Hospice case managers are the masters of multi-tasking. However, even the best nurses make mistakes. (In fact, I’ve made all 3 of them at some point in my career.) So just what are the three most common mistakes hospice nurses make? (They might surprise you or not!)
Just ask any hospice nurse about their day, and they will tell you it’s wildly unpredictable yet extremely rewarding.
Hospice case managers juggle a lot. From care plans and supervisory visits to pain and symptom management. The list of tasks stretches on and on.
(I am not saying this to scare you! Well, maybe a little bit…)
My point is that you have to be organized!
And, I must admit that making some small changes, saved me from certain burnout.
So let’s get to it.
Top 3 Common Mistakes Hospice Nurses Make
1. Not ordering symptom management medications
One of the top priorities in hospice is pain and symptom management. Now, you might be asking yourself how this even makes the list. Well, it’s not because nurses don’t want their patients to be comfortable.
Sometimes, patients don’t have pain at the time of admission. Sometimes families believe the patient will become addicted to medicine.
There are many common myths about hospice. This is one that you will have to help the patient and family overcome.
Let me be the first to tell you. Not ordering pain medications for a new admission is a MISTAKE and here’s why!
It is extremely frustrating when patients don’t have access to pain medications in the middle of the night. Just ask any after-hours nurse and they will agree!
NEWS FLASH: Hospice nurses don’t have a stash of narcotics on them for these types of emergent situations. (However, I have heard that some hospices allow their on-call nurses to carry comfort kits. This is typically not the standard.)
2. Not documenting at the bedside.
(I can already hear the groans!)
You knew this was coming!
Documentation is one of the top complaints that nurses have. And, hospice is no exception.
If you think inpatient documentation is bad, just try to get through OASIS charting or hospice admission.
Being a hospice case manager is tough. You don’t have time to spend all night documenting in your garage.
Honestly, many nurses get burned out because they refuse to document in real-time.
As I was writing this, I couldn’t decide if this was the number one or number two common mistake, Eventually, I decided that patient was first so I put it as #2. That being said, documentation is probably one of the biggest gripes that hospice nurses have about the job.
3. Not keeping their word to the patient or family.
Common mistakes come in many forms. This is one that seems to really get people worked up. If you don’t believe me then I pity you.
Oftentimes, the family is waiting on your arrival. They have likely held their questions and concerns for days waiting on you to show up.
There is a good chance that they are low on medications and supplies. Maybe the patient has pain and they figured they could just hold out. Whatever the reason, this one really gets people frustrated, mad, and anxious.
Don’t assume that just because your patient hasn’t called the exchange for assistance, that they don’t need you.
This is just one of the tips that successful hospice nurses know that you don’t.
I like to think of the hospice service like the cable repair technician. Why?
Have you ever had to wait on a cable technician?
You take off from work for half the day because they should be done in the morning. You wait all day, only to find out that they can’t make it. How does that make you feel?
If you are like many of us. You are not too thrilled. This feeling is amplified when it is a hospice patient that is waiting on you.
How Can You Avoid These Common Mistakes?
Following these simple tips can help you avoid common mistakes that hospice nurses make.
I can honestly say that Tip #2 saved me from a lot of headaches once I figured it out.
1. Order a Comfort Kit ASAP!
A comfort kit contains medications that help manage pain and symptoms that commonly occur at the end of life. You should keep in mind that comfort kits may vary from hospice to hospice. Therefore, it is a good idea to know what is on your hospices formulary.
Fortunately, most comfort kits come with some standard medications.
Sample Comfort Kit Contents:
- Narcotic– Morphine Sulfate liquid for pain and shortness of breath
- Benzodiazepine– Lorazepam for anxiety and restlessness
- Anti-cholinergic– Atropine or hyscosamine for secretions
NOTE: These medications can be ordered from your hospice pharmacy benefit manager (PBM) or the local pharmacy. The guidelines for ordering comfort medications can vary from hospice to hospice. It is important to know your organization’s policies and to follow them.
Also, this kit list only contains the top three medications. And remember, if your patient is on a narcotic, they should also be on a bowel regimen.
2. Know the hours of the local pharmacies in your service area.
LIFESAVER!!
In the past, I covered hospice in rural areas. Many of the pharmacies had limited hours. (Unfortunately, I had to learn this the hard way so I hope this helps you!) This is one of the common mistakes that I made sure to educate new hospices nurses about during their orientation.
When I knew that I had an admission coming I would call the pharmacy to give them a heads up.
This gave the pharmacy time to get the prescription ready. Likewise, it gave the family time to pick up the medications before the pharmacy closed.
If your patient lives in a rural area, make sure the pharmacy carries your patient’s medication.
3. Document at the end of each routine visit!
Trust me, it works! And I wouldn’t suggest it if I didn’t do it myself.
Seriously, this is the type of tip that will change your life and improve your job satisfaction. Your family will even thank you!
Again, this one is hard for nurses to buy into.
I also hear those of you who bemoan the idea of charting at the bedside and “disrespecting” the patient.
If that is the case, you must read my tips for overcoming this mindset.
Communication Tips
Comfort Kit Talking Points
It is not uncommon in hospice for patients and families to express concerns about the comfort kit.
Your role is to educate the family.
If the patient or family refuses the comfort kit, find out why.
Some patients are concerned about young children accidentally gaining access to them. Additionally, there could also be a history of someone in the family with a drug addiction. This may cause the family to resist having comfort medications in the home.
Explain to the family that the kit can be stored in a cabinet or locked box. You should also explain that the patient may need the kit during odd hours.
Furthermore, if the kit is in the home, it will be ready when they need it.
Don’t fail your patients and co-workers.
If you work inpatient, consider sending patients home with a prescription for pain relief.
I can hear some of the managers now… if the patient hasn’t had pain then we can wait.
Although that might work for your budget, it does not make sense for patient comfort or satisfaction.
Documentation Tips
First, get over the fear that somehow documenting in real-time means that you are not focusing on the patient. (It is unfair to the patient and to you.)
Bedside documentation has been shown to increase accuracy and communication.
Electronic medical records make it increasingly efficient to document in real-time. Likewise, checklists can help you capture information while you assess the patient without being glued to the computer.
To be honest, have you ever started documenting only to suddenly remember that you didn’t get the date of the last BM? Have you ever forgotten to ask about pain?
How to Explain Bedside Documentation to Family
I bet you are wondering how to get the family or patient to go along with bedside charting?
Your Objection: My patient does not want me to chart during my visit.
Likewise, I agree that I don’t want someone documenting when they should be listening to me.
Solution: After the visit, explain to the family that you would like to take some time to document. This way you can make sure that you have covered everything.
Ask if they have a quiet place or table where you can review the chart on the computer. Tell them that you want to make sure that you didn’t miss anything. Your note will be available to the after-hours nurse should they need assistance overnight.
This will also give them time to think of any questions that might have forgotten to ask.
(I have yet to meet a patient who says: “please don’t document because I don’t want the night nurse to know what‘s going on.”)
While this seems basic, I know so many nurses who choose to document at the end of the day. This is asking for burnout.
It is difficult to remember details after caring for several patients in a day.
The last thing that anyone wants to do is spend 3-5 more hours documenting at the end of the day.
Don’t make promises that you can’t keep!
This is one of the common mistakes that I have seen all too often. For example, the nurse promises that they will be present when the patient passes away. This is a great gesture. I have made it myself.
The problem is that sometimes, the patient doesn’t pass when you think they will. I shouldn’t have to say this, but you don’t have a crystal ball after all. (You are not Miss Cleo and I am pretty sure that I just dated myself, lol.)
In fact, you might be on vacation when your patient dies. Remember, your entire team is capable of caring for the patient. It is your responsibility to reassure your patient’s family of this fact.
Furthermore, provide your patient/family with a schedule and anticipated time of arrival.
It is critical that you call your patient and/or family to give them accurate information about your visit time.
How You Can Keep Your Patients Informed
1. Always call to confirm your visit time.
2. If you are running late, let the patient and family know.
3. Provide the patient/family with a calendar of your upcoming visits
4. Hang important information on the refrigerator or designated location.
5. Notify your supervisor right away if you need help with re-arranging your schedule. (They can also notify your patient.)
Most people understand that schedules may change. You made need to spend more time with a symptomatic patient. Occasionally, this happens and communication is critical.
Conclusion
Finally, hospice is a team sport that includes staff, patients, families, and caregivers. Now that you know what the common mistakes are, you can avoid them. My goal is for you to avoid burnout and to thrive as a hospice nurse. Constant exposure to the suffering of others puts nurses at risk for compassion fatigue and burnout.
According to research, hospice professionals are 50% more likely to experience psychological distress and a reduction in psychological well being.
Keep your sanity. Use the tools and resources that are available to you. Go and be the best nurse you can be!
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