The sad truth about hospice IDTs: Rank always matters

Understanding how and what to communicate during the interdisciplinary team meeting is a good first step to understanding how to interact with the hospice team the rest of the time.

I’ll tell a story to hint at an unfortunate truth.

When I was just getting started as a public affairs soldier, a senior officer was reviewing my work, and I wasn’t appreciating all of her feedback. During our session, there was an elder sergeant  sitting at our table, not really involved, but just keeping things calm. At one point the two of them had a short conversation that related to rank, and he said, “Yes. Rank always matters.”

And then he tilted his head forward, raised his white eyebrows and his gray-blue eyes glared emphatically at me.

“Rank ALWAYS matters,” he repeated.

I received his message. He was reminding me to show deference to the established pecking order.

The official and unofficial power of a hospice nurse case manager

Sadly, this applies to hospice. There is a pecking order that doesn’t entirely make sense. Nurses officially have more authority than social workers. They are considered managers of the patient care team that includes social workers, spiritual care coordinators and home health aides.

Nurses also have more unofficial power in hospice. One reason is that hospice bosses, whether they are directors of nursing, directors of clinical services, or administrators, are almost always nurses. Our nurse case managers have more in common with our bosses than we do in terms of education, experience, philosophy and mindset.

The other reason for the unofficial power can be explained by the principle of least interest [link to article]. Nurses want and need their $69,000 jobs less than we need our $50,000 jobs. In multiple states I’ve noticed social workers spending months trying to get hospice jobs, and hospices going months wishing they could find a nurse. Hospices can afford to be picky about social workers, but are not unlikely to beg nurses to come work for them. Nurses are in high demand.

So if a nurse doesn’t like a social worker’s social work…

So if a hospice nurse case manager tells a director of nursing, “The social worker is taking an approach that I wouldn’t take,” what do you think the director will say?

S/he will not say “Of course you wouldn’t take that approach. You aren’t a social worker. Let’s trust this licensed professional with a master’s degree to do what he’s trained and licensed to do.”

Nope. The director would assume that the social worker’s approach is different from the one she’d take as well. And the director would be interested in appeasing the nurse.

There’s the pecking order/rank. The practical application of this is to refrain from challenging the nurse case manager before you know that he or she would really value your dissenting input.

The conflict of interest for hospice social workers

One way of judging this situation is as a conflict of interest, because the patient’s advocate may risk her job security when advocating involves disagreeing with the nurse. And because it’s our job to think outside of the box, but thinking outside the nurse case manager’s boss might not go over well.

Another way of looking at this is that the better the rapport we have with the nurse case managers, the more empowered we are to do our jobs ethically and well.

So if I were to do like the old sergeant and lean my forehead in, raise my brown, and glare at you emphatically, I might say instead:

“Rapport always matters.”

Coming up next: what to say when during IDT meetings

We’ll get more into navigating the organizational politics and keeping our jobs later. For now, remembering that the team has different expectations of us than what social workers would have of us. And let’s move forward with exactly what to say and when to say it during IDTs. See you Thursday.