Hateful LTC Staff...How Should I deal With It?

dorianna · Jan 10, 2009

How awful for you! I work in an LTC facility and we love hospice!

leslie :-D · Jan 10, 2009

you shouldn't have to handle this conspiracy by yourself.

it is high time for your mgr to have a chat with the DON at the ltc facility.

submit your grievance in writing to your mgr, so s/he has the hard copy of series of events that is inevitably, compromising quality care.

keep on going up the chain until you get desired/acceptable results.

this is totally juvenile, spiteful and unacceptable.

good luck, tencat.:icon_hug:

leslie

SunnyAndrsn · Jan 10, 2009

I hope you can get your hospice team supervisor to come in and have a little chit chat with the LTC DON! Up until now, we've had great experiences with hospice and hospice staff. We love having them there! We had a hospice pt. a few months back that wasn't with us for very long before he died, I was the nurse on duty when he was admitted to hospice, I'll never forget that nurse working so hard WITH ME to make sure we were on the same page as far as pain medication goes. "Don't be stingy with the morphine" was what she told me. I wasn't, and I'm he was able to pass quite peacefully, without pain.

Our hospice nurses take phone orders for us, when it's necessary, but by and large that's still MY patient and I'll get the care the pt. needs and update hospice if they are not there when changes happen. I thought this was a no-brainer!

We do have one MD who does NOT like hospice for the reasons you mentioned, ie, "you're doing the same thing anyway." He thinks that it's "just one more hand in the medicare pot." Just goes to show the difference between nursing care and medical practice.

I hope your hospice can work things out--but please get them involved. The moving your charts is so nasty, I'm shocked, we have a specific spot for the hospice charts, AND the hospice nurse has access to all of our charts as well.

Yeesh!

I love my job as a hospice nurse. I usually get to go to patient's private homes and treat them there. Within the last couple of months I've been asked to work in our local LTC facility and team-treat patients there in addition to my home patients. Our hospice is not affiliated with the LTC other than we have a contract to also be able to come in and treat patients in their facility. From the beginning the social worker, the DON, and the nursing staff have been adamant that they neither need nor want hospice to set foot in there. They claim that they are doing the same things we do, so what's the point? NOT the case, by the way, but I degress. Every time I see a patient, many of the CNAs, nurses, etc. have been outright hostile and harrassing. I have had my patient records I've brought in mysteriously 'disappear' (found them again, thank God, but had a heartattack). I've had nurses point blank refuse to help me find anything, waste meds with me, or give me access to medications stored in the facility. I've had the DON tell a physician that I didn't write down any of her telephone orders when I had written them AND taped them in the facility's chart. And physician told me "I can't give the orders to you, you don't write them down." So I had to track down the DON to take the orders. I've had the DON tell me that orders from our hospice medical director are not 'valid' in their facility. I've had the assistant DON call my boss and say I told a family to pull oxygen from a patient, when it was the daughter who got it into her head that it needed to be done, and she was POA, AND physician tried to talk her out of it, too. RNs have refused to give PRN morphine because mostly unresponsive patient didn't 'look' like he was in pain (with a BP of 130/75 and grimacing).....and DON directed the nurses not to give the morphine AT ALL, period, the list goes on.
Today was my personal last straw when I had one of the RNs call me to ream me out because she had to call a physician to get an order for one of our patients and I wasn't 'doing' my job as that was not HER job. Excuse me? Who sees the patient 12 hours a day? If patient has a pain crisis at 0700, when I am not yet at work, then it IS YOUR job to call the physician, especially when physician WILL call back the LTC but not the NURSE from hospice......(have left numerous pages for said doctor, nada...zip...zero). My hand hurts from all the documenting I've been doing, but I am at a loss how else to handle this. I spend 3-5 hours of my day dealing with the documentation and crap from this facility, almost daily at this point. So what else should I do? I'm about to have a heart attack from the stress of it all. Any suggestions would be appreciated.

Long Term Care Columnist / Guide · Jan 10, 2009

I'm sorry you're having so much difficulty with this LTC.

Please be assured that not all LTC nurses/facilities are like that. There is nothing I, as a charge nurse, appreciate more than a good hospice nurse who works with me to manage OUR patient's care. I am more than happy to cooperate when I am asked for charts, meds etc. as long as it's understood that I am the patient's primary nurse. It's not about our egos; it's about what's best for the patient and his/her loved ones. It's about coordinating services so that none are duplicated or neglected. It's about efficiency and quality care.

I don't know you personally, but when there is such conflict between a nurse and a facility, both parties involved should probably take a good look at the way they approach one another. From experience, I can tell you that LTC nurses are sometimes pretty defensive---you would not believe the number of nurses in other types of facilities who look down on us for working in such an 'unglamorous' specialty. Sometimes the 'outsider' is seen as arrogant or demanding, or as coming into the facility with an attitude, when s/he really is just focused.

I've also been on the other end, the nurse who comes in to a facility to evaluate a patient, and I always took care to be respectful of the nurses there, for I recognized that they knew much more about him/her than I did.

What everyone needs to remember is that we are all on the same side, for the same reasons, and we need to work together to serve the interests of the patient.

Just my two pence worth.:wink2:

FireStarterRN, BSN, RN · Jan 10, 2009

What a nightmare, I'm so sorry. That place sounds utterly toxic!

DusktilDawn · Jan 10, 2009

I agree with Leslie, you should talk to your manager about what has been going on along with documentation. I think your manager needs to go higher than the DON at this facility. Obviously the Social worker and DON do not understand the purpose of having a hospice nurse come in and that ignorance is passed down to the staff. Obviously some things need to be clarified regarding orders. I'm not sure why you would tape physician orders on a chart, wouldn't they be placed with the other physican orders on the chart. I'm just unclear on this point.

The rest of the behavior you describe is deplorable and inexcusable, but I do think it stems from the leadership on that unit and is based on their own ignorance about hospice itself and the purpose that you as a hospice nurse are there to provide. They fail to see the necessity and have turned the situation into an adversarial battle. They fail to realize how this compromises the patients. This is why I think your manager needs to go above the DON since the DON is probably a bigger part of the problem than the social worker and the staff.

tencat · Jan 10, 2009

Thank you all. I don't have anything against LTC or LTC nurses. It's a tough job, especially when you have to be responsible for so many patients. And I agree that the RNs in the facility know the patients so much better than I do as they are there with them for so much longer during a shift. My boss is going in and we're all going to sit down and hash out exactly what I am and am not allowed to do, and how the facility wants me to handle things when they come up. If there's something in writing (I'm taking notes!) then it's easy to refer back to it when issues arise.

I just have a few of the nurses who say "It's my patient and I know best" which I totally respect, then they turn around and say "but it's your responsibility to get doctor orders" without even ASKING me to do it or informing me that something is needed. I can't read minds very well.....and things come up on weekends, the middle of the night, etc. that need to be handled then, not wait. Also, hospice is not allowed to have the medications on hand that we have on hand in a patient home, so every time something is needed, we have to go through the lengthy process of trying to get the doc on the phone, then get it from a local pharmacy. The problem also lies in the fact that the physicians in my small town blow off the hospice nurses constantly, so getting hold of a PCP is also incredibly difficult for me (not so for the facility). Add to that "your medical director can't write orders in the facility" (who is very available to us all the time) and it feels like a no win situation.

gentlegiver, ASN, LPN, RN · Jan 10, 2009

I am amazed that the Dr's and management of this faculity is doing that to you and the pt! Hospice is such a vital part of keeping the pt comfortable. I wish you luck with the meeting, but I have the feeling that they'll say one thing then do another. Sounds like a really bad place for pts and to work.

CoffeeRTC, BSN, RN · Jan 10, 2009

I agree with Leslie too, but from your second post, I don't think you are part of the problem at all. Since your medical director doesn't have privliges, he cannot give an order for a pt there, he can give you the order then you or the nurses at the facility need to get it approved by the PCP. Our docs always accept these orders and rarely do they even want called. Most of our docs are clueless.

We don't use a lot of hospice in our building, because for the most part, we really do what you do already....but...I wish we would use it more. So much more support for the resident and family. Another reason (at least I think this is why) that they don't push hospice as much as they should, may have something do do with payment issues. Now it has been a few yrs since I've dealth with the financials, but I seem to remember that they don't get reimbursed as much or something along those lines? Not sure if this is true or maybe it could be happening in your situation??

At the very least, your supervisor should get involved and have a meeting with the DON. This is totally unacceptable. Never have I had a hospice nurse give me a "bad" or unacceptable order or step on any of our feet.

deyo321 · Jan 10, 2009

I have to admit when I first started in LTC I was a little territorial. And I do feel like I do an excellent job with end of life care. That being said I have followed nurses who act like they are paying for the damn morphine. You tell me in report that they have had a quiet night with no PRN and I go down there and their RR is 24. Hellooo. I was q2 ing em yesterday. I digress...

I wonder if the nurses are unsure of the role of hospice and just need a little education. After more experience I became quite grateful for the support, especially when it comes to helping the families. So what I am saying is that any attitude I may have shown a hospice nurse was based on two things. My lack of knowledge of the process and my feeling that that was MY patient. So I would suggest your supervisor offer the DON some inservicing for staff on the role of hospice (good luck) and that you work hard to be a team builder not a seperatist. I am not implying that you are not, just sharing with you how I felt as a new nurse when hospice stepped in.

After many, many end of lifes and doing private home hospice I am now grateful for any help I can get. I have been out of it for a number of years but I found hospice to be very personally fulfilling. Focus on all the good you do when the turkeys get you down.

dorianna · Jan 10, 2009

I am a med tech at a LTC. I took the Hospice Volunteer course 3 years ago just to learn more about hospice. I absolutely love what they are doing and would work there in a heartbeat if they had a better salary and benefits. I wish all LTC workers could take that course!