Improved orientation program reduces turnover

Hospice makes support group mandatory

For hospice workers, dealing with the death of someone close to them is an everyday occurrence. And while they provide compassionate care and support to patients and families, there is often little support for the hospice workers themselves, as they move from one death to the next.

Failing to provide adequate support to hospice workers often translates into burnout and high employee turnover. The stress of establishing a loving relationship with a patient and family, only to have it end with the patient’s death, can take its toll if left untreated.

"All of my staff are important, and they deserve to be treated with the same hospice touch they provide to their patients," says Jane Isbell, BSN, RN, CRNH, administrator for the Hospice of Central Virginia in Richmond.

When it came to hiring and training nurses, the Hospice of Central Virginia was like a lot of other hospices around the country. As early as last year, the hospice was hiring nurses with unwanted regularity. New nurses were coming aboard not because they were adding new positions, but because they were losing nurses to the stress of the job. Prior to January 2000, a nursing staff of 15 was saddled with an average loss of five nurses per year.

Implement solid orientation program

That meant having to hire a handful of employees each year, incurring the cost of training them, all the while hoping they had the stuff that would allow them to be long-term successes. In addition, existing staff were handed the additional burden of making up the workload while the organization was brought to full staff.

"Our staff retention has increased dramatically," Isbell says. "I feel strongly that it is because of our orientation and support programs."

Isbell credits the hospice’s new orientation program in reducing its average turnover of five nurses per year to one this year.

In the beginning of the year, the Hospice of Central Virginia implemented an improved orientation program, one that not only introduces new nurses to the organization, but also provides coping skills to help them deal with the emotional rigors of caring for the dying day in and day out. The hospice also conducts weekly support group meetings at which attendance is mandatory every other week.

Most hospices provide orientation programs for their new employees. There, they are shown a series of videotapes, listen to speakers from various disciplines, and learn about workplace safety. At the end of the process, a new nurse is sent out into the field with a caseload of a dozen or more patients.

To some extent, the Hospice of Central Virginia’s orientation program isn’t any different from those of other hospices. They, too, provide basic hospice information and show new employees how to properly lift heavy boxes. But the hospice also goes considerably farther. First, the orientation program is individualized and dependent on the new hire’s ability to grasp concepts about death and dying, not only from a patient perspective, but also from their own perspective. All that means that new nurses aren’t sent into the field in just two weeks, but in three or four, or not at all.

"They aren’t sent into the field until they are comfortable," says Cheryl Rodgers, RN, BSN, staff development/quality assurance coordinator. "The nurse stays in the orientation program for as long as the nurse needs it. It also gives me a chance to determine whether being a hospice nurse is the right job for the person."

The orientation program includes the following topics:

Organizational philosophy: Recently hired workers are schooled in the hospice philosophy and the hospice’s mission.

Hospice basics: For nurses who have never worked in hospice, there is a need to become familiar with ideas such as the interdisciplinary team, palliative care, spiritual care, advance directives, and other tenets of hospice that are critical to getting them oriented.

Communication: New nurses are taught how to listen to patients and take clues from patient interaction.

Death and dying: New hires are asked to explore their own feelings about death and dying, and perhaps revisit their own loss of a loved one.

Stress management: The hospice stresses the importance of communication, not only for the sake of patient care, but also for the mental well-being of its nurses. New nurses are taught the importance of using resources available through the interdisciplinary team, such as other team members who can provide additional support to the patient and alleviate the stress of having to support the patient on their own.

Learning to deal with death

Everyone has unique experiences with death. For hospice nurses who deal daily with death, these experiences can affect how they approach their work. New nurses who have gone through the pain of a loved one’s death, can let their unresolved feelings affect how they relate to patients. For example, rather than remaining empathetic caregivers, they allow themselves to become too personally involved with their patients. If their own experience left them with feelings of guilt or anger, that could translate into poor care and higher job stress.

Some death experiences can leave some with the desire to help the dying in the same way their loved ones were helped or attempt to provide better care than their own loved ones received. While that may be the foundation for the type of commitment hospices are looking for, they still must work through unresolved feelings before being allowed to care for patients.

The Hospice of Central Virginia addresses those issues by making death and dying a focal point of their orientation. Orientation participants are asked to reflect upon their own experiences and are given skills that allow them to approach care from a patient perspective and not from their own viewpoint.

Yet, many of their new nurses are young and have yet to experience the death of a loved one. Their inexperience in caring for dying patients can have an adverse effect, as well. Young nurses, for example, can be overwhelmed by the needs of the patient. With little life experience, they could feel ill-prepared to answer lofty questions about life and death.

Hand in hand with helping new nurses come to terms with their perceptions of life and death comes the need to teach stress management, says Rodgers. Caring for the dying requires a special type of commitment. Effective hospice nurses must walk the fine line between being caring and compassionate caregivers and becoming too emotionally invested in the patient and family. Hospice nurses feel compelled or called to their line of work. While that stands out as an admirable trait, it also can lead to higher stress levels among nurses.

In their zeal to care for their patients, they run the risk of neglecting their own well-being. This can manifest itself in a number of ways. A common example is one where the nurse tries to provide the lion’s share of the care and support to the patient and family.

"They have a hard time leaving the visit," Rodgers says. "Rather than fostering independence and teaching the family and patient how to deal with certain situations, they fall into the trap of trying to do everything for them."

New nurses are taught to rely on others to keep stress to a minimum. Rather than shouldering all the care a patient needs, nurses are encouraged to call upon other members of the interdisciplinary team to provide specific types of care.

For example, when a patient questions the purpose of his or her life as he or she approaches death, a nurse might feel uneasy about trying to tackle such a delicate subject. Although the nurse can play a role in encouraging the patient’s spiritual explorations, he or she might be more comfortable calling upon a chaplain to take the conversation further.

"We try to tell them: You’re not alone. The interdisciplinary team will support you. Everyone makes mistakes — you’re not going to have all the answers. "I don’t know" is an acceptable answer. You shouldn’t be expected to have all the answers.’"

Encouraging nurses to care for themselves

The overall message new nurses are given, says Rodgers, is that if you don’t take care of yourself, your work will suffer and that there are resources available to help them. "If you feel overwhelmed, tell someone," Rodgers says. "Take the day off. People need space from work."

"You need to take the time to care for yourself, just like you teach families to do," adds Isbell.

Even the mundane aspects of the job can cause stress. Providing documentation to ensure Medicare reimbursement is a good example. According to Rodgers, the orientation program addresses that by not glossing over the importance of providing detailed information regarding documentation and required forms. According to Rodgers, program participants are not allowed to graduate from the program until they are proficient at gathering the needed information and completing required paperwork. Aside from the obvious benefit of clean claims, the rule is rooted in the belief that the stress of patient care will not be compounded with the tedium of administrative red tape.

After new nurses have completed the orientation program, stress is still a threat. The continuous loss of patients can take its toll. Perhaps, the death of particular patients can trigger strong emotions. For this, the Hospice of Central Virginia has established support group meetings for its workers.

Many hospices do the same. Heavy caseloads among their staff often preclude them from attending support group meetings. Rather than allowing workers to attend the groups sessions voluntarily, the Hospice of Central Virginia requires its workers to attend two meetings a month. Attendance is scheduled according to the interdisciplinary team. To keep up with the daily slate of visits, one team covers scheduled visits of the team attending the support group.

The support group is facilitated by an outside psychologist. Isbell says it was important to bring in an outside facilitator rather than rely on an in-house chaplain. "Our chaplain needs to be able to express his grief, too," Isbell says.

In addition, the support group meetings are for staff only, and administrators are excluded from attending. Isbell says this allows staff to speak freely.