Don’t let the pressure build up until your employees blow a gasket!

How you can help staff ease the growing stress in home care

Home care nursing has always been a highly stressful profession, but there have been few years in which the entire profession has faced as much stress as in 1997.

Consider these changes and events of the past 12 months:

• The president of the United States condemned home care, painting agencies with the broad brush of Medicare fraud, and gave support to some drastic new requirements that will change the way home care agencies operate.

• Increasing numbers of home care companies were bought, sold, or regrouped. Most recently, Home Health Corp. of America in King of Prussia, PA, announced plans to acquire U.S. HomeCare of Hartford, CT.

• Allegations of fraud have affected some of the nation’s largest home care companies. For instance, Columbia/HCA Healthcare, parent company to Columbia Homecare Group of Dallas, has been investigated by the FBI for allegations of defrauding the government.

• Home care nurses from coast to coast have found that managed care, whether it dominates their region, has increased documentation, decreased patient visits, and focused intently on outcomes.

"What has happened is home care has become more and more of a business," says Susan Brace, RN, PhD, PSY.D, a psychologist in private practice in Los Angeles.

"You have nurses documenting everything they do, and that takes enormous amounts of time."

Shorter visits mean added stress

Nurses find that having patient visits shortened is particularly stressful because the patients sometimes crave that extra time, Brace says.

Patients sometimes are so terribly lonely that as soon as the nurse enters the house they will latch on and talk continuously, making it difficult for the nurse to move quickly to the next appointment, Brace says.

So nurses give their hearts to their patients and often spend their own time providing the extra care that isn’t reimbursed by managed care companies, she adds.

"You get involved in the life stories of your patients," she explains. "And if you see them teetering on the brink of a crack in managed care, it’s so tempting to jump into that crack."

MedCentral Home Care/Hospice in Mansfield, OH, held an inservice on stress management after witnessing rising stress among the staff.

"All the changes in Medicare are shortening our lengths of stay for patients in home care, so all of our nurses, therapists, and staff members need to get in and out faster and teach families more," says Jane Versaw, RN, BSN, home care coordinator for MedCentral, a hospital-affiliated agency that serves a 40-mile radius around Mansfield in north-central Ohio.

No one can turn the clock back, but education managers and agency directors can help their employees cope with these changes and all of the other stressors inherent in home care, Brace and other experts say.

Here’s their advice on what an agency can do:

1. Acknowledge there’s a problem.

The first step is to increase people’s awareness that stress exists and can harm you if it’s ignored.

"Do what you can to increase people’s awareness of stress, to normalize it, and to validate it, so the home care professional doesn’t have to be superman or superwoman," says Arthur Nezu, PhD, chairman of the department of clinical and health psychology for Allegheny University of the Health Sciences in Philadelphia.

Brace, who has worked with home care agencies in group sessions on stress management, says it’s important for agencies to recognize that their staffs are sometimes under enormous stress.

And it’s often a group problem. "Home care is a little different from the hospital setting because people are out there dancing on a wire without a net," Brace says. "With the huge blossoming of managed care, one thing that has happened is people are going home sooner and sicker," she says. "So the home care nurse’s job has been exponentially made more difficult."

2. Explain individual symptoms of stress.

People often visit physicians because of symptoms caused by stress-related disorders that could be relieved by stress management, says Samantha Jeska, MSSA, LSW, a social worker with the 300-bed MedCentral Mansfield (OH) Hospital. Jeska conducted the inservice on stress management for MedCentral Home Care/Hospice.

These stress symptoms include the following:

• headaches;

• irregular heartbeat;

• muscle spasms;

• gastrointestinal problems, such as irritable bowel syndrome;

• dizziness;

• high or low blood pressure;

• fatigue;

• difficulty concentrating;

• increased or decreased appetite;

• rashes and hives;

• emotional signs such as irritability, depression, apathy, increased substance abuse, negativity, anger, and feeling overwhelmed.

The physical symptoms can catch people by surprise, Jeska says. "When my uncle was diagnosed with cancer, and it was a sudden thing, I didn’t have an emotional reaction to it. But five to 10 minutes later, I broke out in hives," she says.

"If you don’t manage your stress, that’s when you get the long-term effects stress can have on your body," Jeska says. (For a list of stress symptoms, see above.)

Emotional signs of stress also include feelings of being uncomfortable, helpless, burdened, tired, anxious, numb, and having no hope, Nezu says.

"It’s the feeling that no matter what you do as a caregiver, you can never have any effect on people," he says.

3. Explain group symptoms of stress.

When many people are under stress in the work place, there are some distinctive symptoms of group distress. These could include:

• burn-out;

• depression;

• bickering;

• excessive complaints;

• increased absenteeism;

• increased illnesses;

• high turnover;

• workplace anger.

Anger is the biggest symptom. It means the employees feel powerless, demeaned, or have had their feelings or pride hurt, Brace says. "Most frequently in our culture anger has to do with fear," she adds. But it also can be a good sign because it means that the stress hasn’t yet done its ultimate damage to the organization, Brace says.

"It means there’s life in the organization. But when you start to see a person flickering out, that’s someone who is burning out," she adds.

When nurses become angry about unacceptable conditions, they often give magnificent care to patients, Brace says.

"If a patient’s well-being is at risk, I don’t think there’s anything you could do to stop me from doing something about it, and I’d be furious."

But anger has its downside interpersonally. "Sometimes the nurses tend to go at each other because it’s not OK to be angry at the patient," Brace says.

The bickering and complaining is natural, but managers need to understand that it is a sign of stress.

4. Teach staff to change their outlook.

Unfortunately for home care professionals, there is little they can do to change some of the more stressful circumstances, such as increased documentation and decreased reimbursements.

Managers can make things a little better by acknowledging employees’ concerns about these changes. Brace recommends the managers listen and then validate the employees’ feelings. "They could say, ‘I understand how you’re feeling, and this is unfair, but you’re still doing a wonderful job.’"

Ultimately, however, it boils down to how each employee views the changes and reacts to the situation. (See prescription for life with less stress, p. 184.)

Jeska passed out a quote on attitude to the staff. The quote, by Charles Swindoll, reads:

The longer I live, the more I realize the impact of attitude on life. Attitude to me, is more important than facts. It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do. It is more important than appearance, giftedness, or skill. It will make or break a company . . . a church . . . a home. The remarkable thing is we have a choice every day regarding the attitude we will embrace for that day. We cannot change our past . . . we cannot change the inevitable. The only thing we can do is play on the one string we have, and that is our attitude. . . . I am convinced that life is 10% what happens to me and 90% how I react to it. And so it is with you . . . we are in charge of our attitudes!

5. Act whenever possible to reduce stress.

Nezu says stress management can be divided into two categories:

• Problem-focused stress management. This means you try to change the nature of the problem. Certain problem-solving skills can help with this. (See tips on what a home care agency can do to reduce staff stress, at right.)

This could involve brainstorming and group activities or working at improving communication between employees, Nezu says.

• Emotion-focused stress management. This involves relaxation training, yoga, exercise, prayer, and humor, he says. (See ideas for reducing stress, pp. 185-188.)

A home care agency’s management could take actions to help staff solve some problems that relate to stress, while education managers could teach employees how to reduce individual stress through emotion-focused stress management. (See story on what people can do to reduce personal stress, p. 190.)