LTC Question

[RNWithAHeart]

Hi,

I am new to Hospice and went out on Fri on my own for the first time. I had 5 patient visits in one LTC. All 5 of these pts were non-verbal. I felt like I was really no help to these pts at all. When I spoke to the RN regarding each pt, I would ask "Have there been any changes, do you have any concerns, do you have any needs" In each instance the answer was one word "no." Maybe bacause I was new to the facility, but I felt like they didn't want to be bothered with me? How can you have 5 pts in a LTC that have NO problems or needs? The wife of one of the pts was there, so I was able to speak with her and comfort her for a while. I spent 7 hours in this facility and felt useless. I am sure that these pts knew that I was there and hopefully I was a comfort to them.

Any words of advice/suggestions?:bowingpur

[SuesquatchRN, BSN, RN]

Talk to the patients. Be at eye level, not leaning over them, and talk to them as if they understand every word you say.

You will have to watch their non-verbal cues. I am going to bet that they are being under-medicated for pain - that has been, almost every place I've worked, an issue.

I have had people who never said a word grab my hand and hold on, simply because I was treating them as if they COULD hear me and were in there.

The LTC people don't have the time to spend with them. That will be your biggest gift.

:)

[doodlemom]

Our role in facilities can be very different than in the home. These patients probably need us equally if not more than those being cared for by their families in their homes. With our care, we can advocate for what they need. We can update and support their families, which is very beneficial to them. We can also support the facility staff. Some of these staff people have taken care of the patients for years and have become like family. Establishing and maintaining good relationships with facilities is mostly seen as a PR thing and may not seem part of patient care, but when we have good relationships with facilities - the patients benefit from our presence and the facility will usually pay more attention to our patients if they like and respect us.

[RNWithAHeart]

I guess my main question is how to get the LTC staff to work WITH me in this situation, it just seemed like they did not want to have any input with me regarding the patient visits. I understand that maybe I need to gain their respect as a new nurse coming into their facility, but I just couldn't believe that there was nothing to report at all for these 5 patients. Can you offer me suggestions of how to present myself and my assistance to engage the LTC staff in supporting my role there as a Hospice nurse so that I can be of help to them and their patients?

[doodlemom]

My recommendation is to start small; pick one person (preferably one of the nurses) to get to know more and more with each visit. It is hard on the first one or two visits, but after you go 2-3 times, you will more than likely feel more welcomed. The nurses may indeed not have anything new to tell you about your patients. Dementia patients can go for weeks and months without anything new. We have gotten so accustomed to crisis care in our line of work that when there is no crisis, we tend to think there is something wrong. Another thing about nursing facilities; a lot of the time the nurses are taking care of a whole hall of residents and don't notice a whole lot unless there is a major change.

[marachne]

I would also say that, in addition to getting to know the/a nurse, find out if there are particular aides who work with your pts. They are the ones who are a lot more likely to notice small changes, be able to clue you in to what behavioral things are "normal" and what are not for that patient. As someone else said, if they are a long-term resident of the facility, it is likely that there are people there who know them well and care about them.

I think facility hospice is in a lot of ways harder than home b/c you're having to interface with a whole system and structure -- AL can be even more challenging-- finding out who are your best contacts w/i a setting is a challenge in and of itself.

Also ditto on interacting with them like they can hear/understand. Touch is very important. Think about the other senses too -- rubbing in some nice (and nice smelling) lotion, playing (or singing!) music that has meaning to them.

As someone else said, pain is often under dx/tx in LTC, and with dementia it is even more of a problem. Look at their problem list--OA? Chronic back pain? Joint replacement? People seem to think that chronic pain conditions don't exist anymore when you can't get a complaint.

I realize I'm making assumptions when you say non-verbal that these are CI people....

A couple of resources: Hospice of the Valley has put together a dementia program and there are some things that you might find helpful.

Also, the How to Try This series just released one on Pain Assessment in Older Adults module.

Finally, if there is family around, yes, give them the same time and energy as you would in the home!

I'm curious, did you get any specific training/precepted time in non-home settings?

Good luck!

[RNWithAHeart]

Thanks everyone for the responses. These pts were non verbal as in 1 has end stage MS and has not spoken a word in 10 years. 1 is Alzheimer's, 1 is post CVA, and 2 are dementia patients.

As far as training, I have had 5 days of training with 3 different RN's. We saw pts in the home setting, AL facility and LTC.

These pts that I saw on Friday will not necessarily be on my caseload, they are having me go out on my own now to get "routine visits" down. I am evpected to be given a caseload in about a week I guess.

[chele9633]

I work as a hospice runner so i don't ever get to build a relationship with the pts or staff but i have found that in LTC some of the nurses are very abrasive and don't want to give much info or act like you are bothering them. I think they feel somewhat threatened like we are going to come in and take over. Thats not the case at all. We are all looking out for the quality of life for each pt therefore, we are all on the same page. I think it gets better each time you show your face and I think you should "kill em with kindness".

As for you feeling like u did nothing, thats not true. Just your presence to comfort and oversee each pt is doing something even if they cant respond to you. Listen 2 ur gut and use your skills to access them. Use the flacc scale to assess their comfort level. Trust me, if someone is not ok, you'll know it. Not only that, dementia pts have good and bad days. You may have caught them on a good day. Keep your chin up!!! They need you:heartbeat

[marachne]

chele9633 has a point about issues of turf wars. And, I hate to say it, but there are some hospice nurses who do come on like they are the font of all wisdom and ignore the "local knowledge" (knowledge of the patient, setting, staff etc.) that the LTC staff have.

As was said, cultivate your relationships with the staff. Show that you are on the same side, that you want to establish a cooperative, collaborative relationship. Share your knowledge with them in a way that informs w/o making them feel like you're talking down to them. Acknowledge their stresses/limitations, show how what you do is both helping the pt and making their life easier and you'll probably get on fine (provided it isn't just a burnt-out, cynical person).

5 days & 3 nurses doesn't seem like much training/orientation. If you're not feeling like you have enough to work on your own, advocate for more orientation time. If that doesn't work, you might just cast about for someone who might be willing to mentor you. Good luck! miriam