Staff support important in belt-tightening era

Support groups, open communication can help

Emotional support for caregiving staff, a cornerstone of the modern hospice movement, is increasingly jeopardized by financial pressures. Belt tightening is threatening anything not directly related to the "bottom line" at a time when outside pressures are increasing staffs’ need for support.

This is only one of the paradoxes of providing staff support. Research has demonstrated that the primary cause of stress among hospice staff is not grief over losing patients with whom they have developed emotional bonds, but organizational issues within their agencies. And managers struggle to reconcile their desire to shield their professional staff from outside pressures buffeting the organization with staff members’ need for information about these issues.

"Staff support is greatly threatened in this day of falling census," says Claire Tehan, MA, hospice coordinator for Hospital Home Health Care Agency of Torrance, CA. "I know some programs have dropped their support programs."

"As with any organization, downsizing is very painful. There’s no way to do it without people having real struggles," adds Dale Larson, PhD, director of the Graduate Health Psychology Program at Santa Clara (CA) University, and a veteran of hospice support groups.

Although organizational stresses have been shown to be the greater problem for hospice staff, it is important not to dismiss the cumulative effects of having so many patients die, says William M. Lamers Jr., MD, a psychiatrist and hospice consultant in Malibu, CA. Such accumulated losses can lead to burnout.

"Staff support is something that sets us apart in hospice," says Marilyn Hannis, RN, director of Hospice of Cape Cod in Yarmouthport, MA. "We need to make sure we have something built into the program to deal with loss, so staff don’t end up with a filing cabinet of grief issues. At the same time, when we bring new people into this agency, we always try to get some sense of what personal supports they have outside of work. Now how do we balance that with psycho- education on basic transition and change issues? It behooves us as managers to be sensitive to, and to provide education around, change management," Hannis says.

Two and a half years ago, Hannis’ hospice embarked on an organizationwide assessment and transformation built around a more collaborative management style. Previously, "one other manager and I had made the judgment that we wanted to protect staff from changes in the larger system — allowing them to be totally focused on the bedside," Hannis says. "That was a major complaint — staff felt uninformed. The staff would much rather have the information so they can begin preparing for what might come. Even if they don’t like the message, they like the fact that they are being told."

This communication has required a huge commitment from the agency, Hannis adds. Currently, many important business decisions are made by an 11-member leadership team, which includes top-level management and three members elected from among line staff. Minutes and notes from this team’s meetings are posted weekly. An in-house newsletter has become a major communication forum, and volunteers have also been brought into the loop.

"What I’ve seen is a real need for everyone to know the financial realities," Larson observes. "If everyone knows those realities, people are pretty rational. But you can’t be partially open with your information. And if the system has greed built into it, people will figure that out. If you have to make painful changes, they need to know why, and in some detail. You can’t protect them, and you have to demonstrate the necessity."

What is the perfect support group?

The classic tool for addressing staff’s emotional reactions to their work is the support group, which meets regularly, and is self-led or led by a professional facilitator. "It is team members coming together, talking about the stress of doing the work, sharing the joys and sorrows, and reflecting on their work together," Larson says.

Larson asserts that support groups should not be psychotherapy or grievance sessions for complaining about what’s going on in the organization. Serious personal issues should be brought to a therapist. "Form a work group or committee apart from the support group to tackle specific organizational issues," he advises. Groups should not be offered as palliative treatment for organizational failings.

Larson describes his ideal support group as having no more than 12 members who meet at least every other week for 90 minutes, with at least half of staff members’ time paid by the organization, and structured so that everyone is empowered to participate.

Other forms of support programming experts recommend include periodic memorial services, setting aside time at the end of team meetings for reflecting on the personal side of work, bringing hospice staff and [their] families together away from the work setting, and even offering stress fighters such as free yoga or tai chi classes at work. But it is also important to make sure that every patient’s death is reviewed and acknowledged, Lamers recommends.

"I believe memorial services help a great deal, as well as parties and outings and annual retreats," says hospice veteran Patricia Murphy, RN, newly appointed director of hospice services for VNA and Hospice of Northern California in Emeryville. "In a time of high anxiety, administration also needs to be more available one-on-one. Emotions can run high when people are anxious, and [staff] may misperceive what is said," she adds. "People also want to have their feelings respected and to get their two cents’ worth in. All of those things go a long way."

[Editor’s note: For additional creative support ideas, see Larson’s Hospice Home Page:]