Why HH nurses quit

Isabelle49 · Feb 24, 2011

It is NOT about time management. I was a legal secretary in Washington, D.C. before I became a nurse. I type well over 100 wpm. I am organized as all get out. In rural areas, the drive to a patient's house--on average is one-half hour. The visit--if lucky--can be made in 40 to 50 minutes. Then, the charting takes--on average 10 to 15 minutes--if you are charting towards Medicare guidelines to substantiate the need for home care. On an average, a visit is made--in its entirety, including charting, in 1.5 hour. Take 1.5 x 6 visits = 9.0 hours. If you have 7 to 8 visits, the time average is 10.5 hours and 12.0 hours, respectively. The only way a nurse can alter the time involved is to cut the amount of time spent with a patient, as well as cutting the quality of his or her charting. Does this affect patient care--you betcha.

Management would like me to be full-time in the field. I am prn and see, on the average 15 - 18 clients per week, I did it full time and didn't feel it was fair to the patients. Increase the number of visits in a day and you will decrease the quality of care. Some field RN's are seeing 10+ patients in a day - this is what I call 'fast food nursing'. I even had a patient tell me that an RN who was seeing her never touched her!! Run in the house, ask how are you feeling, sign here. Yes, the patient even told me the RN made up vital signs. This patient was a retired LPN, the nurse was lucky she didn't get reported to the Board for fraud.

Our company now has a new mandate, a nurse cannot see more than 8 patients per day. I've seen as many as 7 and by the 7th, my butt was dragging on the ground and I felt like I couldn't walk to the patient's door. Never again.

What does my manager do, stares at her computer screen to see what raps have and have not been dropped. I know, I worked in that office and if you weren't fast enough, the manager would email you over and over again. That I call bullying!

Isabelle49 · Feb 24, 2011

i spent my weekend drafting and sending letters. i hope i get a response.
mrs. rn
01/17/2011
the honorable
united states house of representatives
washington, d.c. 20515-4201
dear ,
my name is mrs. . i am a _______ resident and a registered nurse in the state of __________. i have a concern i would like to present to you. i work as a home health nurse. are you aware of how home health nurses are paid in__________? we are basically hired in as salary but we have to see patients to get our points for the week. the average home health agency requires 31 points a week. this changes the salary thing to actually being paid by the visit. most weeks i work 10 to 12 hours a day and i am only paid for 8 hours of that. this week by thursday i had already worked 41 hours. it started snowing and the roads got slick. i called my boss to let her know i was headed home. she said i could put 1.5 hours on my time card for today and use 6.5 of pal time (vacation time) for the rest of the day. well long story short the home health agencies are cheating registered nurses out of paying them what they actually should. with the work load we see 6 to 7 patients a day and drive an average of 100 miles a day. this adds up to a 10 or 12 hour day. they say it should be done within 8 hours. this is impossible. i run as fast as i can and then chart when i get home. they say we are supposed to chart in the home. well while i do wound care, change a picc line dressing, assess the patient, review medications and teach the patient, call the doctor for any complications i guess i could chart and not really do my job. i am not that kind of nurse or person. i have been a registered nurse for 25 years. our elderly and sick deserve our full attention. the patients we mainly serve are the elderly on medicare. these companies are milking medicare and cheating nurses. they will not even pay us for our true gas mileage instead they use bing mileage calculated by an internet bing search. routinely my pay for mileage is way lower than what i actually drive.
i would like to see _________ look into these things. it would be prudent to have an investigative committee look into the labor practices of home health agencies in the state. i have worked for three different agencies this year and found they all do the same thing. one nurse in oregon brought this same issue to their senators and congressmen and their law changed. below is how their law reads now.
http://www.leg.state.or.us/ors/652.html
652.260 payment to nurses providing home health or hospice services; rules.
(1) a home health agency providing home health services may not compensate a nurse providing home health services for the agency on a per-visit basis.
(2) a hospice program providing hospice services may not compensate a nurse providing hospice services for the program on a per-visit basis.
(3)(a) the bureau of labor and industries shall enforce compliance with the provisions of this section.
(b) in accordance with the provisions of ors chapter 183, the commissioner of the bureau of labor and industries may adopt rules to carry out the provisions of this section. [2009 c.141 2]
we are not in the dark ages now and labor laws protect our workers. somehow these companies have found a loop hole to cheat our state's nurses of well-deserved pay. please give this your full attention. i know if it is investigated you will find what i say to be the truth.
attached is an email i received from my boss regarding putting down my time on the time card.
sincerely,

you go girl! i have bookmarked your post and plan to use your template as a letter to out officials. am also going to send it to medicare, don't want to leave them out. thanks

KateRN1 · Feb 26, 2011

What you have posted does not sound real. And, it isn't real. I have often found that 'super nurses' cut corners every chance they can. It takes me as long as it takes me to do the job, and I won't shortchange the patient for company profits.

I am not a "super nurse" by any stretch of the imagination, yet I do not cut corners. I detailed a very real day in my life. I make time for exercise, for my family, and for volunteer activites. I even manage to post on allnurses.com. However, I do have a very good grasp of time management, how long it takes to do things effectively, and work to the best of my capacity. My reason for posting that was that so many field nurses don't seem to understand the role of the clinical manager/supervisor and what s/he does in a day.

Sounds like your job is your life. Slow down, don't let life pass you by. I gave my all for many years and shortchanged my son, now I grieve for him every day (he was killed at age 22) and feel so sorry that I missed so much time with him because I felt caring for others was so much more important. God, if I could only turn back the clock. From Ray'sMom

My job is not my life but it is a very important part of it. I am fortunate enough to have been a SAHM for several years and now I am the wage-earner while my husband is the SAHP. I don't feel that my children are short-changed at all. They had time to experience a mom who stays home and now have the experience of a dad who stays home. Different skill sets and priorities.

I am sorry for the loss of your son. No parent should experience the loss of a child.

shondaRN · Feb 27, 2011

I am not a "super nurse" by any stretch of the imagination, yet I do not cut corners. I detailed a very real day in my life. I make time for exercise, for my family, and for volunteer activites. I even manage to post on allnurses.com. However, I do have a very good grasp of time management, how long it takes to do things effectively, and work to the best of my capacity. My reason for posting that was that so many field nurses don't seem to understand the role of the clinical manager/supervisor and what s/he does in a day.
My job is not my life but it is a very important part of it. I am fortunate enough to have been a SAHM for several years and now I am the wage-earner while my husband is the SAHP. I don't feel that my children are short-changed at all. They had time to experience a mom who stays home and now have the experience of a dad who stays home. Different skill sets and priorities.
I am sorry for the loss of your son. No parent should experience the loss of a child.

:)I would love to know some tips on effective time management. How long do you allow for each visit? Do you complete your work in the home or at your home? Do you have to go into an office or do you work from home?

Thanks!

Shonda

KateRN1 · Feb 27, 2011

To be fair, I am now a clincial manager in the office, leading a double life as the QI nurse, as well as seeing patients in the field. I do not currently work full-time in the field. However, I did work in the field for many years and have worked in just about every capacity, from PRN home health aide on up.

I allow roughly an hour for each visit, to include documentation time. Some visits I know are going to be longer, depending on what's involved, like complicated wound care with a VAC or IV therapy. You must be incredibly organized. I cannot stress that enough. You must start each day by making sure that you have everything you could possibly need, from gloves to lab tubes to wound care supplies. It is imperative that you have all the stock you can have so as to avoid having to go back to the office. If you are using a paper system, make sure that you have all paperwork available. If you use a computer, make sure that the battery is charged and you have the power cable with you. Nothing kills your time like not having everything you need. It's not any different than being in the hospital that way. The first instruction for all of your policies and procedures should be "Gather all of your supplies." If you skip this crucial step, you will regret it at some point. Keep a running list of anything that you discover you need and for patient-specific items, pick them up when you have the time and keep each patient's items separate and labeled so that you can just grab what you need.

Make sure that you call each of your patients the night before to set up a time for your visit and then call them when you're on the way. Nothing throws a monkey-wrench into your day like planning to see Mrs. Jones at 1100, only to discover once you get there that she had a doctor's appointment. This is not only common courtesy but necessary to your time management. Make sure that the scheduler at your office has a projected visit list for the day/week so that you can minimize phone calls of "When is my nurse going to be here?"

Be aware of your limitations. Many nurses get into the mode that they can and should do it all. If it's a job for a social worker, ask for an MSW consult, don't try to arrange for food stamps, meals on wheels, or whatever. If the patient needs a bath and there's no one to do it for him/her, ask for a home health aide or if you want to do the bath visits, ask to be reimbursed for the time. Don't take on more than what you can do, though. Maintaining boundaries is also a must. Be friendly but don't become friends with your patients. You are a professional there to do a job and blurring that line will ultimately make things more difficult for both of you.

Document as much as you can while in the home. When you can't finish the documentation in the home, take two minutes to fill it out in the car when you leave or drive around the block if it's a paranoid patient. OASIS assessments can't always (usually) be finished in the home, so make sure that you have gathered all the information you need before you leave. I used to have an example of "how to do an OASIS assessment in 30 minutes," I'll see if I can find it. Be sure that you understand the requirements of Medicare documentation so that you're not frequently called back to change something. Now we have to put G-codes on the notes as well, so be sure you understand what category your visit falls into.

Map your day/week out the best you can so that you're not criss-crossing yourself all day long. If you have a larger area (I used to cover 5 counties by myself), then allow one or two days per week that you are going to be in a particular area. It won't always happen the way you plan it, so be prepared to move things about as needed.

Flexibility is also a must-have. Just as soon as you have planned your day/week, something will come along and throw a monkey wrench into it and you WILL have to adjust. If you cannot make these adjustments, you might want to rethink home care.

Almost every job I've ever had in home care, I started my day at the office. I don't know why, it's just what worked out for me. I might be there ten minutes, I might be there an hour or more, it just depended on the day. I had a cup of coffee, looked over my paperwork, picked up supplies, gave the scheduler my plan for the day and availability, etc. Communication is essential, make sure that you are communicating as much as possible by as many different means as possible, whether it's phone, text, email, fax, or whatever.

I can go on and on (obviously!), but it boils down to a few simple things--organization, time management, communication, accepting the role for what it is. Not a single one of us here is perfect, we all have something to learn and something to teach. That is the benefit of these forums.

Isabelle49 · Mar 4, 2011

Don't you love it when a holiday falls between Monday and Friday and you still have the same number of patients to see when there is no holiday? Makes me nuts!

Isabelle49 · Mar 4, 2011

Someone earlier commented on the Face to Face rule making them nuts and I think this was a management person.

Don't fret. Relax. Do what our company has done. They have made it the Field Staff's problem. Yes, we have to make the appointments and make sure the patient follows through. As if I have time for this. Handmaidens are out, professional nurses are in and we are not babysitters!

Willow Moonsidhe · Mar 5, 2011

They have made it the Field Staff's problem.

This is becoming a problem they tack on more and more things the field nurse is suppose to do.

Willow Moonsidhe · Mar 5, 2011

Right now were I work we do direct patient care, coordinate care for all disciplines, order the supplies, call the MDs, take pt calls routed through the office to my cell phone, write orders from faxed and phoned in orders. This is just to start now on supplies we are not only to give then a book if the DME if is not our insurance but also place the orders for the patient, we do the HHA care plan and orders, supervision of LPN and HHA visits, the transfer forms both agency one and Oasis, Recerts, RoCs and Discharge Oasis. Write the 60 day summaries, transfer summaries and RoC summaries. I am also responsible for a report to the field nurse taking my patient if I am out sick. Even if I am hunging earl with a virus. I wonder how they think I figure out what to do in the morning. Like maybe read the chart and orders duh. I have to do communication and case conference notes to all disciplines once a week, a case conference note to the CM weekly. It is insane. They just pile more and more on the field nurse. I can barely get through one visit without having my cell phone ring 2 to 3 times. I am going to have a brain tumor from cell phone waves.

Isabelle49 · Mar 5, 2011

Right now were I work we do direct patient care, coordinate care for all disciplines, order the supplies, call the MDs, take pt calls routed through the office to my cell phone, write orders from faxed and phoned in orders. This is just to start now on supplies we are not only to give then a book if the DME if is not our insurance but also place the orders for the patient, we do the HHA care plan and orders, supervision of LPN and HHA visits, the transfer forms both agency one and Oasis, Recerts, RoCs and Discharge Oasis. Write the 60 day summaries, transfer summaries and RoC summaries. I am also responsible for a report to the field nurse taking my patient if I am out sick. Even if I am hunging earl with a virus. I wonder how they think I figure out what to do in the morning. Like maybe read the chart and orders duh. I have to do communication and case conference notes to all disciplines once a week, a case conference note to the CM weekly. It is insane. They just pile more and more on the field nurse. I can barely get through one visit without having my cell phone ring 2 to 3 times. I am going to have a brain tumor from cell phone waves.

Sounds like your company should get out of HomeHealth and get into the business of Micromanagement, cause they are doing a good job of it! The workload will hit it's max soon and HH nurses will head for the hills.

KateRN1 · Mar 6, 2011

Willow, just for curiosity's sake, which of those things do you think you should not have to do (other than call patients when you are sick)?

Willow Moonsidhe · Mar 6, 2011

We have CMs in the office and the time it takes for them to scan faxed orders and email them they could have done it themselves. That and answering the phone in the field when most of the time the CM could have handled in the office is nuts. If we are driving we have to pull over and look up stuff on the computer. If we are with a patient we are interrupting their visit and have to step to another room or outside to keep privacy for bought the patient calling and the patient we are with. Plus sometimes they want us to fax things and the office has the fax machines which is nuts to expect me to come into the office and fax a sheet for an order like a portable xray or such. We have over 500 patients and three CMs in one office and one in the other office. They are giving us more and more of their work. They sit their all day long micromanaging us and looking for errors on our charts then when you get home you have to wade through 20 emails and answer why you did not discharge so and so; when maybe you just had a gut feeling something was not right but you could not put your finger on it. Then maybe you decided to discharge so and so and they ended up having an episode and go in the hospital. Then you are asked to explain why you let them go. Not to mention it may have been a totally new problem that just occurred. I have worked trauma, ICU, L&D and high risk stuff for 25 years and I get irritated when some one looking at a flow sheet thinks they know my patients better than I do. Whew off my soap box now. It is my day off and I usually don't even read this stuff when I am off. I would rather work on my artwork. lol Thanks for asking though maybe there will be a manager on here that might listen and think twice about their office is running.

~Willow