Is this normal? Am I over reacting or just new with nerves? New HHA on Hospice case

[PhillyRNtoBe]

It's 2:30 am and I'm awake, literally losing sleep over a case I was sent on to cover for another Home Health Aide who called out today.

I'm a very new Home Health Aide, I've been working for a month at a small healthcare system and just became CNA certified last week. (I'm also a pre-nursing student.)

I'm extremely nervous in general because patient care is all new to me but I'm eager to learn and willing to help when I can. I'm uncomfortable with the situation I was put into today and I'm wondering if this is just how it is in home health and I have to get used to it or is this not a scenario I should have been dealing with?

My two usual clients are located in an assisted living facility run by the healthcare system I work for. This morning I was working an unusual shift today because my client had a special occasion to attend to and I had been there extra early in the morning. As I was leaving I received a phone call from the scheduler at my office asking me if I could possibly help out on a case right down the street from where I was until 4pm because the aide had an emergency and couldn't stay or called out. I was hesitant because it was a longer day than Im used to and then she said it's a new hospice patient. The scheduler was desperate because the case was 24hr around the clock care and aide already there was waiting to go. She described the case and said this client just became a Hospice and Home Health client as of Monday. She said that she needed food prep, personal care, light house work the typical duties that I already do, she made it seem like this client can talk, eat, swallow, potentially get up and use a commode, no big deal. The only out of the ordinary thing she mentioned was I am not allowed to leave until the next aide comes, even if they are late. She said oh the aide there will tell you what to do......so that didn't happen and this client ended up declining in the last two days and I was blind sided with little to no information.

1.) Report from aide desperate to walk out the door was vague. She didn't properly show me around the clients condo and I didn't know where anything was other than depends as far as supplies etc. She informed me the client declined in the last two days and can no longer, eat, speak or swallow, she said a delivery was coming and the granddaughter might show up and that's about it. She said she just sleeps and you go in and check on her here and there and make sure she is dry, put Vaseline on her lips and ask her if she is in pain or ok. That's it no info about anything else.

2.) I get bombarded non stop from that moment on with people and questions that I could not answer for hours.

3.) I was there for 40mins, then the Visiting Hospice Aide and Visiting Hospice Nurse came at the same time, they didnt identify themselves to me properly to me with titles just first names. I thought the Nurse (male in plain clothes no badge) was a relative at first. I was unsure of what I was supposed to do so I just stood in the room with them and tried to figure out what was going on. They said she had a fever and they worked to bring her temp down. They asked me repeatedly where different things were after I explained I just got there and it's my first time there and I was covering for the girl familiar with the case and the aide before didn't show me where those things were, such as OTC meds, linens, basin, hidden second bathroom that I didn't know existed etc. I said sorry I will help you find what you need but I don't know where that is.

3.) Nurse leaves after vitals, giving Tylenol suppository and morphine and speaking with Hospice Aide. Again says nothing to me about meds or anything new to do except to tell the daughter he was there and gave her grandmother pain medication.

4.) Hospice Aide stays longer and tells me that hospital bed is being delivered, I will be here alone when that happens and I'm responsible for signing for it and coordinating with delivery man and teaching family members later how to use the bed since they didn't schedule to be there when all of the supplies are coming. OH and after that, I'm responsible for TRANSFERRING the patient from her gigantic bed to the new hospital bed with her already grieving granddaughter later and no one else will available to assist. ( small room, large furniture will be filling the room, she offered no advice on how to safely handle the transfer). THEN SHE SAYS," she is declining quickly, this is happening fast, did your office tell you what to do if she passes?" Me: "Nooo, no one has told me or trained me for anything like that." She says to just call the triage nurse number and please stay calm and do not call 911. (I thought this women was eating, talking and able to ambulated when I offered to cover this case, now I'm being told I'm left alone with a women hours away from death and to play soothing music for her.) I just feel inadequately trained for this and I was so freaked out.

5.) Once delivery guy got there, he said there was no room for hospital bed to fit in the space the family requested, I then had to help delivery guy PUSH client's bed, with client in it over to get the new hospital bed. I freaked out when I realized I had to transfer this poor woman in this awkward configuration of furniture.

6.) granddaughter comes back and we did the transfer, we got it done and everything was OK but it could have gone better. I feel like she loses confidence in me after this.

7.) granddaughter begins to ask me about changing morphine dosing times since she just gave her morphine to help cope with the transfer. I told her HHA/CNA's can't answer questions about medication dosing and I suggested she call the nurse if she isn't sure. She looked at me like I had three heads and said "WHY did the other aides help me administer and answer questions about morphine then? Maybe they were just more comfortable than you?" I said maybe the Hospice Aide is allowed to but I as a regular Home Aide I cant. Instead of calling anyone she writes down a note for her sister for later about skipping a morphine dose. (Um Am I wrong here? Have you EVER got involved with Morphine as an aide?!)

8.) client is on oxygen and they were using Vaseline which I though was a no no. Also it was 80 degrees in there and I hadn't eaten in hours and was so hot. Isn't it also a no no to have oxygen in such a high heat environment? Granddaughter acknowledged how hot it was but didn't adjust the thermostat or open windows.

Is all this normal? Why can't Hospice Aides stay longer? What would you do in this situation? What do I need to know or do differently with Hospice clients/families. Should I just decline, taking those cases until I have more experience? Was the scheduler wrong for putting a new aide with no experience on that case or is it my call to say I'm not experienced enough for Hospice cases?

[PhillyRNtoBe]

If there's one thing I've learned in the 18 months since I started working home health, it's to be prepared for anything. Regardless of what

the scheduler or office tells you about a client. The scheduler's priority is to get the case covered, so they really don't care about your

comfort level or length of time with the agency. You may want to decline any further cases like this until you get a few more months of

experience under your belt.

I'm sorry this happened to you, and by the way, I think you handled the situation very well.

Thanks! Yes, after yesterday I realized that they are not the lifeline they were promised to be in orientation that's for sure! They are too busy and just don't have the time to care.

[PhillyRNtoBe]

Instructions are left with the family and usually posted on the refrigerator where I live and work.

If you are the only one in the house when a patient dies, YES, you call the number that hospice gives the family. We teach the family that when the patient dies, they only have to call the hospice nurse. Not her personal phone number (that should never be shared with family) but the number given to the family on the instruction sheet on the refrigerator. The hospice nurse will come out as soon as possible and legally pronounce death. We assist the family about notifying their choice of funeral home and we can stay with the family as long as necessary. There are rules and regs to follow as hospice and people can get into trouble deviating from those.

If the family is there while you are there, they should call the hospice nurse. If they are too distraught, you can call for them. But that's all you need to do.

We do post-mortem care as well and I have had families assist me; I'm assuming if the HHA was still in the home and wanted to assist with this, they could do so. But wait for the hospice nurse to arrive before doing anything with the body.

Your employer needs to do an in-service on hospice rules and regs and what your responsibilities will be. They have short-shrifted you big time.

Thanks for the information! Yes, they had a hospice folder on the table with the triage nurse line number. My office told me its a general number, (I'm assuming to the hospital) that would then transfer the caller to the actual triage nurse. The number she offered me was directly to triage nurse line, not anyone's cell (sorry if that was confusing).

I went through my folder of papers from orientation and the only thing I found was a Hospice guideline sheet that they offer to families with tips on handling a loved one in hospice and a couple little blurbs of information on calling a triage nurse but nothing really insightful about the dynamic between their departments and ours or anything about the Hospice services or any clear rules or policy for aides.

I honestly think the orientation was lacking and they have the wrong aide in there presenting to new hires. She was the type to skip over stuff and say oh you are smart you know what to do, it's common sense stuff that you learned in your CNA class. Wrong, actually, hospital and agency policy trumps what I learned and I'm useless without knowing it. Ugh.

[Nibbles1]

Trial by fire indeed. I have had the same experiences you had. Guess what? You will be able to critically think faster than your cohorts in nursing school, because of these types of situations. Yes, it sucks, but in the long run, you will be able to think on your feet when you encounter an emergency.

[JustMeRN]

That sounds pretty awful.

the worst part of this whole scenerio, to me, is moving a client without proper assistance. As a nurse who hurt her back early on, and still pays for it daily, listen to what I say. JUST SAY NO! You put yours of in a position to potentially injure yourself in a way the would be lasting. I know what you're thinking, you're young, strong, in gcood shape. So was I at 24 when I had an at work back injury. 15 years, and one surgery later it's the gift that continues to give!

Truely though, just say no applies to a lot of things in nursing, and in home care. I have been working in home care 8 months or so now. There are lots of things you don't see in med surg that I have never encountered. Vents, pleurix drains to name a couple. I hadn't seen a vac dressing in more than 5 years. scheduling assigns them to me, because scheduling (at least in my agency) is nonclinical. They don't have access to charts, and even if they did they don't have clincal skills and judgement to read them and assign cases based in acuity, needs, and nurse skills. Even if they could, can you imagine how long that would take! Anyway, when i see something I'm not familiar with a quick call or email to a clinical educator and either someone meets me at the visit, or it gets reassigned. But, I am responsible form my own limits. I think that is something you might think about. If you get somewhere you are not comfortable, don't feel like you need to ride it out. You call a director if you have to and make it clear you need help now. In the end, if you screw up, you are going to be held accountable for not requesting help.

i think you did the best you could but it's a great learning experience for you as well. The biggest lesson is don't be afraid to speak up when you know you are being pushed beyond your current abilities.

[toomuchbaloney]

I am sorry that your agency put you into that difficult situation.

It sounds like you did fine although it certainly didn't feel very fine at the time.

[Libby1987]

Your agency should have provided their dying client with someone with relevant experience, that is their responsibility.

Re you personally, since you're in nursing school, I would advise you to learn more about palliative care and seize these opportunities, it will be invaluable to you as a well rounded nurse.

[nursel56]

I saw your post a few days ago and see that you've got some great advice! Especially about your right to say no to an assignment you don't feel comfortable with and the "trial by fire" part. In home health and hospice or private duty, you are bound to be challenged but you've handled a pretty rocky situation - and sought advice and figured out what to do next time. All the best to you!

[NutmeggeRN, BSN]

You got dumped on, big time! Sounds like you did the best you could with what you had.

[lunchboxRN]

Philly,

It sounds like you did an excellent job in a unexpected situation. I am the RN director at agency with many hospice clients (we work along side Hospice) and I would give you kudos for your actions if you were "my" aide.

A few things:

You did the right thing referring the family member to call hospice with any questions about medication. If other aides before you were giving advice, they were way out of scope. I would encourage you to tell your supervising nurse if you have concerns about any medication administration, etc being done by other aides. This is very dangerous, as you know. Let family members know that that is out of your scope of practice, not legal, and a safety issue. Don't bad mouth the other aides, but you can explain why you cannot do it.

Your agency should have told you what to do in the event of a decline or a death with a hospice patient, plus have the number for hospice on the care plan. Other numbers in case of emergency too, such as family members. In the future, you can always call the office if you don't have the number you need and ask for help.

At my agency the policy is that the aides wait until the relief arrives. If the patient is a&ox3 and says they can leave, they have to confirm with the office. Otherwise, they have to stay as it is for the patients safety. Hopefully it is not a common occurrence at your agency that aides frequently cancel. Hospice aides usually do an hour visit or so, focusing on bathing and other ADLs.

Hospice clients can be very independent or bed bound, as you see. They can decline quickly, slowly, they can bounce back. It can be very satisfying to take care of hospice patients and also very educational. But, I think I would want some experience with "easier" clients at first as well. It sounds like your agency was desperate to fill the shift, so it may not be the usual policy to put new aides in more complex cases. Don't feel bad, you did a good job despite being thrown in a confusing situation. Finally, don't ever feel guilty about turning down an assignment you do not feel comfortable with.

[PhillyRNtoBe]

Philly,

It sounds like you did an excellent job in a unexpected situation. I am the RN director at agency with many hospice clients (we work along side Hospice) and I would give you kudos for your actions if you were "my" aide.

A few things:

You did the right thing referring the family member to call hospice with any questions about medication. If other aides before you were giving advice, they were way out of scope. I would encourage you to tell your supervising nurse if you have concerns about any medication administration, etc being done by other aides. This is very dangerous, as you know. Let family members know that that is out of your scope of practice, not legal, and a safety issue. Don't bad mouth the other aides, but you can explain why you cannot do it.

Your agency should have told you what to do in the event of a decline or a death with a hospice patient, plus have the number for hospice on the care plan. Other numbers in case of emergency too, such as family members. In the future, you can always call the office if you don't have the number you need and ask for help.

At my agency the policy is that the aides wait until the relief arrives. If the patient is a&ox3 and says they can leave, they have to confirm with the office. Otherwise, they have to stay as it is for the patients safety. Hopefully it is not a common occurrence at your agency that aides frequently cancel. Hospice aides usually do an hour visit or so, focusing on bathing and other ADLs.

Hospice clients can be very independent or bed bound, as you see. They can decline quickly, slowly, they can bounce back. It can be very satisfying to take care of hospice patients and also very educational. But, I think I would want some experience with "easier" clients at first as well. It sounds like your agency was desperate to fill the shift, so it may not be the usual policy to put new aides in more complex cases. Don't feel bad, you did a good job despite being thrown in a confusing situation. Finally, don't ever feel guilty about turning down an assignment you do not feel comfortable with.

Thank you for your response! That makes me feel better.

I like that you added not to bad mouth other aides, this is so true. Its important for the client's family to trust everyone involved with care. It never really accomplishes anything to do that.

I'm curious what your thoughts are on the transfer situation. Do you have any specific policy regarding transferring bed bound clients? Are transfers something common for your aides to do and to do without another professional( and without a lift)? Do you think the transfer should have been handled by hospice in this scenario?

I think the reason I feel so uneasy is because I assumed anything regarding patient care would involve a lot of training. My CNA course taught me that we learn basic (general) skills with them but wherever we are hired will provide us with specific on the job training. I didn't realize that this doesn't exactly apply to home health the same way it does LTC. (Don't get me wrong, I love my regular cases and clients, I love working in home health so far, but that hospice case threw me a curveball.).

[JustBeachyNurse, LPN]

Thank you for your response! That makes me feel better.

I like that you added not to bad mouth other aides, this is so true. Its important for the client's family to trust everyone involved with care. It never really accomplishes anything to do that.

I'm curious what your thoughts are on the transfer situation. Do you have any specific policy regarding transferring bed bound clients? Are transfers something common for your aides to do and to do without another professional( and without a lift)? Do you think the transfer should have been handled by hospice in this scenario?

I think the reason I feel so uneasy is because I assumed anything regarding patient care would involve a lot of training. My CNA course taught me that we learn basic (general) skills with them but wherever we are hired will provide us with specific on the job training. I didn't realize that this doesn't exactly apply to home health the same way it does LTC. (Don't get me wrong, I love my regular cases and clients, I love working in home health so far, but that hospice case threw me a curveball.).

In my state CNAs cannot work home health or hospice until they complete bridge to CHHA training, at agency cost (most agencies therefore provide the training) it's approximately 1-2 weeks part time going over relevant legalities, difference in scope of practice and responsibilities, professional boundaries are more at risk in home care. This makes sense to me.

[PhillyRNtoBe]

In my state CNAs cannot work home health or hospice until they complete bridge to CHHA training, at agency cost (most agencies therefore provide the training) it's approximately 1-2 weeks part time going over relevant legalities, difference in scope of practice and responsibilities, professional boundaries are more at risk in home care. This makes sense to me.

It's strange because it's the opposite where I live, there is no type of certification needed to be a HHA, some places have a little class they offer before they have you go out on cases but being an CNA trumps that. If you are certified as a nurse aide you bypass their Home Health training class and can be hired and sent out right away with no experience.