Question re. inpatient hospice nursing....

MissIt · Jun 25, 2011

Just out of curiosity, are there no codes because your hospice requires everyone to be a DNR or because they send people back to the hospital? We don't require DNRs and we would end up calling 911 if someone that was a full code stopped breathing, but we never get to that point because our physicians, NPs, and nurses are so good at educating the patient's family and helping them get to the emotional place where they can let their loved one die peacefully.

I'm new as an inpatient hospice nurse, after having volunteered at the facility. What I did was meet with the nurse manager, tell her I wanted to be a hospice nurse, that the care we provided at the inpatient unit was far superior to any place I'd ever been and ask her whether there was anything she thought I should do to prepare myself to apply for a job at her facility. She offered to let me start shadowing her nurses during my volunteer shifts (sort of a nurse volunteer instead of a patient care volunteer). After she knew me, it wasn't hard to get a job. I think most nurse managers would rather hire someone they know will do a good job than take a chance. IMO, the thing to focus on when you talk with the nurse manager is the care provided by the team at your hospice and how you want to be a part of that. Don't mention patient loads or documentation because nurse managers get a lot of people interviewing because they think it's going to be easier, but then there are the days when you're short staffed and have 7 or 8 patients (we have a 15 bed unit), admissions and discharges to deal with, patients' families in dramatic mode, staying an hour late to finish computer charting and ordering meds, etc. etc. I've worked in acute care at the hospital, too, and I think of inpatient hospice as, basically, acute care during the last phase of life. Many of our patients are in a crisis of some sort that can't be handled at home. The main difference, for me, is that our staff is really a team. We have a doctor there during the day, so we don't have to try to figure out who to call to get help for our patient, we also have some standing orders, which is helpful because things can get out of control quickly. We also have chaplains and social workers who are there every day (the same ones, so you really get to know them). They also come around and talk with the nurses about how we are doing! Our nutrition staff comes up and talks with us and the patients-- we never have to worry that our patient isn't going to get a tray or will get the wrong diet and we won't be able to find anyone to fix it (or if what they want is a bowl of whipped cream that dietary will refuse to send it! LOL). The CNAs are amazing and provide excellent care (they have a much smaller patient load then at a nursing home or hospital), so you don't have to worry about your patient not being bathed or sitting in a wet bed. For me, the team is what makes the biggest difference. We all have the same goal, to provide excellent care, and I rarely feel like I'm in it alone. There are days when we don't get lunch and we stay late, but the feeling of those crazy days is different than at the hospital.

Whispera, MSN, RN · Jun 25, 2011

The hospice where I worked required that each patient be a DNR. They could change their mind, but then they couldn't be our patient.

MissIt · Jun 25, 2011

I think someone said something like 40% of our patients (home care, long term care, and inpatient combined) start out as full codes. Most of them become DNR at some point before they die. So, I guess it just really depends on the hospice.

DeLana_RN, BSN, RN · Jun 25, 2011

MissIt,

thank you so much for the excellent advice. Some hospice pts are still full codes, but I don't know (yet) if this is possible if they're admitted to the inpt facility. Either way, they don't have a crash cart (or keep it well hidden). It's not that I can't handle codes, I just don't like being in an environment where they happen frequently.

I think I will try to meet the nurse manager (have someone who already knows me introduce me to her), this seems best (better than going through HR for sure). And like you, I have noticed the team approach, which is so different from the hospital units I worked at. And everyone seems to be eager, helpful, with a good attitude.

One last question: How much of an orientation did you get before you were on your own? Did you/do you work days or nights?

Thanks to everyone who replied!

DeLana

MissIt · Jun 25, 2011

I work days. No rotating shifts-- Yay! Our orientation is amazing, nothing like what I've experienced anywhere else. I don't know if it's standard for hospice, though, because I never worked in hospice before. We had 2.5 weeks of classes that covered everything from pain management to non-pain symptom management to self care and how to maintain professional boundaries in such an emotionally challenging field. At the inpatient unit, it's flexible and depends on the needs of the individual nurse. Some nurses have come in and done a week or so, but most need 2-4 weeks after the class part of the orientation. Because the initial period of employment is 90 days, you really have a lot of support during that time.

Right now I can take care of patients on my own, but if I run into something I haven't seen or have any questions, I just ask one of the other nurses and they're happy to help me out. Our education staff encouraged us to not rush into independent practice and to make sure we ask if we don't know something. For the most part, the managers seem okay with this approach.

DeLana_RN, BSN, RN · Jun 25, 2011

MissIt, thanks again for clarifying this. It sounds like a very supportive environment (so unlike my last horrible hospital floor, where any nurse asking questions or *gasp* for assistance was considered by the charge nurse to be "inconveniencing the other nurses" :eek: ).

Just one more question, if you don't mind: what was your background before taking this position? Were you well grounded in your skills (e.g., complex wound care, which I know is one reason for admission to inpt hospice care), or were you given instruction/practice during your hospice orientation (and they were OK with this)?

Thanks,

DeLana

MissIt · Jun 26, 2011

My background is radiation oncology, so I had some symptom management experience. However, during our orientation, they did a nurses skills fair and went over all of the wound care products they use (plus how to assess and document a wound), central lines (how to access a mediport, dressing changes, the types of CVADs, etc), peripheral blood draws with one of those fake arms, how to start subQ sites, and how to use the PCA pumps. It was a really, really good orientation. Still, at the inpatient unit, if I had a question about what to use for a specific type of wound, I would have no trouble asking. We also have a certified wound care nurse who puts together a plan for wound treatment on the more complex wounds. This might be something to run by the nurses at your inpatient unit. See if they feel like they have the support they need. Ask them questions about what they're doing and why and see how they respond!

Lucky724 · Jun 26, 2011

Are the shifts 8 or 12 hours or a mix?

MissIt · Jun 26, 2011

Most people do 12 hours, but there is some variety with 8 hours or the occasional 4 if someone has some kind of special circumstances.

tgrosz · Jul 2, 2011

DeLana, the fact that you have volunteered for the last

3 months, you find the atmosphere conducive, and the

positive feedback you are getting from others would indicate

that you may be very successful as an inpatient hospice nurse.

your hospital experience, although chaotic and overwhelming,

was a good learning experience. apply for the job, i don't think

you will have to sell yourself, your actions speak for you.

don't get hung up on charting or codes, your compassionate

care will get you through. Best wishes!

heron, ASN, RN · Jul 2, 2011

Agree with all the above, but I want to interject one caution: inpatient hospice is the ICU of hospice care. It exists primarily for very short term admissions to deal with problems that can't be handled at a lower level of care.

CMS is coming down hard on it because of abuse ... inappropriate admissions intended to trigger the higher reimbursement rate. Before I left, we were told not to list "terminal care" alone as the reason for admission as CMS will no longer accept this.

Depending on where your IPU admissions originate, patients can be quite complex: trachs, complex wounds, patients/families in emotional crisis, IV management, chest tubes, acute psych/behavioral changes, etc.

So ... while the goals of care are very different from a hospital floor, the work can get just as busy and almost as complicated. Add in the fact that the unit of care is the patient and the family (as defined by the patient), you can see how things can get pretty intense.

More than once, nurses new to inpatient hospice were taken by surprise at just how busy we could get.

All that being said, if I could find a non-profit IPU in my city, I'd go back to it in an instant.