help you see a more unstable patient with another nurse if she doesn't have any right now? It will take more than two days with her to see what hospice is about.

[HospiceRN88]

As I recent grad and a new hospice nurse, I see what you're saying. Hospice nursing is a whole different thing. There are times I feel I'm not "doing" anything. I rarely use the skills I learned in school. I don't change dressings or give meds (my patients are in nursing homes). I take vitals at each visit and assess all the things others have stated. I know my patients better than the nurses who work at the facility. Generally, it is me that comes to facility staff and notifies them that there is a change, or death is imminent.

In hospice, it is all about comfort. Comfort in the physical sense and the pyschological sense for BOTH the patient and the family. I have one patient who likes to hold my hand and push my hair behind my ears, so that's what we do at each visit. I have another patient who likes to watch "Jerry Springer" and although I feel dumber for doing it, that is what I do. Those are the days that I feel "lazy" and less nurse-like.

Come follow me on a day when my patient is "tanking" and you will see phone calls to familiy members, meds given (depending on facility) and possibly tears.

I recently had a patient pass and the daughter called me to ask if I would come to the service. I informed her I would be out of town, but would be thinking of her. She stated that they would reschedule the service so I could be there as I was such a huge part of her mom being able to die comfortably. I was (and am) honored.

If you are interested in being a hospice nurse I would suggest becoming a volunteer.