Pay hikes alone won’t halt turnover

Comprehensive plan includes support

Keeping valued employees isn’t just about money. Worker retention strategies that focus primarily on salary may prove to be shortsighted. In addition to satisfying staff financial needs, hospices must provide support to their workers similar to the support they show to their clients.

As hospices try to find ways to keep nurses, social workers, and other employees from leaving for higher-paying hospital jobs or less stressful hospice positions, or from leaving the health care profession altogether, their leaders must consider workers’ spiritual, social, and professional needs.

Aside from complaints about low salaries compared to their counterparts in other segments of the health care industry, hospice workers seem to be consistently frustrated by increasing patient caseloads, emotional stress, spiritual issues, and cumbersome documentation requirements.

Experts say that if hospices can address these needs along with hospice workers’ salary concerns, they will have gone a long way toward reducing turnover and keeping employees professionally satisfied.

Specific strategies include:

• support groups;

• employee ministry;

• manageable caseloads and scheduling;

• more efficient documentation procedures.

The classic tool for addressing staff emotional reactions to their work is a support group that meets regularly. Support groups normally are either self-directed or led by a professional facilitator. What they are not, however, is psychotherapy or grievance sessions. Instead, support groups should address personal issues surrounding care for the dying and feelings of grief following the death of a patient.

A couple of years ago, Claire Tehan, MA, vice president of Trinity Care Hospice in Torrance, CA, noticed what she thought was a disturbing trend: hospices cutting back on employee support groups in response to mounting financial pressure.

Abandoning employee support groups may actually work against the goal of staying financially secure. If worker stress goes unchecked and an outlet for their stress and concerns is not provided, a hospice could find itself the victim of high turnover, which can impede its ability to grow.

"As short-staffed as we are, support groups are sacred," says Tehan.

In addition to support groups, hospices also should provide orientation programs as its first line of support for new employees. Orientation programs can include a series of videotapes of speakers from various disciplines and should include someone schooled in workplace safety.

The orientation program Tehan uses 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.

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 alone.

The overall message nurses should be given is that if they don’t take care of themselves, their work will suffer — and that there are resources available to help them.

In addition to support groups and orientation programs, hospice workers often need the same kind of spiritual care their patients need. Occasionally, hospice workers can benefit from the
services of hospice chaplains. While chaplains consider the emotional and spiritual well-being
of their colleagues a priority, they must also walk a thin line between supporting staff and allowing a staff member to become too dependent on chaplain services, says Jay Stark-Dykema, MA, pastoral counselor with Seasons Hospice in Park Ridge, IL.

Chaplains can provide support in the following ways:

— pitching in when families are demanding too much of the nurses’ time, especially when a nurse is being called upon by the family to address more psychosocial issues than clinical ones;

— direct spiritual care;

— affirmation. Nurses and social workers deal with very complicated and difficult matters, but often don’t receive the credit they deserve.

Nurses may try to do too much for families

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

For example, families in emotional crisis may rely heavily on the nurse for support, which results in the nurse having a hard time leaving the patient’s home. Rather than fostering independence and teaching the family and patient how to deal with emotions, the nurse falls into the trap of trying to do everything for them.

"Hospice families can require a lot of energy from a nurse, which can lead to burnout," says Stark-Dykema.

Aside from teaching nurses to rely on other members of the interdisciplinary teams to keep stress to a minimum, hospice chaplains should recognize situations in which the nurse may be too involved.

As part of the interdisciplinary team, it’s easy and appropriate for chaplains and other members of the team to develop close collegial relationships. After all, co-workers in other walks of life develop friendships that blossom outside the context of work. The relationship between chaplains and their team members is unique, however. In times of personal or professional crisis, the hospice chaplain is often the first person other hospice workers turn to for emotional or spiritual guidance.

Because chaplains have a predisposition to reach out to help, it’s easy for workers to seek their counsel. In most cases, when the loss of a patient triggers strong feelings of grief, ministering to employees is acceptable up to a point.

But one expert warns that hospices should evaluate chaplain-employee relationships to ensure the chaplain is not overburdened and that workers don’t cross ethical boundaries that could impede the team approach to hospice care.

It’s the blurring of boundaries that can cause problems between chaplains and their co-workers, says Stark-Dykema. He offers these warning signs:

• A chaplain finds himself or herself counseling a worker on an ongoing basis.

• Workers without a support system continually seek the chaplain’s counsel.

• A chaplain notices that he or she is spending more time with one team member than others, perhaps diminishing his or her availability to other staff or patients.

• If a chaplain too often plays the role of counselor with a worker, the chaplain runs the risk of diluting his or her effectiveness with the very people he or she is trying to help.

This does not preclude chaplains from ministering to their co-workers. In fact, chaplains play a key role in meeting the spiritual and emotional needs of co-workers as well as patients and their families.

While the feelings of grief experienced by hospice workers are strong, they often are not enough to prompt the worker to seek counseling through the hospice employee assistance program. An observant chaplain will likely notice the signs of grief the worker is experiencing, or the worker will seek out the chaplain’s help.

Experts say chaplains should feel free to help a worker identify the underlying issues at the root of their problems, but they also should encourage the staff member to seek counseling outside the hospice.

This is especially true in situations where the problem lies outside work but is affecting performance at work, such as marital problems, caring for a chronically ill relative, or parenting issues.

Acting as a resource for workers in need is an excellent way to minister to employees. In cases where co-workers have questions about their own spirituality, for example, chaplains should encourage the worker to seek the guidance of their own minister, priest, or rabbi.

Chaplains can use team meetings to openly discuss feelings of grief or distress that arise from a patient loss or other situations that may effect morale. For instance, the death of a patient who has had a significant impact on staff could be addressed during a team meeting where each staff member is allowed to light a candle in memory of the patient and share personal memories about the deceased patient.

"You need to ask how you can love and support your fellow team members," Stark-Dykema says. "You need to promote the sense that everyone is in it together."

Chaplains also can minister to their co-workers’ spiritual needs by holding educational inservice training on religious issues, such as different types of faiths. Chaplains can use the opportunity to get workers to reflect on their own spirituality by talking about how their own spiritual beliefs interact with those of a patient or a patient’s family, Stark-Dykema says.

Strive for efficiency

In addition to spiritual and psychological issues, mundane aspects of the job can cause stress. Providing documentation to ensure Medicare reimbursement is a good example. With fraud and abuse never far from the minds of those who administer government-funded health care services, proving medical necessity
is key to getting paid — and to avoiding the scrutiny of government auditors.

The increased emphasis on documenting details of a hospice patient’s care from the point of referral to the moment of death is taking its toll on hospice workers who were drawn to the profession because it hearkens back to the days of old-fashioned nursing, which emphasized hands-on care. But documentation requirements are demanding more of nurses’ time, which takes away from the time they spend with patients.

"The process of collaboration is the difficult and time-consuming part of documentation," says Tehan. "We’ve got a lot of people complaining."

According to Tehan, documentation is cumbersome because all members of the interdisciplinary team must document their own work, such as assessments, and they also must obtain information from other team members to fulfill their documentation responsibilities.

While at a loss for a specific solution, Tehan says the answer lies in making documentation more efficient. Home care agencies and hospices have dabbled in using the latest technology to help alleviate administrative burdens.

Software developer David Tripp, president of Tripp Consulting in Reading, PA, says the key to making the documentation process more efficient is to give members of the interdisciplinary team access to the same set of information and prevent the need for lengthy meetings where team members compare information.

To that end, Tripp has developed Hospiceware, database software that allows nurses, social workers, chaplains, and others to enter information into a computer and have that same information automatically entered into electronic forms shared by other interdisciplinary team members.

Tripp says the most practical way to facilitate the sharing of information is to equip workers with laptop computers that would allow them to enter data from the patient’s bedside and download the data at the end of the workday using a dial-up Internet connection.

The last component of this retention strategy has to do with showing workers their worth by investing in their professional growth. Experts say allowing nurses time to pursue professional growth by attending conferences and seminars shows support for their work and places a premium on their desire to improve as professionals.

"We are always looking for ways that show how much we value them," Tehan says. "You want to be able to show that you value their work and you need to willing to help them grow professionally."