How Do You End the Visit Gracefully and on Time?

[adaptation]

Hi, everyone,

First of all, I just LOVE this forum! It keeps me feeling that I am not alone out there in the wilderness. Thank you for your candidness-please don't stop!

You might recognize my b--ching. Sorry if I'm too repetitive.

I'm a HH psych RN. Get paid per visit/hourly rate. No $$ for travel time or mileage, reporting, phone calls, etc. You get my drift. Most visits should average 45 minutes. Average 6 or 7 a day.

Yeah, right!

Clients are pure psych, no acute medical problems, wound care, caths...good thing! I haven't done med/surg in 25 yrs.!

BUT I CAN'T GET OUT OF THE HOUSE IN LESS THAN AN HOUR!!! It's more like almost an hour and a half. I keep an eye on my watch, start with the goodbyes and next appt. times (I book them myself) at about the 40 minute mark, but it never works. The family comes in, clt. produces a paper they need me to sign but "forgot" to give it to me at the beginning, the "waterworks" are flowing copiously, the baby is screaming and her mom with PPD looks like she is going to jump out the window....

I am practically working for free, but I feel guilty lots of times about leaving, even though I know I should be out the door. I'm always behind.

My husband says to "act like a psychiatrist"- TIME'S UP, no matter what trauma the client is reliving at the 40 minute mark. He suggests a watch with an alarm. I'm not quite sure how that would work if I had to reset it after every visit or if that's even doable.

I've also been considering an oven timer with a bell, setting it for the right number of minutes, and putting it in my briefcase. Is this too crass or unprofessional?

Anybody else out there with the same dilemma? How have you solved it? I'd love to know!

[hoolahan, ASN, RN]

I agree w your husband.

Start w the phone call. Hello Mrs. X, I will be arriving at your home at XX time. I will spend 30 minutes (or whatever) with you today. Please have any forms you need me to fill out ready, along w your updated insurance card.

Then when you get to the home. Remind them "we have 30 minutes." Outline what your goals are for that visit. 5 minutes before the end of your time, give the five minute warning. If anyone gives you a hard time, say "I didn't keep you waiting, and I don't think it's fair to keep my next patient waiting either."

How much time does the psychiatrist give them? I got 45 min when I went, not a second more!

Also, at the end of the visit, outline what you and the pt think the goals should be for the next visit, write em down, stand up, get your bag, and leave. If they come at you with papers, kindly explain you will be happy to fill them out on the next visit.

Maybe it's mean, but if you let yourself be used, you will be. Psych patient's need limits. So, I don't really think it is being mean. Plus if you burn out, you will become resentful, and not be of any use to your patient's at all.

You can be good to yourself and to your patient's. It's your agency that you need to ditch. Again, letting yourself be used. Do you track your mileage and the hours it takes to do your case management? I would and turn it in w every payroll. Then you will have a record, and later you can make a stand and be in a better position to demand milegae and hourly reimbursement.

In NJ psych nurses in HH are few and far between. You need to megotiate yourself a better deal. Are there so many psych nurses in your sgency that they can afford to lose you?

[renerian, BSN, RN]

Good thought hoolahan.

renerian

[jansgalRN]

I am a hospice nurse. I can totally relate to you dilemma. One of the hardest lessons to learn in home care is setting boundries. I think there are many reasons for this. First of all, as nurses, we all tend to have varying degrees of codependency. Not meant as a judgement (hello, I am a hospice nurse). We go into the field for many reasons, but we are caring and compassionate people in general. Being assertive is difficult for me. I really have to work on this daily. Secondly, we are welcomed into other people's homes. We are in their comfort zone-not our own. I found this quite challenging when I first left the hospital for home care. I think the most important aspect of setting boundries is something that cannot really be taught or learned. It is a sense for being able to determine the various personalities, communication skills, coping skills and emotional stability of the patients and caregivers that we encounter. Our responses and reactions must, in a way be calculated. I am often at risk of being sucked in to situations and manipulated by patients and family members who are grieving. For me, it is important to be aware of the fact that family dynamics become very raw and sometimes vicious during a crisis. This helps to keep me grounded and, most importantly, objective. I am often times a mediator for family members. The patient just wants everyone else to be okay, and everyone else is in so much pain that they can't recognize their own reactions and responses as being damaging. Learning to set boundries is important for us all. We are at risk for being taken advantage of. Knowing the difference between sincere, helpful, compassionate care and manipulation is extremely difficult, and not as obvious as it seems. One of the ways that I approach this with patients is by educating the caregivers and being very direct. Most people respond very well to this. I assign tasks and reward often. I always carry stickers with me and give them out to patients and caregivers. This boosts their confidence on both sides. I don't expect my patients/caregivers to always know exactly what to do. Generally, they are so afraid to hurt or kill the patient (not to mention being overwhelmed with emotions that no one has a clue how to deal with) that they get so nervous and forget to follow their instincts. Open, honest communication is one of key components when establishing a healthy relationship with your patients, actually, this is a good practice for life in general.