Improve bedside manner with 'tuck-in' program

Reduce off-hour calls, improve teamwork

Sometimes a hospice's client satisfaction and staffing problems stem from repeated and often unnecessary off-hour calls by patients and families.

A Colorado hospice has addressed this issue by starting a "tuck-in" program that includes additional staff training and scheduling changes.

The Hospice of Metro Denver identified several problems in the past year, including a disappointing client (77.69%) satisfaction score on a family evaluation survey, says JoAnne Foulk, RN, CHPN, clinical manager for the nursing home Northwest team of the hospice.

As a result, hospice managers began to look at all patient data to identify the nurses who were what they called " the best tucker-inners," or the nurses who had the fewest weekend and evening calls from patients, she says.

"We got these nurses together and tried to figure out what they did that was different from what the other nurses were doing, and we came up with a list," Foulk explains. "Then we presented the data we received to the home staff."

Hospice managers held four mandatory meetings for nurses and will expand the education to social workers, certified nursing assistants, and other staff, she says.

The chief items on the list were communication, clinical skills, and pathophysiology, including how well nurses understand what is going on with a particular patient's disease process, Foulk notes.

"Clinically, what we found was we had a lot of calls about leaking Foley catheters and people running out of diapers," she says. "It was simple stuff, including medications and people not knowing they had medication in the refrigerator that could help them with pain control or nausea and vomiting."

The nurses knew how the clients could take care of these mostly minor issues, but for some reason they weren't doing a good job of communicating what they knew about the patient comfort packs and how these could help the patients, Foulk says.

So the hospice began to teach nurses how to improve their communication skills, including how to sit down with a patient and family member, who still are shocked by the recent knowledge that the patient will not recover, and answer their questions and concerns, she explains.

"We have to reassure the patient and family that everything is going to be OK and that we'll be there for them and they are capable of doing what needs to be done for their loved one," Foulk says. "We want to increase the family and patient's confidence, their understanding of the disease process, and their understanding of medications being used."

Hospice managers teach nurses to bring in all of these details right from the start of meeting with patients, but this information also has to be reinforced many times because the family may only digest about one-tenth of the information at the beginning, she says.

The more patients and families hear instructions repeated, the easier it is for them to deal with that piece, says Maureen Pangle, RN, ND, CNS, clinical manager.

"Nurses need to help them deal with their loved one," she adds.

As part of the nursing education, Foulk asked nurses to imagine that they were the only nurse on call every night and on weekends, and if they were called at 2 a.m., they'd have to travel the hospice's service area, spanning 50 miles across. Then, if they were that only nurse, what would they do to prepare patients and families for all possible small emergencies?

This scenario worked for Maryjean Blair, RN, CHPN, primary care nurse at the hospice, because she has done work on weekends, she says.

"So I started thinking about my patients and what could happen tonight and in the next few days," Blair says. "I started to get a feel for where a family was and whether they could take in all of the information."

As a result, she began to go through the medications in the comfort pack and try to get families and patients comfortable with these, particularly toward the end of the week.

"I'd try to prepare them for a tuck-in for the weekend, and I always remembered JoAnne's words of how you're the only nurse out there, and so I'd try to think broader about what could happen and what would help the families prepare," Blair says.

The additional nurse education focused on teaching nurses how to anticipate and plan for the next step, Pangle explains.

"They know the disease process and can't exactly predict what's going to happen, but they know basic things that will happen down the road," she says. "So we try to get nurses to think about what will happen at week one, two, and three, if we get that far."

Blair soon discovered that her additional time spent educating patients and families was working.

"As soon as I started doing this reinforcing and teaching, I would hear on voice mail messages that when someone did call in, the family had more awareness of what to do," she says. "Patients started calling less, and from the feedback I knew they knew what to do."

From the initial nursing focus groups, managers learned that nurses who did best with tuck-in were great motivators, says Julie Isaacson, RN, MSN, NP-C, palliative care consultant.

"Whether the family was coping well or not, whether they understood what was going on or not, the nurses were motivating the families and giving them confidence," she says.

The most successful tuck-in nurses were telling families that they were doing a great job, really helping their family and loved one, Isaacson notes.

"This gave the family more confidence that if something did happen after hours they wouldn't freak out, but would remain calm and think about what they could do," Isaacson says.

Foulk encouraged nurses to write instructions down for families, leaving some written record that families could refer to.

This also served the purpose of keeping different shifts of caregivers well informed, she notes.

"Keep in mind that a lot of caregivers during the week may not be the caregiver on the weekend, so it's important to have something written down," Foulk says. "We have a packet that's left in the home, and nurses can leave notes in that packet."

Another aspect to the nursing education is to encourage nurses to learn more about their families and customize their communication style to fit a particular family, Pangle says.

"So, if you have a caregiver who has poor eyesight, maybe you could put the information on a poster board; whereas for another family, you can keep a running notebook of things," she explains.

"The nurses in the original focus group were comfortable with communicating with patients, including talking about death and dying issues," Pangle says. "They could have hard conversations and really be able to listen."

So much of the tuck-in problems go back to communication difficulties because the hospice already was taking care of all of the patient's physical needs, including medication, Foulk reports.

Still, it was important for nurses to attend to the details of making certain patients had enough medicine, diapers, and other items to get them through the weekend, whether the patient was at home or in a nursing home or assisted living facility, Foulk says.

This might mean the hospice nurse would have to communicate with the nursing home nurse to make certain everything was in order, she adds.

"You'd be surprised at how many phone calls were about people running out of diapers, which they could buy at a drug store, but they expected us to have them there if they were in a nursing home or assisted-living facility," Foulk says. "It's our responsibility to make sure they have them there as a backup, and sometimes, they can't leave, so you just want to have all your ducks in a row."

After the training, managers conducted evaluations and found that the majority of staff found the education to be helpful, Isaacson says.

"We had a few outliers who were disgruntled that it was mandatory or who felt it was only needed for newer nurses, but we also had seasoned nurses who found it helpful to review the information," Isaacson says.

After feedback from the first training session, managers altered it to provide more discussion in the second session, Isaacson says.

Finally, the additional training stresses teamwork, Foulk says.

"When we go into a home people see individuals," Foulk says. "But we want to stress that each member of the team exchanges information about the patient, and the family needs to know that."