SunDazed

Splitting time between supporting families and documenting. Documentation and care planning is a bigger part of the picture in hospice nursing. And then the way administration and managers solve their problems. Even when they say they are very conscious of how they support the RNCMs, there will be times when you do not feel supported. It would be lovely if there was a hospice where you could call off the afternoon if the morning is unexpectedly emotional. Sure you can call off. No guarantee anyone will be able to do your afternoon patient visits. When there are more admissions and they can't put them on the RNCMs without shifting their load, so they lose 3-4 easy patients to a float nurse, so they can take 2 disaster new admits.

I took mine just over a year ago. I did do some HPNA CEUs in addition to the book. And I had not taken many multiple choice question tests in a while. So I did find some online practice questions, just did internet searches. That was helpful to get me back in test taking practice.

I work on call 3-4 nights a week. 5p-9a. When I started 4 years ago it was 7 on/7 off. We lasted almost a year doing that schedule. We agreed to change to one nurse doing Sun-Mon-Tue and the second nurse Wed-Thu-Fri, and then each work every other Sat. I am the second nurse. Our base pay for the shift is 1/2 of our regular hospice rate. Then at 8-12 hours 1.5x base pay, then 12+ hours are 2x base pay (regular wage basically). Two months ago I started asking if we should be considered on-call or not, since according to federal labor laws we would not be at on-call status. And for some reason I will end up with some pretty busy shifts where I work 10-15 hours, 2-3 nights of the 3-4 night stretch. HR blew my mind and said they never considered us on-call, despite that being the job title. What they seemed to focus on was the formula covering us if we worked about 8 hours per shift. I will say to you, if they calculate your time on your paycheck by multiplying hours of time by an hourly rate, you are probably not salaried. Are you exempt? Or non-exempt? Non-exempt is usually as hourly employee, you must be paid for every hour worked. And if you are required to be at the ready to respond to a call, that is probably considered work time, not on-call time. Also, if you want to speak to your administration about it, you need to figure out if they know how much you are working. Two months ago part of my mind being blown was that there was no way for 'them' to easily see how much I was working. Yes, there was a visit schedule. Yes, there were visit notes with time and milage logs. The did not have a way though to see the flow of the night, how the driving used up time, and how phone calls or behind the scenes indirect time was part of the work. I had told my many different supervisors over the four years about long shifts. No one thought enough about it to examine it, until I started questioning it. Not everyone is open to this being questioned! No surprise. After meeting with managers and administration we determined some data needed to be collected. They also have a triage service that they can pull data from for volumes of calls and number of calls escalated to the local nurse on call. So for the last two months I have been tracking time and turning it in weekly. I might say 5-530p, starting all the machines, email, read report, check messages. Then 530-715p personal time (because maybe a call comes in at 715 that I have to respond to). I have been concerned lately about driving fatigued. The other night I had a shift where I worked 12 hours, then 10 hours the next night. During the 10 hour shift I had my first near miss potential accident. I have let them know. It was a Saturday night between 11p and 12a. Clearly the other driver didn't see me. I was fatigued, who knows if they were impaired. They wanted to make the decisions based on two weeks worth of data. And by chance one of those weeks I had zero home visits in a week. The first time in four years! Of course that was a fluke. Mind you, they often try to say I am going out on symptom management visits that could be handled over the phone. Though they won't bother to read the call notes for triage that says when patients request visits. That is frustrating when you know the family and patient appreciated the visit. We meet in the next couple weeks to discuss the results and what may or may not change. The biggest safety challenge is they say to call off if not rested enough to work the next shift, but then they do not have a pool of people who can take the shift on short notice. I think that we need (to match the needs of patients and families and support them better), on Fri and Sat at minimum, a person who works from 10a or 11a to 630p or 730p, who could break the local triage nurse for lunch, then go on visits. It would probably be good on Sunday too, though the demand is not as obvious except for triage break support and possibly admissions. Then the night shift on call would be shorter, but more "on-call". Anyway... I don't think anyone is going to speak up for you if you don't bring it up. It is super awkward to tell your boss you deserve more money for what you do. And if they have been doing it a certain way for a longe time, it is a big deal to them to bring about change, even if they have a growing census or more acute patients which can translate into more patient and family visit needs. Good luck edited: for typos and clarity of ideas

Our hospice has been growing. It is the goal of the board and the CEO to see the hospice enroll lots more patients. They don't see the need to increase the staff though. Not social work, not triage, not case managers, not weekend staffing.... How do you convince those that never see the patients that increasing the numbers to serve more members of the community, and failing to serve is actually making it only about numbers? We are the only hospice in the area. We have no competition. If patients are close to death already, they are in the hospital on comfort care. If they are short stay, but going home with family and just need a lot of attention... we don't have the resources. It seems they only make decisions based on data but do not actually collect any meaningful data! Wait until the next surveys come out or the next audit to get dinged again? It is crazy making for those of us on the ground who care! We have a hospice house, but staffing issues often limit getting all the beds filled. We don't have the staffing to regularly do continuous home care.

Our hospice is trying to grow. In the last year we were regularly over a census of 110. In years past we might be over 110 for part of the year, then drop for periods in the year to something like 100. It didn't always feel like we were preparing patients and families once the census was much over 110. Now we are regularly over 120, and sometimes at 130. There can be a lot more call ins after 5pm and before 830am, with families or patients demanding visits. The trend I have noticed, is they have called in about the issue for 2-3 days already. And though each triage nurse might have temporarily helped the situation, they reach a point where they just want a nurse to come see. It is the worst around school holidays and vacation times. Management lets as many nurses off as they can, then others are sick. So we might be super stretched thin and more phone calls are made than visits. My shift is 5p-9a. We have a phone service for triaging the simple stuff, but more and more visits are being handed off to me at 5pm or being demanded by family shortly after I start. I have been trying to find information on what number of hours regularly worked in a shift indicates it is no longer truly an on-call shift. I have looked at some labor sites. We are paid above minimum wage (of course). We get a rate for the first 8 hours that is about 72% of our regular hourly rate. Then 4 hours of 1.5x that rate. Then 4 hours of 2x that rate. So that complies with California state law. Just haven't been able to find anything that says, if you work 8, 10, or 12 hours of that 16 hour shift regularly, it should not be considered an on-call shift and the agency needs to move to creating two 8 hour shifts to cover those 16 hours. One hospice I worked at just had one 8 hour shift in the evening that ended around midnight. And another staff member who came on at midnight for an 8 hour shift that lasted until the office opened. I do not know how the other two nurses working this shift feel about it. They are aware that I am asking questions, but not sure what they actually think. It would be legitimate if we were no longer 'on call' to ask the nurse working the shift to do 1-2 visits. It is hard to plan though, as we already have trouble doing things that are passed on by the day shift, as there are always issues coming up that are urgent or emergent (like falls with serious injury, etc.) Anyone familiar with this kind of distinction? When X number of hours are regularly worked it cannot be called "On-call". Or is it just employees in the roll insisting on a change?

It sounds like some good insight for yourself. The little rural hospitals are often looking for travelers. You might find one in a spectacular setting that you would love a work-vacay to see. ?

I wouldn't mind a travel gig again in the future. I am 20+ years a second career nurse. Have about 6-7 years of more full time work ahead to be where I want to be financially. I would be very selective about it. And my focus would not be the money, but the location and the role. And another nurse posted she was always called off first, that is not true in my experience. The travel nurse contract should say they are paid whether they work or not, so the primary staff are called off first. They don't like that. Should realize it is not the travel nurses' fault. They may start flip flopping your schedule around to fill holes, so they don't have to call anyone off. I work with hospice as an on-call overnight nurse. It really matches my skill set of being really good at physical assessments when there are unexpected changes in condition that are not diagnoses related. I do a lot of death visits, but hospice nurses in home hospice are rarely at the death itself. I have been at a few over the years as symptom management was intense due to a disease process excelerating decline with discomfort. I love that my job is not case management. I am aware that if my ability to drive at night in rainy weather becomes an issue, I will have to change jobs before I can retire. Though many at hospice our hospice are able to shift into other roles within the company, at this time I don't know what other role would fit me well. That may change. I am 99% sure I could not go back to hospital nursing. I wish there was more private duty nursing that wasn't pediatric. I would try that. My last travel gig was in 2013-2014. I needed a job quickly, and most places were taking months or more to hire permanent staff at the time. The hospitals and everyone were finally recovering from the housing crash in 2009. Yet it took a long time to get through the process of interviews and hiring. I was more than 50 miles from my permanent address so qualified for the housing stipend. Technically the way the money is paid out, your hourly wage is super low. I was at $20/hour or so, even though regular non-travel wage was over $45/hour at the time. You have cash because you pay less income tax, since it is a lower hourly wage. Also the housing stipend is a big part of the travel compensation package. That is not taxed. So you can have the travel company find your housing, so they manage that chunk of money. Or what I did was find a super cheap monthly rental option and then had lots of housing stipend left over. It depends on what you need the money for. I still had rent on another place to pay. I lost my job due to bankruptcy at a small critical access hospital in CA in 2012. There were no other nursing jobs within a half hour drive. I put together a travel resume, which wasn't hard since I had just been hired at the critical access hospital 6 months prior. And I had graduted from a good BSN program within the five years prior and had worked at the teaching hospital for a few years after. If you struggle with EMR charting, every hospital might have a different system now. They did when it was paper charting too, but it was easier to figure out. Even if hospitals all have something like Epic, they can have different packages. I sat in a new hire orientation charting class at a major hospital in 2014. I had finally been hired on permanent. There were a lot of travelers in the room who thought they had good Epic experience at the time, but then kept saying things aloud that indicated the way it was done at this hospital didn't match what they knew. Same with Cerner. Back then it depended on if the hospital had all the upgrades or the latest version. Would you consider any of the remote jobs where it seems you evaluate care and give an experienced opinion? They don't always pay great, but it would be a way to keep doing something. There are also remote telephone triage jobs, though I think the demands of those can vary a lot per company and shift. There are registry nurse jobs where I live, but mainly get called for SNF shifts and sometimes seasonal things like vaccines. Good luck!

I don't know all the requirements for setting up full time home health or hospice, but I imagine it is a chore!! Wondering what your goal is? I have a friend in Alaska that had two 2 bedroom modular homes put on her property behind their house. One of them was for twins she and her husband fostered then adopted, many hoops had to be jumped through. By age 6 or 7 they were found to have a genetic issues and were in wheelchairs and had full caregiver needs before age 10. They did not live to 25. She had trained as an LVN with me in California. She had the 2 units licensed as something like residential care facilities. One she kept for special needs young adults. The other for elderly or hospice patients. She frequently got calls from the hospital to take hospice patients who did not have enough support to go home. She hired and trained a few residential assistants to work for her. So she worked closely with hospice and home health, but didn't have the burden of administering those agencies. And she was able to provide people who needed attentive care for a short term or long term , just that. Good luck!

There are issues with holding an RN license and being a CNA. You would have the obligation to think at that RN scope. It may be a hurdle.

I am wondering how much different it would be if healthcare wasn't completely profits driven!

Same thing was happening in 2009, after the housing market crashed forced a lot of nurses that were close to retirement to go from part time to full time or delay retirement. New grad jobs in places that were desirable places to live and/or work evaporated. Many had to take jobs outside of hospitals to stay in the place. Or to get hospital level jobs had to go to places that were in the middle of nowheres. It took about 2 years for everyone to get to where they wanted to be to work and live. I think it would be better to work somewhere, getting any kind of experience than to not work and wait for the 'ideal job' in the 'ideal place'. Of course you get paid to work too, which is an incentive. You could try a big hospital system in California like Kaiser if you are not having luck in NYC. I have heard that the hospitals in San Diego are seeing financial changes with CEOs etc. taking pay cuts. That would be Sharp's and Scripp's, so I wouldn't bother with those. Good luck!

I am glad to do my job. If there was another hospice company that opened up here, I would probably go check it out. I guess I should have said that they were directing thinly veiled smack at me at the awards breakfast. So when others figured it out, my name was said loud enough by someone from the other side of the conference room that I heard it. And the CEO was a bit sheepish when I greeted her on my way out. Sheepish is not a word I would have ever used to describe her in the past. It is the "oh" moments when I figure out the deeper connections. Just sends me to the market to buy more lottery tickets. Would quit nursing in a flash if I had the means.

Went to a breakfast at work to honor all the 5 year, 10 year, 15 year, etc. It was an odd one. We have more than 100 employees but less than 200. It is a hospice company in a rural area. Many of the nurses have gone to nursing school together (one junior college ASN and one BSN program locally). Or worked at other hospitals or facilities together. We all expect hugs and such. Praises and good cheer. This time, it happened that at least one of the 15 year, 10 year, and 5 year nurse honorees all seem to reveal they were part of a big work 'clique'? And it also included the presenter/head of nursing. I was not aware of all of their 'deep' connections. One even confessed calling the other to talk smack. WTH? I think it was probably the first time some of the non-nurses finally had the spotlight of nursing politics shine right in their faces. Myself, I was at a table of other well respected nurses who are not in the clique, but who show up every day to take care of the patients and families. And maybe have all also been sidelined in one way or another by the dynamics of the dominant group? We all choose our battles. It was quite shocking. Still glad I am not part of the clique. I just love my work. Anyone else surprised when they found out there were cliques they were not part of? And did it impact your work? Or wanting to work at the place?

I like the idea of including staff besides RNs to take the initial calls and then only calling an RN to do a visit if needed. If those others agree, and it doesn't make them run out the door! With a patient census of 20, seems like it would be hard to just have more nurses! The caseloads for RN Case Managers are rarely below 12-14 patients each!! Unless you are expecting to grow quickly? I think some hospices rely on a weekend RN to cover Friday at 5pm until Monday at 9am. Not sure how easy it is to find someone like that in your rural area. Then everyone else would get some sort of break. I did fill in 8 hour shifts at another hospice from 11pm-7am. We did get paid hourly. Not sure how flexible your hiring plan is. Is it worth it to hire someone to work a few shifts like that each week? In this rural area, we are always short case managers. The turnover is faster than the hospital! I think some take a job here to get any job after moving here, then by the time training is over they have been able to complete the hiring process and get a job for more money at the hospital or clinics. For someone with my years of experience, the union jobs at the hospital pay over $20/hour more. There are some really experienced nurses making double what I make per hour. I would never go back to that mess though, so it is worth it to me to cut expenses and feel better about work. We also have more trouble getting really good social workers who want to stay. Our chaplains are no longer on call, and none of our SWers are. The only way to keep those slots staffed is let them have the firm boundaries about hours worked and days off. COVID changed everything here. Not sure it will ever be back to what it was pre-COVID for nurses, social workers, etc. If COVID had not ended when it did, a couple of big hospital chains in California had started working on plans to have more LVNS do team nursing in the hospitals again. They were even going to have them in the ICUs with 2 LVNs under 1 RN, and in other units 4 LVNs under 1 RN. Finding nurses is a herculean task in rural areas! Not sure that will help. It has helped us to have a couple of per diems who can cover some nights as a second job, so when they work is really dependent on the scheduling of the other job. Peace

Hi there, I am an on-call overnight nurse for a hospice in a rural area with a census goal of 102 per day. We are fortunate that we also have a telephone triage service to take most of the calls. I have been doing this job and previously been more of a visit nurse for another hospice. Also, I am in California so won't speak to pronouncing death in Colorado, as here in the great Republic everything even varies from county to county for when to call coroner's etc. Some things I would look at to better define your needs.... Why are the calls coming in? Is it only deaths? Is it symptom management crises? Is it falls needing to go to the hospital? With a census of 20, are you churning and burning? Meaning how long are people on for? We go through cycles where we get a lot of patients who are imminent at admission, so they are dying in the first week! Hard to feel like the family can get enough training and support on a daily basis in these cases. If this is the case, any strategies in place to recruit patients sooner so they and family benefit more from hospice? So then 2 months of education doesn't need to happen in 3 days? If the calls are for more than deaths, why are they calling in? What expectation has been set for follow up by staff? If they really want to call in for a medication refill or supply request, is there an option to leave a message instead of contacting the nurse on call? I find rural families around here to be old school, meaning they don't want people out driving around at night or in a storm. Where I currently live/work, the family can assign the time of death if the patient dies at home (and no unusual circumstances suspected). We do have to go out and pronounce at assisted living, or board and cares, since it is a facility and they do not have nurses on staff at night or sometimes ever. Again that is county by county in California. And sometimes they don't even want a nurse visit for support at the time of death, just call the mortuary for them. Is it possible to set expectations with patients and families to leave a message and get a callback within an hour? We can have horrible cell service here sometimes. 5G and they still blame weather on the east coast if we can't make calls on the west coast? For deaths anyway.... for symptoms, consider different emergency orders for the family.... if you can't get ahold of us and the plan is not working do this and we will follow up as soon as we can. You can always call us twice... That is if the provider is okay with that. Good luck!