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!

@FolksBtrippin Yes, you know too! I was out to replace a chronic foley last week. RNCM had been there that day. The family had ASKED her to change it. Lots of sediment. She declined. Totally obstructed by bedtime. He had 1000ml out on replacement. They talk to their friends and neighbors and know it had been 4.5 weeks and was in the range of being replaced during her visit. Geez! If it is was only me knowing we could do better, and the patients and families being sort of grateful for anything and not being the wiser, well that is one thing. But when the patients suffer unnecessarily, that is so wrong.

Okay, I have sense had a good night sleep. Meet them where they are. Hospice is messy. Sure wish fewer staff were sick or on vacation at the same time.

I am just posting because I am frustrated or irritated or both? This is a big vent or a lot of little ones. I work 16 hour shifts on-call, from 5pm to 9am. The pay is a formula that is meant to compensate me but also presumes I am not working the full 16 hours. There are times where I work 12 or more hours of the shift, and last night was one of them. These nights have gotten more rare in the last 6 months, but when they come they come in sets of 2 or 3 nights in a row. Argh! This Summer, with a higher census than usual, and staff encouraged to take all the vacation they need for a happy life, so much more falls on to night shift. Of course day shift and management needs to stay a little delusional to avoid upsetting the apple cart. All have to believe that their caseload will be taken care of if they are off sick or on vacation. Even if all but a couple nurses are left after all the sick calls?!? Fridays in the Summer? Ack. It doesn't help that patients are coming on when they are near death's door, it is a very intense teaching EOL and symptom management slope... and de Nile, de Nile. My 85 year old sister who is dying can't have morphine... people die after taking morphine.... but we will agree to Dilaudid. What?!?! So narcotic naive patient can go straight to Dilauid? So she can call out in pain and suffer for 6 plus hours with morphine on hand, but need to wait for Dilaudid. Cuz that will be better? And will hospice be to blame that it takes over 6 hours for the pharmacy benefit manager to process this order? Who knows. I am not there to do the daytime teaching/coaching.... so after being there for 90 minutes in the middle of the night and getting her comfortable and updating the POA, I am going to have to do it again tonight? Hells to the no. If I get a call again tonight at 3am, then I am going to call the POA before I drive 20 miles and ask if the goal of care if actually comfort. If not, no drive. If it is? Well, I guess I will drive it again. And do it all again. And then the sister will come in and blow it all up the next day. People with money and no sense annoy the crap out of me. Okay 1 for frustrated 2 for irritated 3 for sleep deprived

Slippery slope is used because it is a core concept taught in most ethics classes that people take on their way to becoming a nurse or doctor in the US. There are 8 logical fallacies that are generally taught/learned. https://owl.excelsior.edu/argument-and-critical-thinking/logical-fallacies/ What do you perceive are the changes in the medical and nursing establishments over time? If you reference veterinarians, who have to put animals down to end suffering, they have one of the highest suicide rates. https://www.bbc.com/worklife/article/20231010-the-acute-suicide-crisis-among-veterinarians-youre-always-going-to-be-failing-somebody During COVID there were many reports of medical and nursing professionals in mental crisis due to all the death they could not prevent, coupled with the refusal of so many to get vaccinated, which was seen as the primary thing to stop the pandemic along with hand washing and not gathering in groups.

I have not encountered anyone who thought they owed it to someone to die. I think the statistics for people who get MAID meds in California ends up being something between 40-60% die naturally without using them? Most get to the point where they cannot take them by themselves. And euthanasia is not legal. I would not want to be involved in something that allowed doctors to decide without patient consent that the patient's life should end. That is horribly unethical. The closest I have come to patient's being pushed to hospice is the managed HMO-hospital system Kaiser in California. The ED doctors could refer patients to hospice if they thought it was warranted. Most of those patients were surprised and sometimes resentful. So that health system could have slippery slope issues to euthanasia if it were legalized... so far it has not been.

Thank you for the link. When I first started reading I hoped that no one would confuse the philosophical term of liberal with liberal democrats in American politics. It is definitely more the libertarian ideology in American politics today, than democrat. I can't respond fully because I need to digest all of this. But my initial thoughts... MAID (medical aid in dying) in California is not euthanasia. The person has to consent and seek providers, and meet guidelines. It is confusing that MAID term is used in Canada and seems to include euthanasia? Though not the kind where someone says "if I am ever to this point..." It seems more like a couple of providers and maybe an ethics person can make the determination with or without the informed consent of the person's quality of life warranting the continuation of life? That is like when they legally sterilized people in the US up until the 1970's for being 'unfit'. Never mind the prison doctor's who may still be sterilizing women they deem unfit for motherhood. I am not surprised this came from Mill's wife. She lived in a time when women did not vote, and if wealthy and educated were probably mostly in arranged marriages for the financial benefit of the family of both parties. Of course she wanted to make choices about her life and lifestyle. Context people! David Brooks, the author, must have a very rich life filled with connections and relationships. I live thousands of miles from most of my family. I have no kids. New to my community just before Covid, it has been a challenge to become integrated into the community even though I have a service based career. I see so many patients in hospice who have no one. I am in some land of black sheep, who do not naturally band together in their blackish sheepishness. And maybe I am a black sheep for throwing off the coat I was given by my parents? Sometimes it is amazing the created families that exist. Sometimes it is so sad that there is no one else, just conserved to have a representative who tries to be their best champion. I believe in life. I have born witness to suffering near the 'natural' end of life. I believe people can have different ideas of quality of life. Yes the example in the story changed when what she thought life would be was different when she got there. For my mom, never reading and comprehending what she read, ever again... was enough to lose her fight for life. She didn't use anything like MAID. She just gave into her struggle. Dad on the other hand would have been like his mother. If she woke up at all, bed bound and frail, that was enough to make it a good day. I do believe we should have a choice. It will never be black and white. And if we could fix loneliness in the world today, we might be able to figure this all out. In a community racked with homeless, houseless, addiction, and isolation.... it is a luxury to think about the various types of liberalism presented.

I was an LVN in California before I was an RN. I definitely did things like document findings in wound care assessments, though I could not change the plan of care for the wound treatments. I did do some acute care full assessments, but they had to be signed off by an RN on the same shift. In SNFs LVNs can have leadership roles in management. And lately, a lot of the SNFs around here will not have any RNs on the night shift, and only administrative RNs on day shifts

I am about the same age, but have only been in nursing for 18 years. I left acute care for a vaccine research job for 2 years. The nurse role there was just to do chart reviews and give shots, since all the participants had been recruited before I arrived. Then I went to hospice, as the research job was just a 2 year gig. I was in hospice home care as a visit nurse and at a hospice house. I had to take a break from hospice when my dad, cousin, and uncle all died. I went back to the hospital just in time to work through Covid. Luckily, it wasn't as bad where I am at compared to other places. I returned to a hospice job when I was ready, as I knew staying in acute care would wear my body down. Hospice is a great fit for me. And there are many different roles in telephone triage, night on call nurse, hospice house, day visit nurse, case manager. The hospice I work for lets nurses move through different roles when there are openings to keep people happy. It is nice to change it up from time to time. They also let nurses go to per diem when they need a break. They weren't as flexible that way pre pandemic, but they are now. Good luck! I came to nursing late (in my late 30's) so I need to work until I am 65 or 70. Hospice doesn't pay as well, and the benefits aren't as good as the union hospital contract. But I have a better work-life balance and not having to lift as many people, I think I can extend my physical expiration date!

I think that sounds really extreme. May I ask if this was a standard pre-employment type urine test, or are you required to test repeatedly for a previous positive urine drug test? Have you heard about people bringing in clean urine where you are? So that has made them be more 'strict'?

Have you looked into the CSU Palliative Care online courses? I took the one for RN Certification, though it is not the same as HPNA CHPN. I liked the course. They have more courses now. https://csupalliativecare.org The book that is available is Symptom Management Algorithms: A Handbook for Palliative Care by Linda Wrede-Seaman, MD. I have the third addition which was published in 2009, Seems like there should be another on e by now? There is also the Oxford Handbook of Palliative Care if you want to know what the Brits do.