What should I have done differently?

[B-RN-ISEE]

My position as a Hospice RNCM was terminated because 2 facilities did not want me to care for the patients due to "poor communication on my part"

Facility 1: My patient was reporting verbal pain of 8 and after 3wks of persuading her attendant to place an order for morphine they finally wrote one. I informed the facility LPN that the patient was reporting verbal pain of 8 and crying and should please get the morphine. The LPN I spoke to sent a different LPN to give the patient Tramadol instead of the morphine. I politely asked her the reasoning behind giving the patient Tramadol which takes 1 1/2 hrs. to work instead of the morphine. She proceeded to tell me that I didn't know the patient - they knew the patient and they knew what was best for the patient. She walked over to the nurse's station and started telling the LPN I had originally spoken to very loudly "who the f* does she think she is telling me what to do and how to treat my patient." Hearing this I went over to apologize for causing her to get opposite - I stated that for weeks now I had been trying to get the patient's pain under control and finally had the medication needed to manage the pain. Well I was called into my supervisor's office and informed that the facility did not want me there.

Facility 2: I received a message in the AM stating that my patient had been found on the floor but was okay. After my am meeting, I called and spoke to facility RA manager who stated that the had found patient leaning over his walker, and upon assessment decided he was okay. I informed her I would be there later today to assess patient. A few hours later I get a text from the LPN/manager stating that patient's family was freaking out regarding patient's mental status and I should come ASAP. I responded stating I would be there in half and hour. I arrived there and met with LPN who stated that patient had been assessed and had no changes and was fine - the family was just freaking out because he didn't recognize them and she thought it was because he was depressed. She asked that after I had assessed him I should talk to her. Patient was assessed VSS, with poor tracking. I told the family that facility had told me he did not hit his head and patient could not shake his head "yes" or "no" when asked if he hit his head. I told family that I would like to observe patient for any changes prior to sending him out because we generally didn't want to send patient to the hospital unless something was severely wrong and so far I couldn't see anything wrong except for poor eye focus/tracking. I went and told the LPN my observations and she said they the facility didn't want patient to go to the hospital either. I went back into patient's room and the family started insisting that the patient had a CVA - I explained to them I couldn't agree or disagree with them because all I had was my assessments which showed that the patient didn't exhibit signs of a CVA. The family and I went back and fort over the issue of patient being a DNR, hospice, and what treatments he would/wouldn't get if admitted. The facility administrator came in to discourage the family from sending patient to ED - which I insisted that it was both the patient's and their family's which to know what had caused the change. Two days later I was called into my supervisor's office and informed that the facility stated I didn't communicate well with them and I was trying to one-up the family when discussing sending the patient to the hospital and they didn't want me back in their facility. The next day my job was terminated because I couldn't go into two ALFs and facility 2 had threatened not to use our services if I was sent there. Oh yeah forgot...patient had an intracranial bleed.

So what should I have done differently, I had called my administrator and supervisor reporting all of the issues I faced during and after this incident.

[toomuchbaloney]

Wish I had a crystal ball and could tell you what you want/need to hear, but they recalled that globe for repeated malfunction.

There are always more perspectives to a story or situation than one person can provide.

The facilities are also customers of the hospice; they have a mutually supportive relationship. If you are assigned to be a hospice nurse in a specific facility that means that you MUST develop a good, respectful, and professional relationship with the staff and leadership of the facility. MUST. It is not optional and in most cases (IME) simply advocating appropriately for the patient while annoying the facility will not keep you employed in that capacity.

As you have experienced, if a hospice employee irritates the facility it could cost a hospice agency in a competitive market quite a bit of valuable referrals and cases. Most agencies will not tolerate that inability to manage good care AND good professional relationship development.

Facility based hospice nurses should participate regularly in the care conferences of the facility. They should make it a point to get to know the staff and to develop relationships of trust and professionalism with as many of them as possible. They should make it a point to participate in bathing or other personal care as a demonstration of team work while completing full skin and physical assessments at least once in a hospice EOC. They should collaborate with the facility staff rather than give them orders or otherwise tell them what to do.

Similarly, when advocating for the patient with the family present it is never a good idea to stray from the collaborative model or in any way causing the family to question the facility's intent or ability to provide good care. At least not if you want to continue seeing patients in that setting.

Hospice facility nurses are often half marketer and half health professional.

[B-RN-ISEE]

The facility nurse and I had a good professional relationship. Case in point my husband and I ran into her shopping one day and she embarrassed me by telling him "she is amazing...she works so hard and I am glad to have her in my facility." Both the staff and I had a great working relationship I mean I remember several times when I would go in and they would tell me how grateful they were to see me. What was interesting to me was the timing of the facility's complaint against me - they didn't report the "incident" till the evening after I had been there. I don't know I believe that no matter what I had done that day the facility would have had a complaint. This is the first time in my career in the health field I have had issues like this come up and I don't know how to prevent future issues like this. Thanks for your response.

[toomuchbaloney]

Sounds like you got stuck in the middle of a crap tornado...

Sometimes we have no control, must let go and move on. This may be one of those situations where there is no lesson to be learned except that the job wasn't worth keeping if the employers don't appreciate your efforts.

Good luck!

[Jensmom7, BSN, RN]

Facility based Hospice Nurses perform a delicate balancing act; their primary responsibility is symptom management and patient comfort. They are also a guest of the facility, which is a customer of the Hospice agency, and as such has an expectation of satisfaction with the collaboration provided by the Hospice team.

It takes time to build up a trusting and collaborative relationship with facility staff; high turnover rates make it an endless endeavor. My agency made a decision to reduce me from two facilities and a few home patients, and have me only in one facility-it had a reputation for being "picky" and the management was not happy with having to wait any length of time for me to get there.

It's worked well. My caseload varies between 15-18 patients (before the change I had 23 and significant drive time. Yeah. Impossible). I have 4-5 scheduled visits/day, and I do a "head count" on the rest of them, which is great for keeping on top of symptoms, talking to families, talking to staff (I love talking with the CNAs, they're the ones who really know what's happening). I'm a visible presence 5 days a week, and most of the staff now call me by my first name, instead of "Hospice Nurse" lol.

I value the facility nurses, and do not hesitate to give them the credit when they have an idea for symptom management that we then implement. I also do a lot of education, especially with nurses who have not taken care of many Hospice patients.

I always go to Care Conferences, unless they happen during IDT, and even then I give the Social Worker or Manager an update before hand.

Why did your facilities decide it wasn't a good fit? Hard to tell. It could have been something completely out of your control, like a family threatening to have the patient transferred to another facility. It could have been a manager who figured better to have you go than some of her employees, who she would have to scramble to replace.

As someone else said, Hospice Nurses in facilities are as much marketers as they are health care providers. We collaborate with the facility nurses, we don't tell them what to do. Sometimes it's very frustrating, and some of them don't understand or like the whole concept of Hospice. It's a series of small victories that can add up to a very trusting and collaborative relationship, but it takes work.

[guest538567]

I am genuinely sorry for your experience. I severely dislike the level of politics involved in patient care that are evident in the hospice environment and nursing homes. Unfortunately, I think you were caught up in both. In my experience, nursing home staff can be territorial and the environment overly political. Hospices in my area are always battling market share in these facilities and frequently are kicked-out in favor of another hospice. I think the first example you cite is an unfortunate example of territorial staff. The second example sounds like the facility wants to blame you after family complained. It was an untenable position for you given pressure from the hospice not to send that patient to the hospital and pressure from the facility, family, and patient to meet their individual interests. I am sure the hospice agency will now try to save face by explaining they let you go. I think you did your best and would encourage you to keep your head high and move on.

[nutella, MSN, RN]

When you step into a facility as a hospice nurse (nursing home or hospital), you are also "intruding".

Not all facility nurses are welcoming, some are convinced that hospice nurses are spying on their work and will report them for anything that is not 100%. A lot of facility nurses are very protective of the residents and in fact have known the patient for a while and are aware of the patient and family dynamics and have a hard time "sharing" this responsibility. Often times as a RN you will talk and work with a LPN and while something may be obvious to us coming in from the outside, it may be not that clear.

Whenever I go into a facility I view myself as a GUEST. I am there to help, collaborate, make recommendations, sometimes calm down relatives, evaluate, and so on.

Nursing in a facility, especially nursing home, is a hard job and often times hospice nurses and hospice aids are seen as having the better end of the job, there can be some friction due to this conception.

Here are some tips on how to work smoothly in facilities:

1. Always set your mind to "I am a guest and will behave like a guest" - respect facility personnel and their work place

2. Always introduce yourself to the nurses and aides you do not know

3. Always thank nurses and aids for their hard work and how well they take care of the hospice patient - acknowledge their work

4. Get report from the nurses and aids who take care of the patient to get a full picture, use open questions

5. Avoid accusations - example patient has a pressure ulcer stage 2 that is new upon assessment - state the fact without blaming

6. When you talk to relatives and patients and they state that they do not like facility nurses or aids - do not side with them, acknowledge their problems and emotions but do not split. After all the pat will be there when you are gone. Instead bring up problems in a neutral manner like "Mr. X mentioned that he would like this breakfast earlier, do you know if this is possible at all?"

7. When you make recommendations it can take some while to get the order from the facility MD, sometimes facility nurses have to run after it for a day. When you come back after recommending a change look in the chart if there is a corresponding new order, if not just ask politely if they had a chance to talk to the MD about the recommendations.

8. Let's say you disagree with the facility nurse - you assess the pain is 8/10 and the patient is not getting enough pain medication or the wrong one, do a full assessment including the narcotic book to gather a full picture of what the pat is getting. In general - if the patient NEEDS a certain medication around the clock you have to get an order for around the clock, not prn. If the doctor orders around the clock morphine for example, the facility nurses have to administer it that way. That will take away a lot of friction. There is a lot of room with prn orders and you may say the patient needs prn and the facility nurse may say "the patient is not that bad" or similar.

9. If you find the patient has not gotten a scheduled medication do not accuse the nurse. Instead ask about when the patient is getting the scheduled dose. Oftentimes the nurse will then tell me that she is on the way to medicate the patient and I thank her politely.

10. Facility nurses do not want their patients to suffer but sometimes there needs to be an education about medication - this has to happen in a non condescending way with the goal to improve general care.

11. If a facility nurse is hostile or makes remarks (which hardly ever happens to me), I basically pretend I did not hear that. Instead I will ask how the day is going and try to make some small talk. My goal is to work together with the nurse and not compete.

12. "How can I help you today?" is a good opener as well

13. Make sure that the hospice aids are doing a good job and do not forget to educate them as well.

14. Do not get into a power struggle - that will make everything worse and you can not win. A respectful discussion with sincere thoughts will get you better results.

15. Smile...

16. Personally, I wear contemp. scrubs. This makes me more "equal" as opposed to coming in wearing a lofty summer dress with high heels. I know, I know --- does it matter? I think it does....what if the patient needs repositioning, I look ready for work. Plus I signal "I work" as opposed to "I look at charts and do a quick assessment and do not do "dirty" work...

17. If it is a true safety concern you have - of course you have to bring it up in a tactful manner. If the unit nurse or unit manager is not receptive you may need to talk to the supervisor. This has happened to me once.

18. Be aware that the goal is always to give the patient the best care - collaboration is really the main point and I even write it in my care plans.

19. Be mindful about what you write and how you talk when you are in the facility. Don't call you manager for everybody to hear and say "well, they managed to give the patient a stage 2 pressure ulcer, they are probably too lazy to reposition", instead you state the facts like "Mr.x has a new stage 2 pressure ulcer, I will review if we are doing everything to prevent pressure ulcers and will update the care plan and write a recommendation".

20. Do not think "them" and "me" - try "us" - it does make a difference.

21. Even if the whole floor is on contact precautions and was not last week - do not comment on it but follow the P&P.

Anyhow, this got long.

I go into a lot of nursing facilities and all of them are a bit different.

Sometimes I come and the facility nurses and aids are in progress to care for the patient I would like to see - I always offer my help!

Hope it helps.

[HeavenlyRN]

Nutella, thank you so much for this information that you shared. I am a new hospice nurse and will be going into facilities. This is very helpful and has alerted me to some potential pitfalls to avoid.

To the OP, so sorry about your position. Thank you for sharing and I wish you all the best.

[LindaRossmanWilliams]

Not a thing Hon. Don't stress.

I was removed from a facility as case mar in 2010..... they said a pts condition had "deteriorated" since hospice started (2008). Come to find out facility was out of compliance since 2008 as hospice can was visiting 2x a week. The facility was to give a bath 1x a week to total 3can visits a week. As the facility was out of compliance it was easiest to blame ME (who started serving that facility in 2010), rather than blaming themselves. I was irritated...but it is what it is. Let em have a different case mgr.

[pfeliks]

Another small thing. When visiting a patient in a facility you are going to taker Vital Signs as part of your assessment. Offer the results of your vital signs to the nurse taking care of the patient. H/She may have a "list" of "to dos" which may include vital signs. You've just checked that box for them. It's a small thing but nurses will often thank me.