Zippy83

I have been a nurse for 10 years, I’ve done hospital (med/surg and DOU), LTC, subacute, home health, and hospice. I started out as a new grad employee and has to go through the whole orientation process before being let out in the wild. Then after a couple years I started doing per diem and agency/registry, and have been doing that almost entirely for the past 8 years. Before Covid to be registry you had to know your stuff, you had to have verifiable experience, and you were expected to be able to jump in and go. I am so sick now of working alongside registry nurses and CNAs who have no experience and/or integrity. Who on earth would go straight into registry after all that time and money to get your license just to probably lose it because you are taking jobs you can’t handle and are not safe for the patients?? I have had a change of shift in telemetry where I endorsed to a nurse who was obviously clueless but all bubbly and excited, stared she had never worked in a hospital before. She was acting like it was her first day of orientation in a new grad program but she was going to be taking on my 4 patients. Then a bunch of these nurses that don’t understand how 1099 works brag about how much they are making to staff nurses while not doing their job so the staff nurses and other registry like me have to pick up their slack, meanwhile causing animosity regarding pay when they are often clueless about how their pay actually compares to w-2 with benefits. I could tell so many stories but basically the bottom line is that these new agencies will take anyone off the street and these nurses will take any assignment whether they actually can care for the patients or not. And I used to be the one always standing up for the hardworking CNAs, and I still do stand up for the hardworking ones. But I have never seen so many lazy, entitled CNAs than the current crop from registry. In the break room on their phones all shift while the call lights go off AND THEN talk back to you when you had to go find them and ask them to do the job they are getting paid for. Arguing over assignments with the staff CNAs. Arguing when asked to do anything. Missing from the floor half way through the shift and then found sleeping in their car. Or, clocked in and signed in but never checked in for their assignment and literally no longer on the property. I can’t tell you the number of times I’ve seen that. Literally just there to collect a paycheck, not to work at all. While the patients they are supposed to be caring for are soiled or on the floor etc. I’d say I see this in about 50% of registry CNAs. I guess this is what happens when health care companies are all about profit over people for decades. Now they are getting a staff with the same values. The nurses and CNAs that care are burning out like always but now there’s an army of staff that don’t give a good GD about the people in their care to take their place. There have always been these types of nurses and CNAs with no business being there, but to me it’s the sheer volume now and the boldness with which they show up and refuse to do the job that I find shocking and exhausting.

Just did a registry shift where two CNAs didn’t show up and they couldn’t find replacements, and several of the nurses were already pulling doubles. An additional LVN stayed on a double just to help with CNA duties since there was a nurse for each cart. I had 19 patients and luckily it was night shift and the 6AM med pass for these patients was lighter than usual and only had one agitated patient and a couple wander/fall risks. This other nurse who also was on a cart and already on her second shift of the day came over to help me with patient care. I didn’t even ask for help, I knew they were all bombarded so I had already started on a couple patients and she saw me and just jumped right in. Out of my 19 patients, 12 were total care and at least 4 were 2 person. And again I am the charge nurse also, with several patients having PICC lines, foleys, gtubes. I thought it was going to be the nightmare shift of the decade but the other nurses were such absolute team players. Just wanted to share this in light of the convo and give a shout out to those who always give 110%

This conversation came up on a night shift where a fellow registry nurse shared an experience from last year during our regional Covid surge. They only had two nurses, one RN and one LVN, show up at a 120 bed facility. No CNAs. Multiple covid positive and whole facility was supposed to be iso/full PPE for each patient. They stayed and did what they could on that shift. A new grad LVN was part of the convo and she asked what would happen if you leave, and what happens if no one shows up for the next shift. We advised in this case, either don’t take the assignment, meaning when you arrive hopefully before the actual start of shift you call off and don’t take any endorsement or keys etc due to hazardous working conditions. Or if you choose to take the assignment, either way call the Ombudsman, your licensing board, your staffing agency, your malpractice insurance provider, and probably the health dept as well, and report upfront the working conditions, number of staff and patients, everything. That way you won’t get accused of abandonment for not taking the assignment, and protect yourself from liability if you do take the shift. This would be the facility failing the patients but of course they want to shift the blame everywhere they can, so protect yourself and your license first. Then by notifying the proper agencies such as ombudsman and health dept you are also advocating for the patients in the best way you can.

First off, I agree that CNAs are both overworked and under appreciated. I have always tried to show appreciation and respect to EVERYONE on staff, CNAs, kitchen staff, secretaries, maintenance. Everyone is critical to providing care. I also sometimes get laughed at by staff nurses (I’m registry) for being “naive” because I let my CNA team know to call me if they need a two person assist etc, and I am not above any care, I will change diapers, feed etc. But I also have the responsibility and obligation to manage my time and get everything done, and in the past have fallen behind by NOT delegating some of these tasks to free myself up for others that cannot be done by the CNA. As some others have mentioned here, there also is a tendency for everyone, because we are all burnt out, to feel that we are doing all the work and others aren’t, and sometimes it’s because we don’t know the exact ins and outs of others’ assignments. I am also night shift and day shift definitely often thinks they are busier and work more, but I used to do day shift and they don’t realize that night shift has left hands on deck AND you are fighting circadian rhythm, so it is just as hard, but in a different way. I would caution against phrases like “I perform all the duties of LPN except inserting/removing catheters”. That is the kind if statement that can rub people the wrong way, because it’s not entirely true, even if you can perform a lot of hands on tasks. The LPN is licensed and putting not just the job but license at risk every day. Even when you are passing meds as a med tech, you are taking on less risk than a nurse because if the nurse makes an error such as failing to notice an adverse reaction or checking placement of a gtube or giving the wrong amount if insulin etc, they had more education and training and were under license to administer correctly. I cannot tell you the number of times a patient or CNA or family member thought I was “doing nothing” and tried to talk to me and thought I was rude for asking them to wait a few minutes, while I was actually doing something critical with the eMar that could cause a med error if I get confused or off track. I promise there are many things the LPN does, especially in prevention and planning, that non clinical staff, even those who are very experienced and great at their jobs, simply aren’t aware of because it is different training. if the LPN you work with is really just on her phone and refusing to do basic patient care then she is a snob and/or burnt out, and I’m sorry that you are left holding the bag. It is so frustrating to have to do the heavy load when you truly care about the patients and just can’t do everything you know that they need. I commend you for hanging in there for the sake of the patients and I hope you are able to resolve this either through management or simply finding another place to work.

That's the thing though, the agency pay is still significantly higher than what places are offering to staff employees. It's just that agency pay is stagnating at pre-covid levels and the job offers I see on job websites are frighteningly low. I'm talking the hourly rate I was getting paid in 2013 with just a couple years experience, is the average rate I'm seeing offered now for jobs that require experience, not new grad offers. I am already looking to move out of this metro due to rising cost of living and other problems, and the wages I'm seeing offered is scaring me into making moves faster, since it will undoubtedly cause continued staffing shortages, burnout etc, beyond what already is happening. Just wondering if it's a nationwide issue but sounds maybe local, which is a relief.

I’m an agency nurse, and while some places did offer pay boosts during covid (while others had no pay incentives and you were lucky if they had any PPE), I have noticed in the last month, the hourly rate both through agency and on job offers through the big job websites are averaging around what I used to make 6-7 years ago. I am in an area that supposedly has a growing population of seniors which should also mean more chronic conditions and healthcare demands, and we have a nursing shortage supposedly as well, so how on earth is pay going down and not up? Where are they finding nurses to work for these pathetic wages? Especially after the year we’ve been through! Are you seeing the same thing in your area?

I’ve been a hospice nurse for about a decade now, and had good coping skills related to death and dying, but there was definitely context involved. Now that we are having this insane surge in my area, for the past month the majority of the patients assigned to me are Covid positive or had Covid in the last few weeks. Many of them were not terminally ill with anything else prior to Covid, it is Covid that is killing them. Some patients did have cancer or other illnesses and were recovering prior to the Covid infection. And these patients are much more acutely ill and difficult to get comfortable, and time on hospice tends to be short since they are either discharged from hospital when it is determined that treatment isn’t working, or in SNF and never sent to hospital due to no availability of beds. Ages vary from 40s and up, with many of them under 70. I now jump for joy when I get assigned to an elderly person with end stage CHF or Kidney disease etc. In addition to the patients dropping like flies in a way I’ve never seen before, I’m encountering SNF nurses who cry at the nurse’s station because they keep losing patients left and right, healthcare workers who have lost family members to Covid and still come to work because they feel bad for the overworked staff, mortuaries telling us they can’t take the bodies because they are full. Up until December I really only felt like we were Covid-adjacent at my agencies, with occasional cases among patient and families. But the last 6-8 weeks or so have felt like a war zone. Any other hospice nurses experiencing this in your area?

I said something casually about a hobby I’d pursue if time and money were no object, and my boyfriend of 8 years went off on a topic that has come up many times: if you really wanted to do it, you would make it happen. Why didn’t you do it last night when you were just scrolling on your ipad? Etc etc He has a desk job and is not the bio dad of my son so although he helps a lot, he’s not financially responsible for him, and his bio dad doesn’t help either. I’m a hospice and home health nurse, often on call in addition to visits, often working 2 weeks straight with no days off. He doesn’t understand that even if they aren’t full 8 or 12 hour days, your brain doesn’t get a rest from work mode. Even if you don’t get a call while on call, you are at a certain level of stress and alertness. I often do end up putting in 50-60 hours, on an always changing schedule. And driving 100 plus miles per week. After work and family, the tank is empty. He thinks that if he has time to pursue hobbies, that there’s no reason I can’t also. He has never experienced the mental, emotional, and physical drain of this type of work.

Isn’t this private duty, rather than home health? I don’t mean that you should have to do housekeeping, etc. But it sounds like you are there for a whole shift everyday, rather than intermittent visits to multiple patients?

I’m a hospice and home health nurse in a city with many celebrities and I’ve had patients ranging from fairly well known to notable in their field, as well as family members of celebrities. I can’t think of any of them who were rude or snobbish. Actually the opposite, often very humble and appreciative. I’ve had plenty of rude and entitled patients and/or families over the years, though, don’t get me wrong ?

I have done up to 9 visits a day if all were follow ups and relatively simple, and not too far apart. However that would be one long day in a week with other days being 4-6 visits. There’s no way I could sustain that. And of course the documentation would be done later at home, no time for that in a day with 8-9 visits. I have known nurses and PT who do 10+ visits a day routinely. There’s no way those patients are getting adequate care. But the agencies sure turn a blind eye.

I can see why HH would seem like a better option while finishing school, but just FYI there are scarier things in HH than dogs and cats. The flexibility can definitely be there in terms of your hours. But as a nurse who is just about to burnout and leave HH for the second time in 8 years, it’s not ‘easier’ nursing. It can take over your life. Some agencies do let you decline patients for things like pets, depending on their staff availability. If you turn down too many patients they may utilize you less (if you are per diem) or let you go if you are hourly and they can’t keep you busy.

To clarify, if I did see her first thing in the morning it would be Monday/Thursday, or on Tuesday/Friday I can see her with that other cluster of patients in the area. Those were the options I gave her, both of which she declined. I just wanted to clarify that because otherwise it could seem like I’m saying I will either go in the morning early afternoon and might not make sense.

Since I started in home health and hospice it’s gone from patients being OK with just knowing the day and whether it would be an a.m. or p.m. visit, to giving a two hour window, to now at best convincing them to allow a one hour window, but many patients seeming to think that the nurses are like Uber and they just push a button and we show up when it’s most convenient for them. Is this something you all are noticing to? I was also wondering if it’s maybe regional, I’m in a big city and maybe people are more entitled and demanding here. I’m from here, so it’s not like I just moved somewhere and have an impression of people, I’m just trying to think of why this is happening. It’s gotten to the point where I end up having to let the office know I’m not going to be able to see almost 25% of the patients that are assigned to me, due to the fact that the patients can’t make reasonable accommodations for my visit. For example, I have a patient who only wants me to come at 10 AM, because she wants to be fully dressed for the visit and receive me in her kitchen, but doesn’t want to get up too early, then wants to have lunch at a specific time, and doesn’t prefer any visits in the afternoon, which she also has several reasons for. Based on my other visits and where she lives, I would end up having to drive 20 miles out of my way just to see her at this preferred time instead of seeing her in the early afternoon with another a cluster of visits in her area, or as my first visit to get hers out of the way. Her visit is not time specific, a couple of the other patients in her area are, that’s why it would need to be early afternoon, or like I said I’d be ok with seeing her first in my day. But she’s firm on 10 am only. This is for a simple wound care procedure 2x a week. I used to give in when it was only one or two patients doing this, it now it’s the majority and it would be physically impossible for me to meet all of their scheduling demands. What do you guys say when patients are this demanding, and is your agency accommodating to you, or do they try to force you to accommodate the patients?

Also because it’s traumatic for patients and families. When I came in as a hospice nurse to see a patient at a SNF, the charge nurse there had some kind of beef with our hospice agency and was saying things in front of the patient like we didn’t send certain medications, didn’t provide an 02 concentrator, etc. etc. These things turned out not to be true. I didn’t argue with her in the room, I just quietly administered the medication that our hospice had supposedly failed to send while she berated me, found his 02 concentrator in a storage closet and set it up, etc. In this case, the patient had been there a long time and this nurse had a rapport with the wife, so the wife believed everything she said. This was five years ago and every time I think back to it I think how sad that the patient’s wife was under the impression that her husband was not cared for his last moments all because that other nurse wanted to prove that she was better or smarter in someway.

I’m in home health, and admittedly already a bit burnt out with patients starting to treat us like Uber. I have one patient who I visit 4 times a week. She’s already a bit difficult to schedule. She lives very close to me but doesn’t want to be seen too early or too late so she can’t be my first or last visit, but wants me to come at an exact time based on her whims. It’s been an ongoing conversation with her. A few weeks ago I told the nurse that alternates visits on this patient (she’s daily visits) that I might go out of town the weekend of 9/21, and asked if she wants to cover those days or should I ask the office for cover. She said she usually doesn’t like to work weekends. My family did not end up making the plans for that weekend trip so I never told the office anything, since there was no issue. On Saturday, I have several visits to do and I am flying around to see my son’s soccer game right in the middle.The patient wanted me there at 2 PM my son’s game ended very close to that so I was rushing like a maniac to the visit not wanting to deal with her drama. I get there at about 215pm expecting to be yelled that, but instead there’s another nurse already there. After some investigating I find that the nurse who alternates visits with me took it upon herself to tell the office that I was going to be off on Saturday, and nobody at the office called or sent me a text to confirm whether this is true, they just got me coverage. First of all, I don’t know why they wouldn’t be concerned if I was going out of town and not telling them myself, and second of all it would’ve been for the whole weekend, not just that day. So either way they had bad information. I then sent out a flurry of texts post to the other nurse, and the scheduler at the office. I didn’t say anything mean or unprofessional, but I did tell the first nurse to please never take it upon herself to report to the office anything about my days off or schedule, that I will always handle that myself. And I told the scheduler the same thing, that I would never go out of town without getting my visits covered and no matter what she hears from any other field nurse, always double check with me directly. Although I wasn’t mean, I was quite long-winded in these texts just like I’m being now in this post, and I sent them out immediately after the fact on Saturday afternoon instead of waiting til Monday. I don’t know if I overreacted, I just felt like this was a common sense issue and I could not believe that both of those nurses would’ve made the decisions they made. Not a huge deal when all is said and done, but I wouldn’t have had to rush out of my son’s game if I had known another nurse was there, and I did rush over there and I’m not getting paid.

Axxess, Devero, and HospiceMD (I work with two HH and one Hospice) Axxess is the best software I’ve ever used! Super user friendly, once you input certain info you can override each new note and just change what you need to. Very thorough documentation can be done super quickly. It’s also very easy to see your daily schedule, monthly schedule, and to bounce around as needed. I can open the POC while completing my visit note without losing anything.

You’re full time but PPV? Do you mean that you prefer to have a full schedule and usually do, but are per diem? You can’t be classified as a full time employee but also paid per visit, at least not in my state. Do you receive benefits? I’m per diem, I work for 3 agencies now, I will probably never go back to single agency as long as I’m PPV. I accept patients that I want, turn down any too far from my coverage area. I’m able to keep a full schedule but still have a lot of control. I use my own phone always, and my own iPad for two of the agencies, but I do have a dedicated tablet from one of them. I can be a scatterbrain sometimes but I haven’t had any issues keeping track of communication and policies between agencies. All 3 use different software, and that’s also no problem. I do strongly prefer one software, and keep trying to get the other two companies to switch. ? Mileage - I get a flat rate per visit, so I don’t have to track. Meetings and training- I’d better be paid for my time if I’m expected to be there, and whether or not any agency calls a meeting mandatory, they can’t enforce that for per diem. I do make an effort to attend meetings and tradings as my schedule allows. But I’m also confused about your current arrangement. Can you elaborate? Because if what you are saying is that they expect you to take on the responsibilities of a full time employee, without the benefits of full time employment (including steady, predictable pay regardless of census), then you are being exploited and ripped off. But I may be misunderstanding.

It can be hard to compare markets, so I’ll put it this way: My total per visit rate with mileage is about 1.6 times what I would make per hour at an hourly job based on my current level of experience. Most companies will try to low ball you because the rate itself sounds good at face value, but you have to consider that they are paying you a flat rate instead of covering various benefits such as: Paid time off, sick pay, health insurance, 401k, etc. Then you have to consider the amount they would legally have to pay per mile to an employee, and the amount of miles you are driving, plus wear and tear on the car. Depending on which state you live in, there are also state employee benefits such as paid family leave or state disability that an employer might pay into. You also have to factor in your drive time. If it takes you 8 hours to see 7 patients, you need to make sure you are getting 8 hours worth of pay (after subtracting travel and ‘benefits’ from your total). So even at the rate I ask for, they still save money by paying less ‘employee related expenses’, and they don’t have to retain a large number of full time staff to guarantee that they have nurses available to see their patients. They obviously hire per diem to save themselves money in the long run, and that’s fine because it can still be very lucrative to the individual nurses. BUT if a nurse doesn’t do the math and takes a rate that puts them at a below market pay level, most agencies aren’t going to volunteer extra money. Decide how much you can accept per hour, multiply it at 1.6, I suggest not taking much less than that unless your travel time is minimal. I know some nurses who accept very low pay that I would never accept, they end up pressured to do 10+ visits a day in order to make ends meet, spending maybe 10 minutes at each visit because most of their day is travel to hit all the stops, providing low quality care. Bad for the patients and bad for your morale in the long run.

This kit actually didn’t have a stat lock or a bio patch included, whoever made it at the infusion pharmacy was probably not clinical. Luckily I noticed that the bio patch was not there and I did get a separate one for my own supplies. And the irony is that I had another picc line dressing change today, this one had a comical overflow of stat locks in the bag. When I keep thinking back to the incident, it was a domino effect, after I started getting flustered about the stat lock I am pretty sure I broke sterility a couple times and made a few other errors. It was not a good look. I will definitely learn from this and acknowledge my anxiety ahead of time, I think my biggest mistake was that I was mentally trying to rush through it to get it over with, so I threw all of my training out the window essentially and acted like I had never done this before. Next time I’ll tell myself don’t rush, go slowwwwww. I’d rather have someone hover over me for 30 minutes while I do everything perfectly, rather than watch me make a bunch of errors quickly.

So my favorite home health agency that I currently work for is being sold, and yesterday without any warning, the outgoing DON informed me that the incoming DON will be joining me on a visit so that I could orient her. Now of course I’m just a staff nurse, so why would I be orienting an experienced DON? I definitely had it in my head that she was probably shadowing all of the nurses. I have never met her before, so it’s not as if we met in the office and now we were going on the field together, this was my first time meeting her. I have seven years of experience in home health and I’m very confident in my skills. If I was teaching a new HH nurse, I would be able to breeze through my visit and explain everything. And even if there is an emergency in the home or someone is panicking, I have a reputation of remaining calm. But anytime that I feel like I’m being tested or judged, I just completely freeze up. Like I forget my own name practically. So on this particular visit, I made one stupid error after another, including missing the fact that the pharmacy did not include a stat lock in the picc line dressing change supplies, and then having everything ready and starting the dressing change and not realizing I had no stat lock until the old one had already been thrown away. And because I became so flustered by the stupid mistake, I am thinking back and pretty sure that I broke sterile technique during the rest of the botched dressing change. This was also the first warm day we’ve had in a long time, so the patient’s ceiling fan was on, I didn’t even notice or take that into account during the dressing change until the new DON mentioned it. I went back to the office and got a stat lock and came back to see the patient and fix that. This is a patient I’ve been seeing for a while and we have a good rapport, she thought I was training that nurse and when I told her it was my new supervisor she did laugh out loud and said she was sorry that had happened. And I basically spent all night last night going through my head and thinking of all the other little things I probably did wrong. It’s so frustrating, it’s almost like anytime I am told that I’m being observed, I just push a clown button on myself and all my skills go out the window.

I do both hospice and home health and love both. I would gently caution the use of the term ‘traditional’ for home health and referring to hospice as if it is some form of nontraditional or alternate home health. Just for your own benefit in how you view them. They are completely different worlds, the only thing in common is that they take place in the home. I can’t personally speak for kindred at home, but I would advise you to run far away from Vitas, and ideally start your journey in hospice with a smaller and, if possible, nonprofit agency. Vitas has a terrible reputation where I live, the nurses say they are awful to work for, patients and facilities say they are terrible. And then in a completely different city, I had a family member on Vitas, and I experienced what I considered to be the worst hospice care imaginable for this family member. Not only are they for-profit, which several of the agencies I’ve worked for are and they have still done a good job, but Vitas is the only publicly traded hospice. Wall Street does not belong in hospice care. There were so many medications and supplies that all of the hospices that I work for regularly provide, that Vitas does not provide. The nurses didn’t even practice any form of hand hygiene or infection control, they were disorganized in terms of when to send out staff, many nurses came to the door and knew nothing about the patient. They are ALL about the bottom line. And the lastly, consider going into only one or the other first, for at least six months, before venturing into the other. Like I said, they are completely different worlds, and if you are new to both, the huge differences in documentation, care plans, etc might be overwhelming. But no matter what, good luck!

I think this belongs in Private Duty

That has always been my dream to squeeze all of my visits into three days a week. No matter how hard I tried, it has just never been possible. I work for multiple agencies, but they all assign patients to individual nurses, and then you follow the case and if you can’t work on a certain day you have to get those visits covered. We have too many patients who are on an every three day visit schedule either for wound care or infusion, daily patients, and then those patients who will just not work with you, even if they are literally just sitting around all day they will insist you come on Tuesday because the wind has to be blowing a certain way LOL. So in order for me to make that perfect beautiful Monday Wednesday Friday schedule, I would have to turn down so many cases that they would probably stop offering me work all together.

When you are talking about cost and efficiency, I assume you were talking about the number of visits for an individual patient per episode? She doesn’t say that the other nurses are taking on more visits for the same amount of patients. It’s more likely that the nurses taking on 50 visits a week are taking on more individual cases. So the company makes more profit if they can take on more patients. I certainly know some nurses who cut corners in order to do lots of visits and make lots of money, but I also know nurses who just work a lot of hours. Personally, I keep my weekly visit limited to about 30 also, but every once in a while when there is a lot of work available and I could use some extra money to save or for an upcoming vacation or something, I will go ahead and take on 50 visits or so, but that does mean probably a 60 or 70 hour week, weekends included, so there’s just no way I could do that regularly.