Improve hospice staff skills on being compassionate presence for patients

Ohio experts create training curriculum

Hospice nursing work is different from the typical health care experience, but how often has it become rote and driven by schedules and regulatory tensions?

An Ohio hospice initiated a research project that teaches hospice staff how to become more fully present and engaged in patient care, resulting in more satisfying hospice staff-patient experiences.

Participants who received the compassionate presence training reported significantly improved purpose and meaning and reliance on inner resources than before the training, says Sharon Stout-Shaffer, PhD, RN, an associate professor at Capital University in Bexley, OH. Stout-Shaffer was involved with the research project.

The idea for the project came from a hospice nurse. When Ruth Frankenfield, RN, MS, CNS, a staff nurse at HomeReach Hospice in Columbus, OH, found herself questioning the lack of spirituality in her daily work, she asked her director for permission to conduct a research project on the topic.

"I was interested in doing work around enhancing spiritual care amongst staff with our patients," Frankenfield says.

Frankenfield teamed up with Kate Dean-Haidet, RN, MSN, CS, a psychotherapist in private practice in Pataskala, OH, and a graduate student at the Ohio State University Comparative Studies Department.

"It was a serendipitous meeting with Kate," Frankenfield recalls. "She had just started doing work at Ohio State in comparative studies and had expressed a keen interest in spirituality and the death and dying process."

The result was a research project about what would work best in helping staff understand their own spirituality and be more present and active in engaging patients from a spiritual perspective, she says.

"We pulled together key people at the hospice to serve on an advisory board and began to develop our definition in terms and concepts that would be key to the content," Frankenfield says.

The result was six weekly sessions of 90 minutes duration, designed for groups of eight to 12 people. All participants were voluntary, and the only criteria was that they be a hospice staff member directly involved with hospice or family care, Frankenfield says.

"So we worked with managers to figure out how they could spare those individuals from their care for each of those 1.5 hours for six weeks," she says. "That was a major concern for us, and in any hospice setting that would be a concern."

The project has involved three groups and a total of 32 participants, Frankenfield says.

After Frankenfield and colleagues presented the project and its results at the Ohio Hospice & Palliative Care Organization 2005 annual conference, held Nov. 9-11, 2005, they were approached by other hospice staff interested in replicating the program.

"They were very excited and enthused and hopeful about being able to integrate a program such as this," Frankenfield says. "There's a lot of hunger on behalf of staff providing hospice care."

Each participant received a notebook with handouts at the weekly sessions, and each was organized around a theme, Dean-Haidet says.

"There was a glossary of terms and a reference sheet in the back," Dean-Haidet says. "There was a practice journal given to the participants because this program is really predicated on the assumption that practice is involved in being compassionately present."

Each class had an experiential component that participants could practice at home during the week as time allowed, and they would write down their experience in the journal, Dean-Haidet says.

The weekly journal would give participants a question to answer.

For example, one question was, "How did your practice of meditation and participation in this group affect your ability to be present to yourself, patients, and families?"

Among the answers written in journals were these:

"I've become more present when I give baths, like appreciating the sound of water in the basin when I wring the washcloth, the look on the patient's face, their breathing pattern, mine, and I realize how much I receive through the giving," a home health aide wrote.

"I am seeing that I am learning from this class how to quiet myself, center, release tension. I also realize I've been a rabbit jumping quickly into and out of activities for a long time. I was centered before a visit Wednesday. I'm not sure if my presence made a difference to the patient/family, but it kept me from being totally drained during and after the visit," wrote a hospice nurse.

Participants were tested before and after the six sessions on their awareness and spirituality, based on four dimensions, Dean-Haidet says:

  • spirituality as an integrating or unifying dimension of need;
  • spirituality manifested through meaning and purpose in life;
  • awareness of inner resources;
  • meaning, strength, and transcendence.

While the data from the journals provided a qualitative way to look at the participants' experiences, the Spiritual Assessment Scale, developed by Judy Howden, provided quantitative data with measures of pre- and post-changes in the participants' spirituality, based on how they completed the test, Stout-Shaffer says.

The scale had 28 questions that participants answered, she says.

The pre-training data showed that participants rated themselves fairly high on the spiritual dimensions measured. Then the post-training data showed that they had significant improvements on eight dimensions, Stout-Shaffer explains.

"It was a little surprising that we would see that much difference at the end of a six-week program," Stout-Shaffer notes.

"What the results were telling us was that participation and the ability to go through the exercises and process did create a change at a significant level in quite a few categories on the scale," Stout-Shaffer says. "For people who are interested in this kind of experience, this does suggest a pretty powerful intervention."

It's unclear whether the positive results would apply to a hospice orientation program that included this training, Stout-Shaffer says.

The program has six themes, which are carried out over the six sessions. They are as follows:

  • Creating sacred space:

This session could also be called centering and compassionate presence, Dean-Haidet says.

"In this session, we talk about what kind of definitions there are of spirituality," Dean-Haidet says. "We tried each week to create this kind of space where people would feel comfortable discussing their experiences with spirituality in a nonjudgmental way."

Each session had some kind of relaxation experiential where they engaged in stretching, imagery, or breathing exercises, followed by discussion of that week's theme.

Hospice staff already understands compassionate presence, but they may not always be able to manifest it, Dean-Haidet says.

  • Compassionate presence, mindfulness, conscious intent:

The advisory board had spent a couple of hours discussing how to define spirituality, finally choosing the term "compassionate presence," Frankenfield says.

"It's one thing for us as individuals to be with patients and families and pay them attention and do good clinical work and be present emotionally," Frankenfield says. "But it takes it to a whole new level when you have an awareness of this person beyond how you see them physically and emotionally."

This session covered mindful meditation, building on the first week's focus on centering meditation, Dean-Haidet says.

"Centering medication is a way to find an inner reference of calm and peace, using a repetitive kind of anchor," Dean-Haidet says. "Mindfulness, on the other hand, is a kind of meditation where you're open to anything that comes through consciousness with attention to the flow of moment-to-moment experiencing in the present."

  • Compassionate presence and inner resources:

"We talked about what are the inner resources of the healer, and this was different for everyone," Dean-Haidet says. "People mentioned many different things, including family, church, nature, prayer, and music was mentioned a lot."

The session included a discussion of what hospice staff needs to do to refuel and renew themselves, and how to expand that repertoire of approaches, including using meditation, Dean-Haidet says.

  • Meaning and purpose; service as a spiritual path:

"We talked about the life of a healer and how healing as a profession can be a spiritual path," Dean-Haidet says. "We talked about how they can see meaning occurring in their work."

There were many stories told in this session, and participants discussed questions about values, principles, beliefs that guide one's life and life's work, and how these involve caring for hospice patients, she says.

One story a participant told was how she was taking care of a 13-year-old girl who was dying. When the nurse came to change the IV bag, the nurse just sat there with her because she really didn't know what to do and there were no words she could use to express what she felt, Dean-Haidet recalls.

"The girl took her hand and started singing with her, and in some way it was like the patient was ministering healing to the nurse, so this was very meaningful to the nurse," Dean-Haidet says. "There were dozens of stories like this told throughout the group."

  • Transformation and transcendence:

"In this session we talked about times when you were able to go beyond the usual limits of ego and achieve something of integration with a larger reality," Dean-Haidet says. "So people had stories about transcending personal trouble."

The participants discussed their crises and illnesses or those of their family members, she adds.

"We talked about meditation as a way to transcend non-ego consciousness, being able to go beyond separate sense of self to a greater sense of self," Dean-Haidet says.

  • Integrating compassionate presence skills into practice:

The sixth session showed participants how to integrate the skills they had learned into their hospice work.

"We talked about barriers to being present, which sometimes involves just listening or being with someone," Dean-Haidet says. "We talked about things that might facilitate that, and we talked about the psychosocial spiritual stages of dying."

The big issue hospice staff faced was their own perception that they didn't have time to do spiritual care with patients, Frankenfield notes.

"This was a typical reaction on all levels," she says. "How do you slow yourself down and almost sit with a person in a whole new way."

While the training is for hospice staff, the benefits could extend to hospice patients and families, Frankenfield and Dean-Haidet say.

"This training is really focused on the staff, and what we're hoping is that as they learn these things and become more present that this spills over into the family," Dean-Haidet says. "We would like to eventually study the effects that being involved in a group like this has in patient care."

Need More Information?

  • Kate Dean-Haidet, RN, MSN, CS, Psychotherapist, 3750 Alward Road SW, Pataskala, OH 43062. Email:
  • Ruth Frankenfield, RN, MS, CNS, Staff Nurse, HomeReach Hospice, 3595 Olentangy River Road, Columbus, OH 43214. Telephone: (614) 566-5377.
  • Sharon Stout-Shaffer, PhD, RN, Associate Professor, Capital University, 1 College and Main Street, Bexley, OH 43209. Email: Telephone: (614) 236-6363.