anashenwrath

Hi all, Hospice RN seeing COVID+ patients exclusively. So far, all my patients have been at SNFs or ALFs, all are geriatric with lots of comborbidities and usually dementia. One thing I'm noticing is how mild symptoms seem to be: mild cough, a few days of low-grade fever, poor PO intake and increased lethargy. I've only had one patient that needed supplemental O2 and one who developed really significant pain (she had a hx of chronic pain and I think the virus just amplified it). Don't get me wrong, these patients are still dying super fast. Usually within days of coming on service. I've had to move my "actively dying" goalposts, bcs the s/sx I usually look for for active dying aren't there. People are still rousable, maybe even eating a little bit and then the next day they are gone. I read an article about that SNF in Washington that had that terrible outbreak, and it said most of their patients were asymptomatic. Is this something others in LTC are seeing? It's hard bcs I have so many families who are reading about these distressing symptoms, and then when their loved one isn't experiencing them, they start getting hopeful that it means they might recover. It's heartbreaking. I feel like having more experiences to speak to will help me support them.

Hi all, hope everyone is taking care out there. I am a hospice nurse, so normally have a mix of home patients, SNFs, ALFs. My county has a little under 1,000 positive cases; we are in our surge, not yet peaked. We hadn't had any confirmed positive cases at my hospice, but there was recently an outbreak at a nursing home and my company asked if I would see patients in this building and any subsequent positive cases. Essentially, I'm the "covid" nurse for the time being (no, I'm not seeing my routine patients at this time!) Any other visiting or hospice nurses in my situation? I am having kind of a hard time bcs I can't really do anything bedside. I use the facilities equipment for vitals (but can't always find it), and I bought a very crappy stethoscope that I can disinfect after use. I carry a small pile of recommendation forms in a clear plastic bag that I leave at the nurse's station so I can write out recs after my visit. Most of what I do is deal with family members who are freaking out bcs they can't be bedside. Normally I would help them facetime, etc, but I don't want to bring my tablet or phone into patient's rooms, even with plastic bags. I don't know. It just feels very surreal, and I want to make sure I'm doing everything right for myself and for my patients. I'm just wondering if there are any visiting/hospice nurses who have been caring for COVID patients in LTC settings for longer and maybe have developed a good routine? Thanks all and please take care!

Ugh. I have a vague memory of a hospice patient at a SNF (not one of mine, but I knew the patient and the staff) who was having significant secretions. Apparently the floor nurse on 11-7 called the on-call doc (for the facility, not hospice) and he said Lasix IM.... which. she. gave. From what I recall hearing, it was a terrible ordeal. The patient was super uncomfortable from the shot and the SEs, and apparently it just made the secretions worse bcs fluid started coming out from his nose and mouth. I try not to medicate for secretions unless they appear to be causing the patient distress or if they're really freaking the family out. Atropine is usually my preferred recommendation, since it's easier to administer vs levsin and less expensive then scopalamine. I agree this order should have been questioned. I don't think it's appropriate. Keep us posted when you talk to your colleague... was it an effective intervention?

Ask about census, how many patients you'll be expected to see a day, mileage, etc. Investigate the turnover... see if you can talk to the nurses/aides and get the real-deal scoop. Is there an on-call/weekend nurse, or do case managers rotate? I have found historically hospices have pretty terrible onboarding/training. Not just the EOL care stuff, but understanding recert periods, eligibility criteria, etc. I'm guessing you're applying for a case manager position, so it's more than just your bedside knowledge. Honestly, I just got my CHPN, and the study guide I used had really good basic info of hospice/medicare legislation that I wish I had had access to as a new hospice RN. I also like The Hospice Companion for symptom management and The Field Staff Crash Course for Hospice for just basic, "what to expect when you're on the road" kind of stuff. Hospice Quickflips will give you eligibility criteria. As far as interviews, nothing stands out as different from any other nursing interview in my memory. Maybe be prepared to explain why hospice (and obviously don't say, "Oh, I just needed a change" or "I heard you get to make your own hours" lol!) Hospice has high turnover, in no small part due to compassion fatigue, so you need to demonstrate that you're committed and caring, but also that you're not the type of nurse who is going to burn out by giving their cell phone number to every patient. It also helps if you're involved/aware of death and dying rights in your state. There are a lot of ethical issues that come up in hospice, and I think interviewers are impressed when you can kind of speak to those issues and demonstrate that you stay up-to-date on legislation. Don't hesitate to message me if you want more info. Good luck!

I don't stress about miles; I feel like I get fairly compensated. I drive a hybrid, which definitely helps! I average about 100 miles a day. If I wasn't getting reimbursed, though, I would have a big problem with that! The thing that gets under my skin with all those miles is how frequently my car reminds me it's time for maintenance. I feel like I just get it done and before I know it, I've hit another "maintenance mileage milestone" and my car reminds me every time I turn it on if I'm overdue!

Getting called to leave an actively dying patient with grieving family that you've been taking care of for a month to admit a 60-something year old who lives at home independently and who you didn't find eligible in the first place. bcs it's all about the census. ...not that i'm bitter today or anything.

Sweet summer child. They will say ANYTHING to get you to pick up a shift. It will never change and it will never stop. Screen your calls and rest easy. You are under no obligation and they are lucky to have you. Nurses are made to feel bad for saying no. And it works, because we are compassionate people who want to be there for our patients. You know who else you need to be there for? Yourself. Your family? Your pet? Your... succulent plant? I dunno. Other things! I stopped agreeing to every overtime request when I ended up on a floor I didn't know, on a shift I didn't know, with an agency nurse who left halfway through the med pass. Oh, and it was after working the night shift the night before. I was tired and stressed and I ended up making two med errors. Not worth it. You are NEVER a last resort. You are the FIRST line in keeping your patients safe. And you can't do that if you are overworked and stressed. Screen your calls. Mute your phone. Whatever it takes. You're worth it.

I'm on Cape Cod (ie, that place where HBO did a documentary about the opioid crisis) and find overall it's not too bad. Like anywhere, different prescribers prescribe differently, but it's not necessarily about the opioid crisis... it can just be ignorance about dying or symptom management in general. Same old same old. I think it's actually become easier with families because I can be very upfront about checking meds. "Sorry I have to count your pills every visit; it's just the way things are done these days." People who may have taken it personally back in the day totally understand it's just the climate of our times. I have had to manage comfort kits when there were active users in the house, which has challenges. We usually deal with it via lockboxes and trusted family members. I had one lockbox broken into. That really upset me. I'm pretty sure I know which family member did it, but couldn't prove it. We ended up double-locking the next kit and only the hospice crew had the combination. THAT was annoying. I thought we would have to do continuous care, but the patient actually passed very quickly and peacefully. Oh, but what really cheeses me is, at least in this state, nurses aren't allowed to destroy meds in the home (or take them, obviously). Usually, families are more than willing to destroy them right there in front of me, but sometimes I will get a family that will be like, "Ehh, thanks. We're just going to hold onto these." THAT concerns me. Even if they do dispose of them later, if they just chuck them in the garbage, someone might notice and pick them out! I feel like dumb protocol like that contributes to the ongoing crisis.

As others said: not sure what your working environment is, but I think you'll be fine. I remember when I made a narcotic error. And I didn't catch it, my supervisor did the next day! I was horrified, mortified, and thoroughly convinced I was going to be drawn and quartered. I can't even describe the SHAME I felt as I sat in her plush office, mumbling about how the error had occurred when I picked up an unfamiliar shift to cover short staffing. (Like that was an excuse) I didn't get any sort of reprimand except some education and a reminder not to rush. You went above and beyond. You sound like an excellent nurse. Be at peace!

Congrats OP! Based on your username, I'm going to assume you're in Oregon, which is a very good state for EOL care! Reading through your pros and cons, I noticed a lot of "logistical" factors, so I wanted to chime in as you get started as a hospice nurse. Yes, we get mileage, amazing bedside experiences, and awesome self-management. Yes, I have ended my day at 3 pm sitting on the beach in my scrubs, documenting on my tablet. BUT: that's not a reason to be a hospice nurse. I have sat at a patient's home for 6 hours (until 1030 pm), putting all my other visits on hold, while that patient breathed their last breath and their 12yo daughter screamed at me (most of my other families were ok with rescheduling, some made me feel like crap). I have had my phone ring at 8 pm with the on-call nurse trying to figure out how to get symptoms under control. I have had to drive an hour out of my way to change a dressing or have a family meeting because "dad seems depressed." I have had family members--HCPs--who were so in denial that they accused me of lacking compassion bcs I advised against CPR. I'm not trying to be dramatic or anything. I just really want to make it clear, hospice isn't all about the mellow hours and "kumbaya" philosophy. We work ourselves to the point of exhaustion caring for people and families at the darkest hour, and our reward is frequently tears, occasionally anger. Please prepare yourself for a type of burnout you may have never experienced before. Yes, there are hospice nurses who kind of "coast" through their caseload without ever really investing in the work. The other RNCMs are not fans of these individuals, and usually the families ask for another nurse after a while

Ugh my heart breaks for our on-call nurses (especially bcs the RNCMs have been covering for one of them for the last three months!). On-call gets called for anything (ignoring actual out-of-control symptoms, admissions, and deaths). Boo boo? Fall with no injury? Anxiety? Out you go! Not only that, but triage is not the most dependable... patient called triage with c/o low bsfs in the morning...triage didn't let me know until almost 4pm! The plus side is, you can tell triage (at least in my company) to HOLD on putting a visit on your tablet until you speak with the patient. For example, I called the low-bs patient's nurse and she confirmed patient always runs low. Then I called patient and confirmed BP before lunch was 129. Called triage and said everything was cool, then wrote a note and left report covering everything. I always try to triage on my own: call the patient or family and talk it through. ALWAYS make it crystal clear you are more than happy to visit, but let them know you wanted to call first and talk out what was going on. When I was covering, I didn't have to go out too much. Maybe three nights a week? I honestly don't think on-call is a bad gig. But if people call and say "Gram gram is on hospice for COPD but she has a canker sore that's really bothering her! WE NEED A NURSE" Yeah, you'll be going out to look at it.

Cape Cod RN here! The healthcare system on the Cape is kind of a horror show. Cape Cod Health basically runs the show, Outer Cape Health is "reorganizing," and we only have two major hospitals (both owned by CCH I believe). Emerald physicians is the biggest primary care group, and they recently became members of (surprise!) CCH. That being said, I love working here, because my specialty is hospice, and we have a pretty big senior population. (Like 85% of some of our towns are over 65 years old). There is, IMHO, an enormouuuusss need for better home and community care. There have been a lot of attempts to get "house call" programs off the ground, but they never make enough of a profit. NPs can do well here, I think (I'm actually looking into pursuing my own NP license), because there are so many SNFs and ALFs that rely on NPs. Oh, and obviously, summer the population booms and thus the need for nurses! Since my focus is visiting nurse/hospice, I can't speak too much about the hospital (even though I am in there a lot), but feel free to PM me if you have more specific questions. I'll do my best!

Hey ya'll! Just in case anyone was lurking to find out an answer.... I found out that the training is not yet available and we MA nurses will not be held responsible for it until it is posted on the Board's website. After it is posted, nurses who have not yet renewed their license will have 6 months to complete it and those of us who have already renewed will have until our next renewal date. Hope this helps someone besides me!

Hey there, My colleagues and I are all SO confused bcs we keep getting emails saying we have to complete a mandatory Domestic and Sexual Violence Training when we renew our license. However, after navigating a million links on mass.gov, all we can find is a "Training will be available soon" page. (Training for Licensed Professionals to meet Chapter 26

Great responses from you both. Thank you! I've incorporated this advice into my last few visits, and I think we'll get on the same page (hospice/patient, spouse, and facility). much love to my hospice homies!

I see about 4 patients a day. Prefer 3 so everyone can get plenty of TLC, occasionally have 5 and then I'm antsy and grumpy. I know nurses who do up to 7 (but they're in there for about 15 minutes a pop). I assume an hour a patient and factor in drive time. I divide my patients by area and visit one town a day. If I have multiple patients in a SNF or ALF, I try to see them all the same day. (Not sure what your census is. I have 14-18 visits a week.) Home care patients get priority for picking their day/time. After a couple visits, I get a sense of whether this is a patient/family that needs lotsa love (so let's always assume they'll get an hour at least) or if they're kind of get in-get out (so I can probably get it done within 30 minutes). OH, and I always top-load my week. Best case scenario, I will have an easy Friday. Worst case scenario, I won't be drowning when the inevitable Friday afternoon admission comes in. XP

Hello all! I am dealing with some drama with a patient on hospice for end-stage Alzheimer's at an ALF (darn ALFs!) and was wondering if the community could give me some feedback. Pt is total assist for all ADLs and has significant dysphagia, yet her husband comes in faithfully three times a day to feed her (and with that I'm sure a lot of you know exactly where this is going!) Diet is pureed. Recently, pt has had incr coughing, gurgling while feeding. She pockets and takes minutes to swallow. Otherwise afebrile, lungs sounds clear. Facility can NOT thicken, but I ordered thick-it and did nectar-thick teaching with spouse. Unfortunately, while he always smiles and nods and gives me return demonstration, every time I come to the facility, the staff complain that he is not thickening enough, feeds her way too fast and will sit with her for over an hour trying to get her to eat. I sit with him, reinforce teaching, and the cycle begins again. Earlier this week, pt began coughing and vomiting up liquid at breakfast. Facility freaked out and spouse became angry bcs they refused to feed patient until I assessed. I found her asymptomatic, but ordered a swallow eval to make everyone happy. Swallow eval concluded what we all know. Patient is at significant risk for aspiration. They recommended pleasure feeding w precautions. Now the facility is basically asking me to police this spouse and are saying that if they see him attempting to feed her too fast or not thicken appropriately, they are going to call Elder Services. It's important to note that ALFs in my state are SOCIAL MODEL, which means they are considered a "home" environment, NOT a medical environment. I'm thinking of maybe writing up some sort of "aspiration contract" that the spouse could sign indicating that he understands the risks of aspiration should he continue to be noncompliant. Anyone ever done something like that? Samples? But beyond that, I don't think there is much I can do... I don't feel comfortable "policing" this guy. If the facility wants to call ES or tell him he can't come in at meal times, I guess that is their prerogative. But I feel like the spouse has verbalized an understanding of the risks and there isn't a way to "force" him to comply, unless I recommend his wife be moved into a skilled setting (as she has no symptoms, it's not like I can GIP or inpatient her). If this was a home patient, I think I would do my best with teaching and reinforcement, but at the end of the day, I would drive home and leave it to the powers that be. If it was in a SNF, the staff would be able to thicken food appropriately and follow through on interventions in a way the ALF can't. Is there anything I can/should be doing here that I'm not???

Testify! I'm salaried now and making less as a Director than I did as a 7-3 SNF nurse! I put in 60 hours a week, never take a break or lunch, and that's fine! But I'm not paid for it, and after a while it starts to feel like I'm being taken advantage of. Given the choice, I definitely prefer to get paid by the time.

Guys thank you so much! Not only do I have a little more confidence about the role, but your info gave me some good things to ask about during my interviews! one more question if anyone is still scrolling this thread: can I expect the position to be salaried or hourly? thanks again all!

That's excellent to hear! So you feel like a nurse, not just an administrator?

Hello all! Looking for some opinions/advice. I worked 2 years as an LTC nurse on the Alzheimer's/Dementia unit of a SNF. Enjoyed it, but became frustrated with the constant staff shortage and 16-hour shifts, so I moved onto a special care unit in a social-model senior assisted living facility. I've been working as Director of the Memory Care Neighborhood for about 7 months. I realized pretty quickly that this was not for me. I LOVE doing the family education piece, and I love spending time with my residents, but most of my day is spent trying to keep everything "tour ready," and chasing the aides to lead residents in engaging programming. I have learned that I just don't enjoy being a part of that high-level management circle. I think some people are natural team leaders, but I prefer one-on-one interactions working directly with those I serve. Hospice has always been my goal in nursing. It's why I became a nurse. And now, finally, I've made some excellent connections and I'm ready to step into this field! Unfortunately, the local hospice that I most admire has invited me to interview for a Hospice Case Manager, and I'm not sure if that's the role for me? Don't get me wrong, I work well on a team! I just don't think I make a great team leader... and I'm not sure how much a Hospice Case Manager is expected to manage the rest of the Hospice Team, or if their focus is primarily with the patient and family. Thank you for any advice and info!

Oh, and it is an overnight camp if that makes a difference. I'm at the desk from 8a to 10p

It's an educational camp, I guess? Right on the water in Plymouth, MA. Schools come here for the week and do activities like rocket-building, shark dissection, coastal walks, field trips on a lobster boat, etc. My tasks have been med administration, basic treatments (had a splinter and a cut cheek so far), checking insulin pumps, and putting together e-kits for the kids that go offsite. Maybe start w $20 and expect to be negotiated down? THANKS!

Hi everyone! I am a LTC RN, and my boyfriend works at a camp. The nurse called out at the camp and they didn't have any available backup. I got asked to pick up, since I'm able to pass meds, which was their big need. The director wants me to meet with him to talk pay and I was just wondering if any of you professional camp nurses had input. I make 22.50 an hour at the nursing home: should I start there? I feel like I should lower a bit bcs I spent most of the day hanging in the office, but on the other hand I am here on short notice as a big favor, so I kind of don't want to sell myself short. Thoughts?

I agree with those who are suggesting you look into LTC. If you can swing it, apply for the night shift. They're always looking for the night shift! You can also look for float pools and per diem work. I hate saying it, but your standards might need to be pretty low at the start. It doesn't mean you're not a great nurse, but putting in a year at a 2-star nursing home might give you the experience you need to move in the direction you want. A lot of hospitals even have training programs specifically for LTC nurses making that transition, but you got to have the LTC experience first! (And who knows, maybe you'll end up loving LTC like I did!) Also, make sure your resume is a NURSING resume. List all the skills you learned in school, list all the different units you worked on. Dedicate maybe a sentence to any previous non-nurse work, and in that sentence, focus on your ability to manage, work on a team, improve outcomes, etc. As soon as you can get into a BSN program, do so! And if you get an interview as an ADN, mention how much you look forward to pursuing your BSN asap. It sucks. And I'm sorry you're going through this frustration. But especially in an urban setting, you have a lot of competition. Focus on getting that one year of ANY nursing experience under your belt. It might be a crappy year for you, but you'll start seeing a few more doors open afterwards!