Future looks bright for hospice nurses

When Steve Kramer's patients call him an angel, he says he's "touched" — but the Providence Hospice Seattle nurse isn't getting fitted for a halo and wings anytime soon.

Kramer — like several hundred other hospice nurses in Washington state — is too busy caring for the growing number of patients near the end of their life.

It's a health-care specialty that deals with 10,000 patients and their families each year in Washington. That's why it's no surprise that hospice nurse hiring almost has tripled over the past 10 years.

Such hiring growth is expected to continue as baby boomers age.

Just over the past decade, the number of hospice patients statewide has doubled, says Anne Koepsell, executive director of the Washington State Hospice and Palliative Care Organization.

This, she says, is in part because "there's a greater understanding of how hospice fits into the post-disease process and ...

word of mouth is making a big difference in the number of people who access hospice services."

That patient need is what's driving hospice-related job growth in King County at five agencies: Group Health Hospice, Highline Home Care Services, Evergreen Hospice, Providence Hospice of Seattle and Swedish Home Care Services.

"Just 10 years ago," says Providence Hospice of Seattle director Dr. Darrell Owens, "we were at less than half our current staffing. It's just phenomenal."

Highline Home Care Services has grown from two to today's 12 hospice nurses since the agency started in 1993.

The story is the same on the Eastside, where the daily patient count at Evergreen Hospice was about 40 in 1991 — and has since soared to current daily count of 140 to 150 patients daily. Even now, Evergreen Hospice director Debbie Kelly has openings for two full-time nurses and one part-time nurse because she staffs at least one hospice nurse for every 10 to 12 patients. As the profession grows, Owens says, more nurses, their patients and families are recognizing that the job is "not just hand-holding."

"One of our nurses describes it as being a midwife to the dying,'" Owens says. "It's a different kind of transition at the other end of life, dealing with symptom management and pain control."

It's work best suited for nurses with experience, good clinical assessment, and problem-solving, organizational and time-management skills, he says.

"Your nursing philosophy is not one of cure, it's one of symptom relief," Owens says. "To do that, you really need to be able to work on a team, because a hospice nurse has to be able to identify emotional pain as well as spiritual suffering. You have to be able to recognize that and refer that to the right discipline."

Most hospice nurses work in teams that include a social worker and nursing assistant; other teams involve chaplains and other specialties. Such teams typically handle a caseload of 18 patients, with full-time shifts that cover four 10-hour days or five-eight hour days.

Typically, many hospice nurses have worked in oncology departments or geriatric nursing facilities so "dealing with death is a natural fit for them," Owens says. "It does take a pretty broad knowledge of disease management — from cancer, heart or lung disease," Owens says, "but we get people from a variety of other settings because all hospice nurses need to be cross-trained."

Before earning his RN degree, Kramer was part of a team as a nursing assistant and, later, as a geriatric psychiatric nurse. It's why, he says he knows "this is very much what I was called to do," he says. "I feel like hospice nursing is a calling."

Hospice nurses get more autonomy than most other nursing practices. Working outside the confines of a hospital requires hospice nurses to be ready to improvise and make a variety of independent decisions.

"I never know what I might encounter in someone's home," Kramer says. "It helps to have creative troubleshooting skills. ... You can't just call up central supply when you need something. I have to improvise with what I have."

Kramer recalls a patient who refused to give up a favorite chair that was becoming physically uncomfortable for her.

"I had to be creative — pad the chair, modify the seat, get it so it fit her better," Kramer says. "It's important to be flexible. And yes, there are times when I feel I'm flying by the seat of my pants."

That, he adds, is why a "sense of humor keeps things in perspective. It's about coping with a situation. When I'm working with a patient and we can find some humor to lighten things up, that can be helpful. ... It's always in a manner of respect, and I'm happy that if I can bring some joy to their day, I'm doing my job.

"Another key part of what we do is to provide information and teach," Kramer says. "We empower patients and their families to make end-of-life decisions and support them in those decisions — even if we disagree — because it's their journey."

But before hospice nurses can begin that teaching, they must go to school themselves. Owens praises several schools whose students complete clinical rotations in hospice care. Shoreline and North Seattle community colleges, Seattle University and Seattle Pacific University offer training that help nurses prepare for this specialty, says Owens.

Once hired, hospice nurses can expect slightly less than the average registered nurse, says Owens. National labor figures show the median salary for a registered nurse is about $44,840; salaries range from about $31,890 to $64,360.

Those who have passed the test for the National Board for Certification of Hospice and Palliative Nurses can earn about an 80-cent hourly wage increase.

Salaries are considered quite solid, Koepsell says, because Medicare support, the major funding source for hospice care, remains strong.

"Hospice care is one of the few areas of health care that has not been cut," Koepsell says. "In fact, we've seen increases in reimbursement because Congress understands the practicality of it."

They are jobs that often deal with the profound issue of life and death.

"This is a really important part, and natural part of life, and we can help them understand the process," said Bev Fletcher, a longtime hospice and oncology nurse who now works for Providence Hospice of Seattle.

"My personal philosophy is that life comes into this world in pain, and when we leave this world, we can try to eliminate that pain and help people celebrate what that life has meant."