Flying Solo - Week 2 orientation

[captain morgan]

I am in week 2 of orientation in hospice and wanted some feedback on a situation that happened today. I was the only nurse in today with an admission on a Friday afternoon of a holiday weekend (need I go on???) I have not been oriented on an admission, or the CAAD pump that the pt required for continuous pain relief via a chemo port. (are we having fun yet???) I stumbled my way through the above in a little over 3 hours and left the pt's home wondering what the he.... I got myself in to. The pt is very sick with lung ca and multiple comorbidities. Also, the PCP was on his way to sunny Florida for the weekend.

The only other RN that I could ask questions of was over 3 hours away and there was no cell reception where I was at.

I feel I did the pt and his family a disservice by just "making due" and "getting it done".

Any advice for a week 2 orientation newbee?

Thanks.

[aimeee, BSN, RN]

I'm incredulous that a hospice would send a nurse who is completely new to hospice out to do an admission, untrained, in her second week of orientation. If this is indicative of your training program, it sounds like you will not be getting the education, support, and mentoring you need to succeed. My advice is look for another position at a hospice where they invest the time to TRAIN their staff to ensure they are delivering quality care to their patients.

[Hospice Nurse LPN, BSN, RN]

I'm incredulous that a hospice would send a nurse who is completely new to hospice out to do an admission, untrained, in her second week of orientation.

On Tuesday I'm starting with another hospice and will be getting a two week orientation. They asked me if I wanted the full two weeks and I said "I sure do"! I've been doing hospice nursing for about 7 years now, but every place is different and I couldn't imagine trying to go at it with less. Good luck to you!

[aimeee, BSN, RN]

We have a full six weeks orientation for case managers and we have found that when they have no previous hospice experience, if we attempt to put them in the field solo any sooner than that, we do ourselves and them a disservice. They flounder and burn out before they really get the wind beneath their wings. They suffer, their patients don't get the excellent care they deserve, and we suffer with them. Its a false economy not to put the necessary resources into training and orientation.

[debblynn13]

aimee, how does your orientation work?

I started at my current job 7 weeks ago and am now officially off orientation. I had no previous experience in hospice. I was on the oncology floor for 18 months prior. Last week our referal /admit nurse was sick and the other new nurse and i were thrown into doing them. It has just been overwelming. By friday I was 3 days behind in charting and paper work. I know I will get faster but it sure has been frustrating to struggle through it basically on our own.

And can you tell me how long it takes to do an average admission? Both the visit time and then the charting time? I am not sure the manager knows how time intensive it is. {she doesn't know how to do the computer charting at all}

debblynn

[aimeee, BSN, RN]

I am not certain what all is on the agendas for training because I am not in charge of it but we do have all our nurses spend a full day with each of the other disciplines. They also usually spend a day observing in the Intake office as well as going out to observe an admission. They attend and observe IDT meetings. We have two other branch offices so they spend a day at each of those as well (we can do double duty by having them go out with the other discipline from that office) We have a fairly complicated computerized charting system so there is a lot of time devoted to learning how to do things in the computer system. There are a number of required modules on bloodborne pathogens, body mechanics, cultural sensitivity, etc. I know there is not as much on symptom management as I would like. A lot of that is learned from their peers as they do joint visits while they are starting off. When they seem like they have things they will be given maybe 4 patients to case manage and then gradually the case load is increased as they gain expertise and become more efficient and proficient.

Admissions take a minimum of 4 hours including travel, visit, and documentation. It is not unusual for them to take 5 or 6 if the patient is in a mess or there are lots of difficult dynamics to sort through. This includes all the collaboration with physician and counseling services, phone calls to pharmacy, dme company, etc which can take as much as an hour before they even start typing! Time in the home is rarely much less than an hour an a half, even for the most brisk of the nurses.

[wonderbee, BSN, RN]

My orientation was similar to that described by Aimeee. I've only been in hospice nursing four months and have just begun taking call at the end of last month. My PCC wouldn't dream of putting a new case manager in the position of the OP. OP, maybe you can negotiate for a complete orientation? If not, this is not a good indication of what's ahead.

Admissions take me a good long while because I do them so seldom. So much paperwork to sort through. Throw in family dynamics and raw emotions and it's all afternoon.

[captain morgan]

Thanks for all of your responses - Tomorrow is a new day and I can only pray that it will go better than Friday went. I am planning on having a very serious conversation with "corporate" and let them know how I feel about being thrown into something I have not been adequately trained in. That being said, does anyone know how to access a chemo port for IV morphine (how often do you change the needle and dressing???). I have never even seen the procedure in the "clinical procedures" manual in the office. So, again I go to the experts - YOU. Thanks and God Bless.

[debblynn13]

Ask them for training on the port. Ports are wonderful creations and you want to keep them working properly. You will need to use the SASH Method when you administer medication. {saline flush, administer med, saline flush and then heparin flush).

The port needle and dressing we change weekly. I would not change a port needle without training. Is this port being used daily? Some of our ports are not accessed and we just access them to flush with heparin once a month.

Deb

[aimeee, BSN, RN]

The infusion company that supplied you with the pump and morphine cassette will probably have a standard protocol sheet for you. We use the SASH too, but don't recall the exact amounts. I agree with Debbie that it would be good to have a training session on the port before you attempt the needle change. The huber needle has a little bend in the tip and there is a particular stabilization and removal motion that works like a charm. We also change needle and dressing weekly.

[AtlantaRN, RN]

we had a nurse start on tuesday, and she did her own admission on Friday. Granted, it was a simple admission and No pump to deal with. I offered to go out with her and she said she would call with any questions. She did better than I did, I went with a nurse to do 2 admissions (just to get used to addressing the questions families may have). Shoot, I STILL have questions!!!