Special Report: Improving Staffing Quality

Improving interdisciplinary teamwork also boosts quality improvement

Even two hurricanes couldn’t shatter one team’s bonds

Staffing continues to be a major issue for hospices and other health care organizations that must face periodic shortages in nursing and other disciplines, as well as cope with high turnover rates. For hospices, attempts to implement basic strategies for improving staff morale and retention are challenged by the high demand for employees who embrace the hospice philosophy, which may improve loyalty but can also lead to faster burnout.

"Basic hospice care for patient and family is very holistic," says Joy Berger, DMA, BCC, MT-BC, director of the hospice institute at the Alliance of Community Hospice & Palliative Care Services of Louisville, KY. "It includes physical, emotional, spiritual, and bereavement care, and it goes far beyond the standard medical care model," Berger says. "We provide a lot of emotional support and education for the family, as well."

This is why an interdisciplinary team approach is crucial for a hospice, she adds. "We have an orientation model and process for helping new employees transition from non-hospice, interdisciplinary roles to the hospice model," Berger says. "This is a significant transition for many employees who come from the curative vs. palliative perspective."

Likewise, the Hospice of Lancaster County in Lancaster, PA, helps LPNs make the transition from skilled nursing facilities to hospice care, where they become hands-on providers who provide services that they’re accustomed to seeing aides provide, says Janet Carroll, MSN, RN, CHPN, vice president of clinical services for the hospice.

The not-for-profit freestanding hospice does not hire home health aides and homemakers. Instead, it has LPNs provide those services, which enhances the quality of care, Carroll says. "Although we have not analyzed the hard numbers, we know we save money because we don’t have the staff turnover we would have, and there are things LPNs can do that home health aides cannot," Carroll explains. "Looking at it from a quality perspective, we’ve always gotten good feedback."

"By virtue of their license, training, skills, and experience, LPNs are able to help out in numerous ways that complement the RN staff," Carroll adds.

One of the chief staffing challenges arising for hospices and their interdisciplinary teams involves communication breakdown. "Usually when you have any group of professional people and team members, there is some disagreement or conflict," says Martha Lasseter, MBA, RHIA, vice president of compliance at Hospice of Martin and St. Lucie of Stuart, FL.

"You have to have team cooperation and have the team mesh so the best interests of patients and caregivers are met," says Kathy Moon, RN, BSN, clinical director of day programs for Hospice of Martin and St. Lucie. "Each member of the team has a defined role, and they all have to mesh together to accomplish the end result so that the patient and family experience a peaceful death."

Hospice managers focus on strategies for improving communication and reducing the common staff conflicts that result in a dysfunctional employee team dynamic if left unchecked, Lasseter and Moon say. For instance, one of the typical conflicts that arise involves staff-patient boundaries. "Occasionally, a nurse or social worker becomes too involved with family situations and crosses the ethical boundary, and that creates conflict with the rest of the team," Moon says.

"As you’re dealing with families, you can’t help but get enmeshed," Lasseter says. "Maybe you see a family struggling financially, or maybe you see that there’s not enough food in the home." Hospice of Martin and St. Lucie once had a situation where a nurse saw that the family didn’t have enough money to pay for food, so she tried to help them sell some of their belongings to free up their cash, Lasseter recalls. "Her heart was in the right place, but she went about it the wrong way," Lasseter says. "All she needed to do was let her supervisor know about the problem, and as a not-for-profit agency we could partner with United Way to get the family the food they needed."

In another instance, an employee saw how a patient was struggling with finding a home for a pet, so the employee took the pet home to care for it, Lasseter adds. "Or staff will give up their private home phone number and have chats, answering the patient’s questions at all times of the day and weekend," she says.

Even the more benign of these examples can have a negative impact on team morale, Moon says. For instance, if the nurse crosses a boundary by handling financial issues with a patient, then the social worker might feel as though this hinders her from doing her job, Moon says. "Rather than working together and collaborating as a team, the nurse’s actions have created a divided team," she adds.

When these issues arise, managers counsel employees individually and then pull the team together to determine how best to correct boundary problems, Moon says. "Sometimes we may have to reassign the patient to another staff member if the situation can’t be resolved without further harm to the team or the patient’s care plan," Moon says.

Lasseter and Moon, along with other hospice managers, learned how important a fully dedicated and integrated staff could be during the fall 2004 hurricanes that pounded Florida.

When hurricane Frances struck the Stuart area on Labor Day weekend and then hurricane Jeanne struck the same coastline three weeks later, many staff members and patients were displaced, Lasseter says. "You’re taking care of patients, but at the same time thinking about how you don’t have a roof over your house or your bedroom is ruined and the carpet is soaked," Lasseter says. "All of these are the types of things our staff was having to deal with."

From the beginning of the hurricane disasters, hospice managers had to keep the teams cohesive and help people deal with personal losses and patient losses, Moon recalls.

Under adversity, team pulled together

"We had to identify the staff that had a need and work with them so they could continue to function to provide for their patients," Moon says.

The team cohesiveness was readily apparent: "Our staff came through with flying colors," Lasseter says. "I can’t say enough about how unselfish they were. People came to work without electricity in their homes; they had to use the water and electricity here to do laundry and take showers."

The entire agency pulled together to make certain all of the patients were taken care of and to make certain new patients were handled as well, Lasseter and Moon add. The hospice’s 16-bed inpatient residence doubled to 32 beds when some patients were brought in because they had lost their homes and when another hospice needed to find a place for the patients in its residential facility after the hurricane had damaged it, Moon explains.

When the agency’s telephones were down for three days, the entire staff contacted patients and kept track of one another through three cell phones shared by the only employees who had cellular phone service, Moon notes. "We had staff members who worked on their time off so others could contact FEMA [Federal Emergency Management Agency] and their insurance companies," Moon says. "It was truly a team effort, and everyone pitched in wherever they were needed to help their fellow co-workers, as well as the patients."