New grad in hospice = doomed?

tnmarie · Nov 1, 2012

I certainly wouldn't say you are doomed. Hospice is a whole other animal. I'm not saying that having med surg experience wouldn't offer some advantages, but I know it is not mandatory in order to be a great hospice nurse. Congrats on your new hospice job :-).

tewdles, RN · Nov 1, 2012

That med-surg experience is not required. Home hospice care requires well developed critical thinking skills that often come after some time in a more controlled environment where you have immediate access to peers for their knowledge and support.

The rigors of case management are too often a bigger jump in responsibility than many new grad nurses can handle. The whole objective of training a new case manager is to create a successful transition to that autonomous work environment. Putting someone in over their head right from the start is not a recipe for success in home hospice.

appleman · Nov 3, 2012

Thats great that you like Hospice care. Everyone has a different calling !

OhioRN1234 · Nov 8, 2012

I started my career over three years ago as a hospice homecare nurse. I did it for six months until we moved. It was tough and a real running start to working. You know what though, I have stayed with hospice and work in an ipu and love it. You have to start somewhere and while the traditional route is great for most, you have found yourself in a different place and are making it work. Medsurge work can be done in the field and learning will be had!

Your previous experience is invaluable! I was a cashier right before I graduated with my bsn! Talk about green!

MarcyRN · Nov 10, 2012

I agree. You're definitely not doomed!

I went to nursing school knowing I wanted to do hospice. Through a series of circumstances, I ended up doing three years in a hospital; one year on a cardiac stepdown unit, then two years in its cardiac ICU. For me, I'm glad it worked out this way, even though it's not what I originally set out to do. I feel the hospital experience really honed my critical thinking skills and helped me visualize the various disease processes and their progressions. Not sure how to explain it. Let's see. Take your CHF. Okay. I sat in nursing school and heard the teacher lecture about CHF and its treatment. I read about it. But I'm not sure I really learned about CHF in nursing school. I think I wouldn't have recognized it if it bit me in the butt when I first got out of school. But seeing it over and over and over again at the hospital, well, I learned all about CHF by rote learning. Maybe that's just me and how I learn. But the three years in a hospital gave me first-hand experience in the things we do and see over and over again. It gave me the confidence in assessing my patients and offering my recommendations to patients, families, and especially the NPs and hospice docs I work with. I'm CONFIDENT in my assessment skills for the first time since I've been a nurse. I don't know if that makes any sense.

I'll see one of my hospice patients and be like....hmmm....they're not peeing as per family reports. The little bit they do pee is STINKY. My patient is really warm to the touch, and is flushed, but reads afebrile on my thermometer. I'm thinking he's either dehydrated or maybe has a UTI. He doesn't have any change in mental status. Hmmmmm. Okay. I'm leaning toward dehydration because the family reports he's been refusing food and drink. Just to be sure, I'll call the MD or NP and tell them what I'm seeing and what I'm thinking. 9 times out of 10, they'll totally agree with my assessment and go with whatever I think. In that scenario, I'll usually ask the MD/NP if they want to do a course of abx just in case there's an infection brewing. They almost always do. I like that I feel like my docs and NPs rely on me, my assessment and my critical thinking skills, and trust my judgment and most times accept my recommendations without a second thought. I'm not sure I'd even have the confidence to MAKE such recommendations if I hadn't had the hospital experience.

So, while I think hospital experience before hospice experience was beneficial for ME (maybe a slow learner? ;-), I certainly also believe that anyone can be trained/mentored/apprenticed into any specialty. I just think if you get to spend some time in a hospital first, you have greater exposure to a host of problems you might not recognize or know what to do with when it's just you in the field.

That said, it sounds like you're doing a great job! Doomed? Nah! Enjoy!

eaduarte · Nov 22, 2012

You are NOT doomed. I speak from experience. My first "real" RN job was with hospice and I loved it and excelled at it. I am one of the top RN case managers that the company has and I have stayed longer than some other "experienced" RNs who have come and gone to work with our company.

I think that your experience as a CNA and your PASSION to learn and care for these patients is what makes you successful. I don't think that you are missing anything that would make you an awesome hospice RN. I know that a lot of people think that getting all your RN skills honed in on by working med-surg is the only way to do things, but I don't think this is entirely true, especially since you have years of healthcare experience. Any job or role that you do as a nurse is going to require learning and discovering (knocking the dust off) certain skills that you don't use daily, but this doesn't make you any lesser of a nurse. Also there are numerous RNs who do administrative work and who would need help and assistance in doing patient care because they have developed a different skill set. I even knew one of the nurses in the ICU who was afraid and bad at starting IVs and that was because she worked in a unit that had an IV team and she never had to do them and when the time came up that she needed to, she would have to get someone else to do it because she couldn't perform that skill.

But back to your question...you are not doomed and it sounds like you are doing an awesome job and are on your way to being an awesome hospice RN. It sounds like you are on top of things, so I think that you will continue to be successful!!

rnchpnhospice · May 1, 2014

Since this was first posted 2012 I would take it you are doing well in your job as a hospice RN. As an Educator for a hospice organization and having work in the hospice field now for over 10 years. I think the reason why many "state" you need time working in Med-Surg, ED, ICU is because may "new" nurse have no or very little "bedside" experience prior to graduating. I take it you worked as a CNA which is good. I was in the US Military and a Corpsman, served in combat so had a lot of "clinical experience" to pull from.

The concern I have about bringing in a new nurse who will be going to patients homes with limited experience is the fact they are just that. In a home "alone" with the patient and family. The family looking to the nurse as the "medical expert". Yes, there is a "Doc" at the end of a phone line.

But, when a patient is bleeding out, or having terminal agitation or Resp. failure. The family "boning" off the walls that nurse needs to have the confidence in their clinical assessment, critical thinking to know what to do. All the while projecting a level of calm and peace through it all.

Also, without seeing what a patient looks like prior to having terminal agitation/Resp. Failure how can you then teach it to your families?

I hope you have gotten your CHPN, and was able to go the ELNEC (ELNEC being a learning course for a new hospice RN).

Also, I take it you had a good mentoring/preceptorship program. (If a new nurse is looking for going into hospice shortly after graduation this is something I was ask about and get information on before coming on board.)

Again from your posts you have taken the ball and ran with it. For that great job!! We need "new nurses" coming in.

One last thing if an "experienced RN" are thinking about doing hospice, "before they retire" please do it sooner rather than latter. I don't what to say "older nurse" feel well I will do it before I retire. Thinking hospice RNs just sit at the bedside and hold the patients hands.

Hospice RNs work hard, they are independent which is fun but hard as well. There is a lot of reasonability to running a case load of 16-25 patients. It is the RN that runs it, in charge if it and "makes it happen".

Take care

Drew.

Tenebrae, BSN, RN · May 18, 2014

I'm just entering my second year (new grad last year) in district nursing. We do alot of palliative care.

Best advice I could offer, dont panic about what you dont know. Never be afraid to say to a patient or their family "look, I actually dont know the answer to that however I will ask a colleague about this and get back to you'. You will find that you will be like a sponge and probably be surprised about how much you have learn in a short time.

When I first started out I didnt know how to explain the role of the specialist palliative care to a patient. How does one say to a patient "this service is here because you are going to die from your illness". Never thought that one day I would be able to be having conversations with family re how they want the end to be, does the person who is palliative want to stay at home, are they ok with an inpatient hospice service if needed. Have they discussed with their family members what they want done in terms of funeral. Am also doing medications, setting up of syringe drivers, giving bolus medications, inserting catheters etc Things that I never thought I could do my first year out from nursng school

All the best

rnchpnhospice · May 21, 2014

Tenebrae,

Happy to hear that you are out there and having fun as a RN.

Just to remind you of a couple things "Palliative care" can occur while a patient is under curative care. It's focus is to address symptoms (pain, N/V, fatigue, etc.) as a result of aggrieve treatment. This normally occurs in hospitals.

Were "Hospice Care" is focused also on symptom management but when curative treatment is no longer on the table. In a lot of our older patients they are taking advantage the Medicare hospice benefit.

It is for patients with a "life limiting illness" meaning a presumed prognosis of 6 months or less. This of course does not mean the patient "must be dead" in six months but it is presumed if the "illness takes a normal progression" the patient may be dead in six months.

True it is hard to have the conversation! It is equally hard to go up to an attending and speak honestly advocating for the patient. Asking the question, "What are we really doing for Mr. Smith" "Is this really want he and his family wishes" Only us nurses (if we allow ourselves the time) can truly get to know our patients. Their fears and wishes. One of the things I say to those coming into hospice or possibly coming in. Is "If you were to write the story from this point on what would it be. True, you would of course rather not have the "cancer" but, what is important to you and your family now and in the further."

Then I go into how we (hospice) can possibly achieve some of the those goals.

Again happy to have you on board and wish you luck on learning more.

Drew

vic.10 · Jun 25, 2015

Thank you so very much for your response to the nurse just like me. I had same thoughts brewing because I accepted hospice case manager position as a new grad. I too had many nurses telling me that ICU is better and I am good at it and "you don't have to critically think at hospice" and that's why when you decide to take hospital job no one will want you". I strongly disagree with that. I was critically thinking a lot during my preceptorship. I was hired right after hospice preceptorship because I did an "awesome job" and I really cannot picture myself doing anything else. I love hospice and now I know I will do great!

gala

PghRN15 · Jun 28, 2015

I was a CNA with Hospice, when I became an LPN I stayed with the same Hospice and now as a new RN I continue to be with the same hospice. It is all I have ever done. You are not doomed.