Mold the shape of hospice visit into best practices model for care
Mold the shape of hospice visit into best practices model for care
Adjust training for the front lines
One way for hospice managers to ensure their staffs are providing the highest quality care and following best practices is to define the optimal hospice visit and train staff to follow specific guidelines toward achieving that goal.
As a former director of a free-standing hospice, and the current director of clinical and regulatory affairs for the Carolinas Center for Hospice and End of Life Care in Cary, NC, Susan Balfour, BA, RN, has given a great deal of thought to how hospice staff could best shape a hospice visit.
"The model I came upon that was the most similar to a hospice visit was the private psychotherapy visit," Balfour explains. Balfour spoke about the shape of the hospice visit at the Ohio Hospice and Palliative Care Organization conference called, "A Season of Growth with Hospice and Palliative Care," held Nov. 9-11, 2005, in Columbus, OH.
"What I heard from the field is that the patients are in a crisis, and so we need a long visit," she says. "In the early days of hospice we believed a good visit was a long visit."
But now that model no longer works, and it's more useful to look at the hospice visit as akin to the 50 minute psychotherapy visit model.
"The therapist comes in and skillfully guides the client into the meat of the work," Balfour explains. "Within 20 to 25 minutes into the appointment, clients are wallowing in difficult stuff, but then by 40 to 45 minutes, the therapist is shaping that visit so the client is ready to walk out the door at 50 minutes."
Shaping a visit takes definite skills, and these are what hospices need to teach their staff, Balfour says.
"If an agency wants to change the culture, then visits need to be taught in orientation and should be part of the ongoing competency evaluation and performance evaluation because it's not something you present once and never present again," Balfour says.
To determine which skills were most important for effectively shaping a hospice visit, Balfour spoke with hospice directors, asking them to name the employees whom they'd tag as being really good at conducting visits.
"Then I asked those employees to tell me about how they conducted a visit," Balfour says. "I asked, 'What do you do when you approach a visit to plan for it? What do you do during a visit and what happens?"
For some hospice staff the skills were so second nature that it took a while for them to articulate what they did that was special, Balfour says.
"Then they started to talk about what they did, and I noted all of their comments, and the comments began to fit into four separate areas," Balfour says.
The four areas are:
- Approaching the visit with focus and attention: "They knew what they were going to do when they got there, and they knew why they were going," Balfour says.
- Involving team members: "They knew how to involve other team members and were very skilled at getting the social worker and chaplain in there," she says.
- Knowing boundaries: "They were quite clear about boundary issues," Balfour says. "They knew there was a clear line and which side they needed to be on."
- Basic organizational skills.
Some hospice staff have difficulty with meeting goals during a hospice visit and typically have problems with one or more of those four areas.
For example, hospice nurses or other staff often do not have a specific plan for a visit, other than knowing that a set number of visits per week has been approved, Balfour says.
"All the nurses should get together and define the steps of the visit and then come back and describe what happens," Balfour says.
Questions they should ask themselves include these:
- What exactly needs to happen on this visit?
- What happened at the last visit?
- What was planned pre-visit?
In some cases, staff can get off track during the visit and lose their opportunity to provide the best possible care.
Linda Levi, RN, BSN, president of Glory Health Systems in Weaverville, NC, had worked as an accreditation surveyor for the Joint Commission on Accreditation of Healthcare Organization of Oakbrook Terrace, IL, and she sometimes witnessed futile visits.
For example, Levi accompanied one hospice nurse on a visit in which the nurse spent 30 to 40 minutes sitting at a kitchen table while talking with a patient. Finally, the patient complained of pain, and the nurse gave her pain medication, but continued the social visit at the table until the patient asked to lie down.
Even after the patient was resting, the nurse did not begin the nursing assessments, and finally the patient asked the nurse to leave because the patient was too tired to continue the visit, Levi recalls.
"The visit took over an hour, and the nurse never did the assessment," Levi says. "If there was a purpose to the visit it was not known, and the ironic thing was the nurse had to go back later that week and do the nursing assessment because she didn't finish her work on that day."
On another occasion, Levi accompanied a nurse and a social worker to a discharge visit, and Levi asked the nurse how long they would be there. The nurse replied that it would be at least an hour, but when Levi asked the social worker, separately, how long she thought it'd take, the social worker answered, "Maybe 30 minutes."
The dramatic difference in what they anticipated for the visit was due to the fact that the two team members had not communicated with each other about the visit and what had been accomplished previously, Levi says.
"The nurse thought she would have to do all of this teaching, and the social worker thought it was all done," Levi explains. "So if there was a purpose for the visit, the two were not on the same page of it."
These kinds of problems can be avoided when hospice staff are trained to focus on their goals for a visit and plan how they'll carry out their objectives, Balfour suggests.
Every visit has a planned purpose visit with something that the hospice worker can accomplish with the patient and family, Balfour says.
The key is to be conscious of these plans, she adds.
One of the nurses who has best practices in shaping the hospice visit explained to Balfour how she accomplishes an effective and efficient visit. The nurse's comment was as follows: "I always take a moment in my car to clear my mind, and then when I enter the home it's with focus and clarity. My full attention is on the patient, and they seem to perceive that."
If hospice staff aren't clear about why they're visiting a patient's home, then it is easy for the patient and family to distinguish friendly visits from skills and interventions, Levi and Balfour note.
"One social worker said if she made a visit and wasn't clear within herself then the family would sense that uncertainty, and it would be much more difficult if not impossible to establish the necessary level of trust," Balfour says.
Likewise, it's important for hospice staff to know and communicate clearly how their fellow team members will benefit a patient and family. The most effective nurses during visits were skilled at bringing the social worker and other staff into the home when needed, Balfour says.
"This gets into scripting as a concept, having words ready for situations where you know they are going to be repeated, so you have the script as a tool at your disposal to use when needed," Balfour says. "Some nurses we talked to shared with us the kinds of words they use."
For example, one nurse told Balfour that she would say, "I can see that you're having problems. Let's sit down and talk about it for a few minutes, and then let me call the social worker."
By introducing the need for a social worker to make a visit in this way, the nurse showed the family that she cared about the problem and provided as much support as she could, but ultimately would ask someone to help the family who was better equipped to do so, Levi explains.
"I think it's important that this nurse identified the concern by saying, 'I see you're having problems,' but didn't discount it or ignore it," Levi says. "She acknowledged it and acknowledged her own limitations, and that's better than just saying, 'Let me call the social worker.'"
By handling the situation in this way the nurse is supporting her team and her team members' particular skills sets, Levi adds.
"We say the visit is the patient's experience and the family's memory," Levi notes. "It's the clinical and medical and social interaction, but from what you leave with the patient and family it's pretty special."
Need More Information?
- Susan Balfour, BA, RN, Director of Clinical and Regulatory Affairs, The Carolinas Center for Hospice and End of Life Care, P.O. Box 4449, Cary, NC 27510. E-mail: [email protected].
- Linda Levi, RN, BSN, President, Glory Health Systems, 113 Church St., Weaverville, NC 28787. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.