Although common in all aspects of healthcare, compassion fatigue and burnout can particularly hit employees in oncology centers.
Such was the case at Huntsman Cancer Institute (HCI) in Salt Lake City. An initial inquiry into the problem revealed how many workers, including parking valets and housekeepers, were dealing daily with dying patients.
Hospital Employee Health asked Susan Childress, RN, MN, OCN, director of nursing services at HCI, about the Compassionate Workplace program.
HEH: How did this program evolve into these comprehensive efforts?
Childress: The program was initiated by one of my nurse managers who was going to school for her degree in nursing administration. One of the projects she did was to look at compassion fatigue on her medical oncology unit. She used the ProQOL [Professional Quality of Life] 5 survey, which is a validated survey that identifies burnout, compassion, satisfaction, and secondary trauma. (More information on ProQOL is available at: https://bit.ly/2W4toGd.)
She was getting a baseline on her staff and was surprised. Even though she had a well-functioning staff and didn’t have high turnover, they were certainly below the norm as far as compassion satisfaction and burnout. They were affected by the number of deaths they were seeing and the number of sad stories they routinely heard. As we talked about it, I realized that this wasn’t just her unit.
HEH: You realized it was a phenomenon that was affecting all staff?
Childress: We are a cancer hospital; everybody is exposed to deaths and sad stories. My guess was it wasn’t just nursing, but everybody from the valets who parked cars and transported patients.
In fact, right about that time, my son was working as a valet. It made this personal to me because he is a kid, an artist, who has done frontline, minimum-wage jobs. After the first week, he said, “Mom, this is the most meaningful job I’ve ever had. Patients come out and tell us the good news they got, or the bad news.” He told me the story of transporting one of our bone marrow transplant (BMT) patients — a young 19-year-old — to a CT scan. The kid says to him, “The docs just told me I am going to die.” Some of the valets are right out of high school — how do they handle something like that? It definitely gave me pause as I listened to my son and started thinking about all the other frontline staff.
For example, housekeepers are sometimes the most trusted people in the organization for patients to talk to as they are cleaning the room and sharing. These days, many of our housekeepers are immigrants, and sometimes they share the language the patients have, more so than the nurses and providers.
HEH: What did you do next?
Childress: We asked everyone in the organization to do this ProQOL 5 survey, and we really looked at whether there was compassion fatigue across the organization. Once we got the data, we found there was fatigue. Some of the most meaningful comments were from valets, housekeepers, bistro workers, and people who delivered the food trays. They connect with patients to try and help find something that they will be able to eat when they are struggling. They get to know these patients well, especially our BMT patients who are with us for weeks.
Often, when a patient dies, we will do a debriefing with the frontline staff, physicians, nurses, social workers, pharmacists. But we had never thought of including the aides who brought the food tray to them every day for five or six weeks. We are looking at a bigger picture than just nursing and providers.
HEH: What were some of the specific findings?
Childress: As we looked at the data, one thing that was amazing was that our most burned-out staff were our pharmacists. I went to our pharmacy director and said, “I’m really concerned. These are high-performing, high-paid, difficult-to-replace professionals in our organization, and I don’t think we are supporting them the way we need to.”
So just looking at the data gave us some opportunities to be a little more inclusive in our efforts. For our pharmacists, part of what we found out is that they had too much work to do. They were trying to meet unrealistic expectations, and during the two years after we started this initiative, we really looked at workloads for all areas. We have grown a lot and added a new building, and there were a lot of opportunities to address staffing issues. We added over 50 FTEs [full-time equivalents] in all different areas once we started this and got managers and directors to really look at what the needs were staffing-wise. The burnout is primarily workload — not having enough people to do the job, or unrealistic expectations. The compassion fatigue is related to those sad stories and deaths, but you kind of get into this whirlwind of compassion fatigue that then can create burnout.
HEH: You already had a wellness center set up for patients and families?
Childress: We were lucky to have some things already in place. We have one of the best wellness centers in the country for a cancer center. Many are offsite, but ours is right here at the hospital. They provide massage and acupuncture for patients and families. They also provide free exercise classes, art therapy, music therapy, and a lot of other things.
The manager of that department said, “What if we just opened everything up to staff?” Now, we have these services not only for patients and families, but for our own staff. That has been hugely successful. I go to the yoga class and have done the acupuncture a couple of times. I am just blown away by how much it helps when I have been lifting boxes or exercising too much.
HEH: Is your employee health department separate from that wellness center in terms of treating typical occupational injuries from handling patients and slips, trips, and falls?
Childress: Yes, we are part of the University of Utah Medical Center, and they have a work wellness center. If you are hurt on the job, you can go down there, or if it is off hours, to the emergency room. I’ve had a part-time wellness coordinator for the past couple of years, and she has done a really good job of showing up at staff and department meetings and saying, “We are going to do five minutes of exercise in the hallway.” Just trying to promote things like a two-minute meditation. We are requesting an FTE in the budget for next year.
HEH: You have found some positive results from 2015 to 2017 in terms of reducing burnout and affirmation from employees that the organization helps them deal with these types of issues.
Childress: We are doing the next employee satisfaction survey in the fall. We do it about every year and a half. But the big thing I’ve seen recently is the decrease in turnover. When we started this, we were probably about 12% to 15% in RN turnover rate. We are down to 2% to 3%, so that is certainly a significant decrease.
HEH: How do you handle the challenge of common work culture problems, conflicts, and issues that arise with patients or between staff?
Childress: I look at it as three different buckets. You’ve got patients and families being inappropriate with staff and all the complications around that. It could be a patient with a brain mass or a stroke — an organic reason. You still must deal with it, but you have to be sensitive to the fact that we are trying to help this patient. Everyone tries to understand that, but it doesn’t always make it easy. Then you have patients and families who are just not nice people. At what point do you say, “I’m sorry, we can’t treat you if are going to act like this”?
In any organization, you always say we put the patient first — that message is all over the place here. But sometimes, we don’t put the patient first when it is a safety risk to our employees. That is dealt with at a high level.
We have issued at least two letters this year to [patient] family members saying if they come on the premises, they will be arrested for trespassing. This is related to egregious, threatening behavior. There have been a couple of times when we have talked to patients, saying “clearly you are not happy here, let’s help you find another provider organization.”
HEH: What about problems between co-workers?
Childress: Yes, the next bucket is peer-to-peer, and we have spent the past year really focusing on that. As much as you would think that would not still be around, it still is. Holding people accountable for their behavior is really important. We have that in place in our reporting system.
The third bucket is providers, and we have a system there: If a provider is inappropriate with a staff member, there is a reporting mechanism, and we have a process where it goes directly up the physicians’ board chain of command. It is taken seriously, and we have seen great results on some challenging situations.