Help hospice staff develop better boundaries and organizational skills
Is action therapeutic or not?
While any type of home health work makes it more challenging to recognize and respect boundaries, it is particularly challenging for hospice workers who see people at the most intimate and difficult time in their lives.
"The assumption is that 'I'm here as a hospice professional, so I have a carte blanc because death and dying is an intimate experience,'" says Susan Balfour, BA, RN, director of clinical and regulatory affairs for the Carolinas Center for Hospice and End of Life Care in Cary, NC.
So hospice staff might assume that because they are taking care of a patient at this time, it is all right to be personally involved with the patient and family, Balfour notes.
"But we've had patients and families give feedback about how they, frankly, find it very much an imposition, and sometimes they don't know enough to say, 'You need to leave' or 'That's not appropriate,'" Balfour says.
Sometimes there are situations where hospice aides are telling patients about their own problems, and this clearly is not appropriate, says Linda Levi, RN, BSN, president of Glory Health Systems in Weaverville, NC.
Balfour spoke with a hospice social worker about boundaries, and the woman's comment was as follows: "If you're taking your own stuff into the home, there had better be a therapeutic reason."
What hospice staff sometimes forget is that people are trained to be polite and make guests feel welcome, so even if they're uncomfortable with a hospice worker's visit, they won't ask the person to leave or try to correct the person's behavior, Balfour says.
One person who had experienced hospice visits told Balfour: "Just because the hospice staff share the intimacy of death with us as a family does not give them the right to become intimately involved with our affairs."
So if hospice workers' actions or words are not therapeutic, they don't need to do or say it, Levi says.
"Therapeutic doesn't necessarily bring healing, but it certainly means doing no harm and promoting the wellness of that situation," Levi explains.
Hospice managers should teach staff to look at all of their actions through the filter of therapeutic, Levi suggests.
Another strategy for helping staff learn boundaries is to promote the use of the team as a boundaries safety net, Levi says.
"You can go to your team members and acknowledge with them what the situation is and what you're doing and get some feedback," Levi says. "Don't go out there as the Lone Ranger and just do things."
For example, at one hospice an aide wanted to bring a small gift to a hospice family member. It was an inexpensive figurine she found at a garage sale, but the team let her know that it would be better if the gift were given through the entire team so the family and patient wouldn't construe the gift as meaning that the aide cared about them, but the rest of the team did not, Levi says.
Also, there was another situation in which a hospice nurse took a sausage biscuit to a patient each time she made a visit, Balfour recalls.
"Then one time another staff member came for the visit, and the patient was mad because that person didn't bring the sausage biscuit," Balfour says.
While the nurse's actions were altruistic, they had crossed the boundary, she notes.
"People rarely identify whether they've stepped over boundaries," Balfour says. "Nature is such that we can be over there and not realize we've crossed a bridge that we shouldn't have crossed."
However, when a boundary is breached within a highly functioning team, it can be recognized and resolved, Balfour says.
Some cues hospice staff should ask to help them recognize boundaries are these, Levi says:
- Does the action benefit me rather than the patient?
- How is the action viewed from the perspective of the patient's family?
- Does this patient mean something special to me?
"If you start treating someone special in some way from all the different patients, then you know you have a boundary issue," Levi says. "We try to give cues and use team support to bounce things off and get some balance, but the bottom line is 'Who does this benefit—me or the patient?'"
Another analogy for maintaining boundaries is to think of it as like a tennis match, Balfour says.
"Hospice staff talk with family members about their lives and kids," Balfour says. "But a skill we need to teach our staff is for the front-line folks to get that ball back over the net and back into the patient's and family's court because it's all about them and not about us at all."
Organizational skills also needed
Nurses who conduct the most effective hospice visits also have better organizational skills, which some might say are more nature than nurture, these still can be learned, Balfour says.
"You should set up a structure that includes those organizational steps that someone would take automatically, and then you assist and evaluate them," Balfour suggests.
Levi recommends hospice managers follow these tips on improving staff's organizational skills:
- Look at what tasks need to take place to make up a visit.
- Note what a hospice worker needs to do to get ready for a visit.
- Outline how they will conduct patient care, collect supplies, complete forms, etc.
- Explain what actually will be done on a hospice visit.
- Describe how a hospice worker will introduce him/herself, including saying what he/she will be doing in the home.
- Script how the hospice worker will explain what will occur on future visits.
- Provide context for the visit and post-visit phase of care.
- Show what happens when there's a change in the plan of care.
- Break down the visit into steps and phases, explaining what needs to be done at each.
- Help nurses and staff develop their own visit protocol, including what takes place, what are time savers, what can be done differently, how to do documentation, and identifying which tasks can be completed ahead of time.
"As a hospice director, I always had a couple of staff members who were chasing down documentation," Balfour says. "Some agencies have solved that because of laptop computers."
But for those who have difficulty with documentation, one good strategy to follow is what one nurse described to Balfour: "I start the charting in the home, and it helps my patient and family see that I'm taking everything seriously."
One way for a hospice manager to monitor staff's organizational skills is by teaching staff to debrief and ask themselves these questions, Levi suggests:
- Was the purpose of the visit achieved?
- Were my and the patient's/family's expectations met?
- What organizational skills did I use?
- Did I identify the plans for the next visit?
Another way to look at the importance of organizational skills in hospice work is for hospice staff to keep in mind that the last thing most hospice families and patients need is change, Levi says.
They already are experiencing a big change, and what they need from hospice is consistency, which is what a well-organized team can provide, Levi explains.
"The gift we can give to patients and families is if our visits are consistent," Levi says. "They really need that feeling that if their nurse is not visiting them that day, then someone else will come in who will do things pretty much the same way and within the same time frame."
While any type of home health work makes it more challenging to recognize and respect boundaries, it is particularly challenging for hospice workers who see people at the most intimate and difficult time in their lives.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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