Hospice Nurses The Good the Bad and the Ugly

Hospice is a program that provides palliative care and attends to the emotional and spiritual needs of terminally ill patients at an inpatient facility or at the patient's home. Nurses General Nursing Article

Hospice Nurses The Good the Bad and the Ugly

Care for terminal patients is becoming a booming business as the Boomers come of age. Being one myself, I can tell you that Nursing care for these patients will only become more critical as shortages continue in the nursing field, even as new nursing schools ramp forward for the next big boom in our industry!

I have a Pet Peeve though which really irks me. It's nurses who do not truly care for their patients. It's Nurses who perform their jobs with reckless abandonment. It is nurses who entered the field for the money and not for providing true Nursing care to patients.

When we look back at Florence Nightingale and the inspiration which sprang forth from her and the drive to help others the Modern nursing method began to take hold and develop as she created and started the first school of Nursing.

What is it hospice Nurses do? A Primary function is support! Familial support, patient support, physician support, facility support, logistics and planning, record keeping and followup and follow through with orders and basic nursing functions as we go about our Jobs taking care of patients.

If there is one revolving theme among hospice organizations it is turnover! Not only patient turn over which is expected, but care giver turnover.

There are of course many reasons for such turnover. Burnout is a key factor in this specific and very frustrating segment of the health care field. Lets face it our patients are going to die and there is nothing we can do to stop it! That is a hard thing to get use to for a Nurse I think. We spend a few years to a number of years in school to learn to care for people and to help facilitate the healing process and the real blunt truth is Non of our Patience will heal or get better save a miracle from God and they likely will die.

I think some nurses enter this field because it is one of the fastest growing fields in health care along with the Money which is often the best in the industry for such a specific field as far as nurses go.

One should be a well rounded nurse. Having cut their teeth in Med surge to gain basic skills and often many other specific fields within Nursing. Experience is a key factor in ones ability. I see such dynamic changes nowadays. I see nurses coming straight out of school with basic skill set entering this field because of the money and not because of the ability to effect change for the patience.

Call me old fashion but patient care is an all encompassing field and requires a skill set with many different areas and is a dynamic field. Dealing with Terminal patience takes a certain type of person, male or female it takes what I like to call a caring soul. One who with empathy for the patient and with a self propelling drive to make their situation as comfortable and as easy as possible. Dying is not an easy process and some deal with it very differently. I believe in my heart the Nurse has to be an Jack of all trades. An advocate for the patient, the ability to stand up to the physician when they wish to do things which the patient does not want to have done. The ability to hold a hand, share a hug, hand out a kiss or two and to be a support to the patient, family and friends and also help them to gain knowledge of their rights and to help them do the things they can do and to be at ease as one can be with their impending death.

In reality everyone wants to be cared for and to feel that they are in control of their situation as much as possible and our job is to facilitate that in every way possible. To make sure that they are as informed as they wish to be about their condition and to help them navigate the health care system and to receive the best possible care and to provide the best options possible giving their conditions and situations which may dictate.

Nurses need to be careful that they do not simply walk and perform basic skills with out including their patients into the mix which a number do not. I have seen nurses walk in a room never say hello, never acknowledge the patient, simply sit read the chart begin to do things to the patient and never tell them what they are doing and forget that they are dealing with a Live person and not some Log. Nurses need to stop take a deep breath and to bring the patient into the conversation where possible and include them in everything they do. They need to seek the patients assistance and to help the patient to navigate the dying process if possible and to help them in every way possible.

nursing is a well respected field going through many changes and growing so dramatically and as nurses, health care professionals we have got to get back to the basics of Florence Nightingale and to help our New nurses to gain critical knowledge of patient dynamics and teach them skills in communication which seem to be seriously lacking.

To be fair there are a great Many nurses who care deeply about their patients and do everything in their power to help their patients in every way possible and are very deliberate in their actions on the patients behalf and to those nurses I give them a pat on the back.

Hospice is a difficult field as are many such specific nitch nursing fields and require a well rounded and capable nurse able to navigate the entire process for their patients.

I intend to create a course for Hospice nurses and to get it approved for CEU's on dealing with Hospice patients and I pray that the next wave of nurses out of school before they jump straight into hospice go and gain some well needed knowledge and practicle work experience in a hospital so that their skills are well rounded it is so critical to have some basic knowledge and Nursing school only gives us a very small snap shot of skills.

Lets face it if you get to do more than one procedure twice while in nursing school it is a Minor miricle given the time constraints in the hospital settings in which we train while doing clinical settings.

I love this field so much and worry that without the kinds of skills and basic understandings and knowledge its the patients who ultimately suffer...

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hissteps4u

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Lovely sentiment. What do you think of Assisted Living Facilities having Hospice patients and do not provide direct care services? Who advertise Hospice Services but do not have staff to provide direct care or pain medications because they "are not trained to assess pain" or how to care for a bedridden patient. In Hospice "comfort" is the focus, and how does one provide comfort when the care givers are not qualified to care for the patient and when family is not told this care will not be provided? Families are led to believe Hospice is present 24/7 We know what constitutes eligibility in Hospice for 24 hour or continuous care. If education is needed the Hospice Nurse provides it but it goes unheeded.The nurse is told by these Assisted Living facilities that they do not want the "patients" to be out of their rooms for fear of the "wrong image" for their facility. How wonderful caring and compassion would be but in reality the bottom line is the dollar. The AL facility charges $8,000 a month for a room...when the person becomes debilitated or terminal rather than lose this income ( perhaps 6 months worth) the Assisted Living preys on these families to squeeze out another profit...and promises what they do not in reality provide.

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lovely sentiment. what do you think of assisted living facilities having hospice patients and do not provide direct care services? who advertise hospice services but do not have staff to provide direct care or pain medications because they "are not trained to assess pain" or how to care for a bedridden patient.

i live and work in the pacific northwest wont say where it makes no difference the concept and ideals are the same. i know a number of excellent al facilities who are not only capable but do an excellent job at helping their patients get the full range of services required depending upon their particular diagnosis. conversely i know many facilities who's only drive and ambition is numbers because numbers=$$$$$ this is particularly true in private pay facilities. while they are generally in a very beautiful location and have beautiful homes and amenities that is the facade and lurking beneath is the almighty dollar to pay off these homes. generally run by immigrant families as a business venture in this area anyway and it is a cash cow! it's just that simple in the industry.

way to many folks are in it for the money and not for the care of patients. while it is a regulated industry the regulations are so lax and levels of competence between one facility and another can be daunting for families when they are out there seeking help for their family members and legally we are not allowed to steer a family in one direction or the other

in hospice "comfort" is the focus, and how does one provide comfort when the care givers are not qualified to care for the patient and when family is not told this care will not be provided?

it is true that some care givers are not really qualified to a degree or even trained adequately to handle the myriad of problems which can develop in hospice patients along the way. there are some very minimum qualifications in place for care givers. certification as cna/cma is in my view important yet even with that many who enter the field lack the compassion required for service in such a nitch industry.

families are led to believe hospice is present 24/7 we know what constitutes eligibility in hospice for 24 hour or continuous care. if education is needed the hospice nurse provides it but it goes unheeded.

24/7 hospice facilities are few and far between. the real issue is education of the patients, their families and facilities as well. hospice organizations are everywhere with licensed nurses working all over with varying degrees of experience and expertise sad to say but as in my original post there are many nurses who are in hospice for the money and not the patients and do not have the personal communications skill set to be an effective hospice nurse. lets face it. i have stood toe to toe with a dr and argued that he could not force a patient to do tests if the patient stated they did not wish to do them. most nurses i know do not have the gumption to make such a stand for fear of their jobs yet as a hospice nurse who is first in the equation the physician or the patient? it is the patient always! conversely there are some dr's in the field who are ill suited for such work and they usually do not last long as hospice directors. i have seen them come and go as i have seen nurses come and go. it is hard work yet worthwhile work.

hospice generally speaking is not a 24/7 constant contact yet they are available 24/7 for consults and problems as they arise. most patients get seen 2 times a week by a hospice nurse this is the norm and the frequency increases as the patient deteriorates and becomes worse and all this is natural..

what i fine more than not are going back over a nurses patients and what i fine disheartening are nurses who go for a visit sit for two hours looking through a chart and then spending no time at all with the patient in evaluation of their current condition or if they do not addressing with a sense of urgency the problems they may discover with that visit. sending a fax for instance for an urgent situation and letting it go at that is simply unacceptable. where is the sense of urgency, where is the call placed to the dr demanding they answer the problem at hand? yes dr's have a life yet as the primary caregivers they have a duty and responsibility to address the patients needs in a timely fashion and we as nurses have a responsibility to make sure that the answers and issues get addressed promptly which effect care and the well being of the patient

the nurse is told by these assisted living facilities that they do not want the "patients" to be out of their rooms for fear of the "wrong image" for their facility. how wonderful caring and compassion would be but in reality the bottom line is the dollar. the al facility charges $8,000 a month for a room...when the person becomes debilitated or terminal rather than lose this income ( perhaps 6 months worth) the assisted living preys on these families to squeeze out another profit...and promises what they do not in reality provide.

there are unscrupulous alf's around that's for sure. thats where a great ombudsman or case manager ought to be involved and giving the family some great advice. it is a money game unfortunately.

when hospice becomes involved we assume control of meds and dme and bills related to the admitting diagnosis only>>>>> many folks think we pay for everything no matetr what and that is just not the case at all.

if the patient for instance wants aggressive treatment for a cure then they are usually discharged from hospice that's not what hospice is nor what we do. hospice does not pay for aggressive treatment or for long term rehabilitative measure which are not palliative in nature or designed for relief of pain in adding comfort or control of the patient.

some nurses fail at communicating properly to the patients families and patients what hospice is and how it functions. some do excellent jobs at it while others may simply gloss over the important points rather than go in-depth. a great hospice nurse will spend as much time as necessary to teach the patient and family and help them in the process and instruct them why we are there and what the ultimate outcome is and how we can help them in the process.

if we as hospice nurses walk in the outcome is usually not in doubt.

hospice has a ways to go and need to be careful when hireing staff for these jobs. times have changed and the industry is growing so fast it is hard to keep up and staff.

companies need to be cautious when staffing and seeking qualified applicants. we can train most folks to do most any kind of job but you can not train out an attitude or behavior from someone and there are many who want to enter the field who may have great skills yet do not have the drive or energy required to follow through for their patients.

20 or more patients is not uncommon to have and staffing is always a problem it seems and more disturbing then that is watching nurses go from hospice organization to hospice organization and still as ineffective as they were in the first one yet because of the constant openings they are hired yet again to fill vacant positions and perpetuate the problems in the kinds of service which the patients deserve.

one bad nurse can cause a company to stumble and fail and lack of action on the companies part to correct the problem can bring down a company and cause problems across the board.

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I'm currently a hospice nurse. I graduated nursing school May 2007. I've been a hospice RN since June. I LOVE my job!! I can't tell you how many times I've heard "You're too young to be a nurse," or "I can't believe you're doing hospice nursing, you're not a seasoned nurse yet." "Hospice nursing is for older RNs." I believe all these statements are false! I maybe young *(I'm 21 years old) and I may have only had one year acute care experience, but I dont believe that ultimately effects the care I give. All of my patients are so thankful to see me, and anything they need I take care of immediately (whether it be medication supplies, etc)! People ask me how I can do hospice and deal with death and dying everyday, but in reality it doesn't effect me like people think it would. When I was in an acute care setting, I saw the same patients come in and out, in and out and suffer through procedure, after surgery, after procedure. Many of these patients are terminal. What kind of quality of life is there when you spend your last few months in the hospital or even worse, dying on the table during a hopeless procedure?? The patients I have enjoy everyday of their last few weeks or months with their loved ones and doing different activities. It's such a privledge to be a part of their life before God decides to take them to a better place. :redbeathe

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Specializes in oncology.

I agree with you, in that I worry the nursing profession will succomb to the desire of people who just want to make good money. In my 14 years as a nurse, I have seen my share of nurses whose hearts just don't seem to be in it for the right reasons. As an oncology nurse, and now a hospice nurse, I am often very close to the patient's family, as well as the patient. I don't think a nurse whose reasons for nursing are financially related can give one on one care in a truly loving, giving way. You must love people, be a "giver" and get satisfaction from helping others, and making them feel good. Especially in the hospice home setting, a genuine desire to love people, and ease their suffering is a must. I feel blessed that I have been able to help my patients transition comfortably to their next life, and provide comfort and support to their family members. How can you do that without being sincere about it? Everything from bandaids to burial requires a level of compassion and love for the patient! Nursing needs to remain professional and legitimate!:nurse:

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Specializes in Hospice. Also home health and oncology..

I'm currently a hospice nurse. I graduated nursing school May 2007. I've been a hospice RN since June. I LOVE my job!! I can't tell you how many times I've heard "You're too young to be a nurse," or "I can't believe you're doing hospice nursing, you're not a seasoned nurse yet." "Hospice nursing is for older RNs." I believe all these statements are false! I maybe young *(I'm 21 years old) and I may have only had one year acute care experience, but I dont believe that ultimately effects the care I give. All of my patients are so thankful to see me, and anything they need I take care of immediately (whether it be medication supplies, etc)! People ask me how I can do hospice and deal with death and dying everyday, but in reality it doesn't effect me like people think it would. When I was in an acute care setting, I saw the same patients come in and out, in and out and suffer through procedure, after surgery, after procedure. Many of these patients are terminal. What kind of quality of life is there when you spend your last few months in the hospital or even worse, dying on the table during a hopeless procedure?? The patients I have enjoy everyday of their last few weeks or months with their loved ones and doing different activities. It's such a privledge to be a part of their life before God decides to take them to a better place. :redbeathe

I have been a nurse for almost 20 years...17 of those years are in hospice. I started as a home hospice nurse and have spent most (15) of my years in hospice administration. I have always, always made sure that the care of the patient and family are the center of my decisions and the care we provide. Over the past years, I have hired and lost many nurses and in the process learned alot about turnover. One of the "rules" in general is to make sure a nurse has at least a year of med surg or ICU nursing prior to hiring into hospice. There are many reasons for this. I don't think anyone would ever question a nurse's dedication to patient care or their desire to want to "be" a certain type of nurse. Hospice, like ICU, obstetrics, and ER, is a very specialized area of care. It has been my experience that for a nurse to succeed they need a minimal amount of experience in various areas of nursing. Hospice nurses are performing care in patients' homes...they have to have excellent assessment skills. The nurse must be comfortable and experienced in making on the spot decisions regarding patient care. In hospice we utilize medications for symptoms that are not traditionally used for some symptoms...therefore nurses have to be able to assess symptom needs, understand how those medications are used and why as well as their mechanisms, etc. The hospice nurse must understand the dying process, nearing death awareness and how to assess for those signs and symptoms. The hospice nurse must take all of the aspects of hospice care (including the regulations and how they work in caring for the patient) and be able to educate the patient and family with confidence in all aspects of palliative care. Even more importantly, the hospice nurse has to know how to effectively integrate all of these aspects of care in order to provide the highest quality end of life care possible to the patient and family. Most likely when people are saying you are too young, it has more to do with your lack of life experience than it does with your nursing experience. Most young nurses have not had a ton of experience with life and death in general...not to mention so many other psychosocial issues that come into play when you are dealing with, not so much the hospice patient, but with the patient's families. So much of what we do is based off of life experience, and that is something you cannot be taught through a textbook or through a powerpoint presentation.

I'm not saying that a young nurse cannot be successful in hospice. What I'm saying is that the young nurse needs exceptional orientation, education, and continued oversight in order to succeed. Nurses don't know what they do not know. I'm sure you believe that you do know how to be a hospice nurse. Would you walk into the L&D unit thinking you could deliver a baby? Or would you think you could walk onto the ICU and think you could take care of a patient with multiple monitors and tubes without ever having been there? A lot of hospice nursing is innate. I believe there are qualities of hospice nurses that cannot be taught...I also believe that this is the reason for much of the turnover. I wish there were more enthusiastic young nurses like you that desired to become hospice nurses. What I'm trying to say to you is please be open to continuing to learn. It takes at least two years to mold a well-rounded, experienced hospice nurse...and even then if someone does not possess those innate qualities their probabilities of success are probably going to intervene with their ability to succeed at some point. After 17 years in hospice nursing, there is never a day that goes by that I don't learn something new...and so much of that has been from the patients and families with which I have had contact. I don't believe anyone questions whether you love your job or whether you provide your patients with what you "think" it is they need. But there are needs a patient may have that you may not have experience in dealing with, or needs that maybe you have not been trained to manage or assess...like I said, one does not know what they do not know...most of the time that comes with experience, many times the life experience that you and others may not have yet. The next two years of your hospice career will tell you alot...I wish you the very best...it is one of the most rewarding and outstanding area of nursing that exists. I want you and all of the other young nurses in our professional field to succeed (I am currently mentoring a very young nurse myself). We need all of the great nurses (of all ages) that we can get in hospice nursing. More than that, I hope with all of my heart that you have an experienced, dedicated, knowledgeable nursing supervisor that understands and identifies the special needs of the young hospice nurse. I hope this person also understands that hospice nurses need to be nurtured and cared for as well. For it will be that person who is most responsible for the success or failure of anyone that desires to be a great hospice nurse. :wink2:

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I want to share a letter my mentor in Hospice shared with me when I chose to enter the speciality of Hospice nursing as a novice, although I had been in nursing nearly 20 years. I was so encouraged by this Hospice Nurse who demonstrated each and every day the embodiment of compassion. This nurse is an author, a nurse educator at a local university and has a Masters in Hospice Nursing. Of these credentials , those that she possesses that are the most profoundly evident are true compassion, dedication and commitment to her patients, their families and the people whose lives she touches every day. Here is an excerpt from "Hospice through my eyes"..."Care is a promise we make to all of our patients and their families." "Care is focused on easing the physical,emotional and spiritual pain that often accompanies terminal illness." "Our common goal is to walk with our patients at the ends of their lives and with their families, to treat them with respect and dignity." "They have often come from months or years of cure focused treatment where they have had little choice in what happened to them." "We give them back their choice when choices seem so few.""We treat them as human beings." "When people find out I am a hospice nurse, they usually have one of three responses---I could never do what you do." "I don't know how you do what you do"", or they have a story to share of an experience they have had with hospice."...She continues by saying :"The trouble I think is that death has become a medical event and caring a professional role and it is really a matter of relationships to ourselves and to others."...This letter is a long one and too long to quote in its entirety here...but it I hope will give the young hospice nurse some insight on what it takes to be a hospice nurse. The writer has been a hospice nurse 18 years and a leader that mentors new hospice nurses in a postive and holistic manner just as she cares for her patients and families. We as nurses all have skills and we can all learn to perform the tasks of clinical nursing .However, hospice calls for the nurse to reach within her/himself and be willing to walk with our patients and families on the final journey and to do so with true connection and compassionate care. The unfortunate truth is : that as in life we do not live in a perfect world . Institutional concepts of business and profit often overwhelm nurses with the push to take on as many patients as possible. This drives many hospice nurses away from the speciality just as it does nurses who work in hospitals,nursing homes etc..We have to choose to do what is right for the focus of our care..our patients and their families. Sometimes, it means speaking up when we face these corporations and institutions that are involved in hospice for sheer profit and speaking as advocates for compassionate care. It is a humble and sacred place to be and deserving of our best.

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Specializes in Geriatrics, Hospice.

I have been in Hospice nursing exclusively for a few years now. When I made the switch to Hospice only, there were many many great nurses. Most of the fellow nurses are gone now, frustrated and moved on. We have a plethora of nurses now that have poor language skills, very poor clinical skills and view the job as "easy" and frankly 8 out of 10 night nurses sleep the majority of their shift. The quality of the nurses has gone downhill at a 90 degree angle. I had one primary nurse show up at a patient house wearing something down to her navel and up to her crotch and had her kid with her. Does that say proffesional to you? The language barrier seems to be the hardest on both the patients and myself. I can't understand a word they are saying in report and when I say what or speak slower they get an attitude that I am being racist or something. The patients are frustrated becuause they can't understand the instructions and tell me about it becuase they can understand me! I also get relieved on average of 20 min late each shift. Is this happening everywhere or only in south Florida?

I do want to be clear that I love my job and adore my patients, just would appreciate a little more proffesionalism and a higher standard of care from my co-workers.

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How sad that as a profession nursing has become just another "job". I was employed by a Hospice organization that I was unfortunately mistaken in thinking had wanted to change the direction of for profit healthcare and incorporate high standards of care into the corporate rat race for medicare money. I was sadly mistaken. The Hospice was swallowed up by a mega corporation soley out to make dollars from the elders in our society. Greed now consumes inheritances,homes,and life savings meant to provide for the last years of life. Families having to attach second mortgages on homes long paid off and put spouses living in them out ,so the other spouse can remain at an assisted living or apply for medicaid once they have been gleaned by this organization.The tragic part is even when paying 8,000 a month for an AL the resident will not be cared for if Hospice is needed ( although this organizations boasts of Hospice services). Yes Hospice is provided but according to COPs we cannot provide 24/7 care and the AL leads families to believe their dying loved one is being cared for 24/7. The care managers however cannot administer the potent Hospice medications to patients in pain and cannot care properly for a severely debilitated Hospice patient who may need to be fed or is incontinent. The Wellness nurses are calling Hospice in to change colostomy bags at 2 am or replace foley catheters ( not part of the patients terminal diagnosis but a comorbid). I had a med tech say to me in front of AL management that "Hospice nurses write Roxanol orders to keep a patient sedated and eventually kill them". I was informed many times that is is not the responsibility of AL care managers to change a Hospice patients urine saturated sheets. So my patients did not recieve compassionate, dignified, comfort care and their loved ones spent precious time angry because they saw the patients care was substandard. I sat by one patients bed 8 hours a day to ensure appropriate care and in that 8 hours not one manager or staff member in that organization charging $8,000 a month walked into that patients room. The patient was not on continuous care but I knew without Hospice's physical presence the patient would not be cared for. Why then are these huge for profit senior living communities allowed to advertise they provide Hospice services? Hospice would teach family caregivers if the patient's were in their home but we could not expect to teach these care managers. Time and again we were demeaned and ignored. Who suffers from this? The patients who are living the final phase of life and their families.

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Specializes in Hospice, LTC.

I became a hospice nurse with only 1 year of LTC experience and have been a hospice nurse for 2 years now. I had been an aide for several years before that, and had worked in the hospital as an aide. I don't necessarily think that experience is the true determination of whether or not you can "do" hospice. I think it is a calling and you must be called to do it in order to be appropriate. I know that this is what I am meant to do, this is my PASSION. I live to do what I do on a daily basis, it is what drives me. I feel that I am very good at what I do, and strive every day to learn better ways to provide palliative care. It is that desire that makes a good hospice nurse. I have seen nurses that are "seasoned" who couldn't cut it. It takes a special type of nurse to provide hospice care and IMO no nurse that is in it for the money will ever be happy or adequate at their job.

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Hospice nursing is a calling and it is a challenge like none other I have experienced in 20 years of nursing. It requires a willingness to engage with another human being and their loved ones at a time when emotions are raw and open. It also requires a willingness to listen and at times simply be present. The skills end of Hospice can be "learned" but the compassionate skills cannot and must be within the nurse from the get go. This applies to all Hospice team members. NurseAlwaysNForever your correct "seasoned" nurses or Hospice novice we are all called on to constantly improve the delivery of palliative and comfort care, improve ourselves and grow as compassionate Hospice clinicians. We must never neglect our own emotional.spiritual and physical needs as well. Hospice is a team approach to care and team members need to support one another , be available to lend an ear, provide comfort and support one another.

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I made the mistake of pointing out flaws in two ALFs and my Hospice organization terminated my position. I did not know asking why a patient wasn't getting the prescribed pain medication would lead to me losing my job.

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