The emotional toll of caring for the seriously ill contributes to high rates of burnout among palliative care workers.
Burnout is a state of complete mental, physical and emotional exhaustion. Symptoms of burnout can include depression, compassion fatigue, stress and anxiety, and apathy, both in general life and towards work tasks. For palliative care clinicians, that apathy can lead to the depersonalization of patients, negatively affecting patient care.
Clinicians face relatively high rates of burnout “due to the secondary trauma and emotional exhaustion that develops from working with death and dying daily,” Aprille Waldrop, social services manager for Florida-based Hospice of Health First told Palliative Care News. “There can be long hours, higher caseloads, patient/caregiver heightened emotions that lead to higher levels of stress than in other medical care settings.”
A 2020 meta-analysis of 15 studies on burnout among palliative care nurses found a 24% prevalence for emotional exhaustion, 30% for depersonalization and 28% for feelings of low personal accomplishment.
While those who work directly with patients such as nurses and CNAs are more likely to report symptoms of burnout, social workers, grief counselors, doctors and chaplains working with palliative care organizations experience the same degree of trauma and need the same support, Waldrop said.
The need to roll with the near-constant changes in the health care system also takes a toll, according to an executive panel from Houston Hospice. The panel included Rana McClelland, president and CEO; Jayne O’Brien; vice president of patient services; Arlene Coffman, director of clinical services; Dr. Hanh T. Trinh, team physician and medical director designee; Mary Grace Holvenstot, senior human resources generalist; and Shelia Robinson, human resources generalist.
“Nursing is not the same kind of work it used to be. Patient length of stay is too short these days and everything is a crisis,” the Houston Hospice executives told Palliative Care News in joint email. “Nurses don’t have time to build relationships with their patients and families as they did in the past and this can be very stressful.”
The risks of burnout
When a nurse or support provider becomes burned out, their patients and the organization suffer.
Burnout can lead to an increase in absenteeism and paid time off use from nurses who don’t usually miss work, the Houston Hospice team said. Burned out nurses can also decide to leave the profession altogether, leaving fewer clinicians to care for patients and increasing the workload for nurses who stay — this can perpetuate the cycle.
“When burnout leads to staff turnover, continuity of care for patients and families can suffer and also lead to less productivity for the organization,” the Houston Hospice executives said. “Turnover affects organizational memory and history, as well.”
Beyond potential staffing issues, burnout can lead to negative attitudes toward patients and cynicism towards providing care, leading to a lower quality of care, even if the nurse stays on.
Both Houston Hospice and Hospice of Health First have robust employee support programs to help mitigate the risk of burnout among their staff. Both teams emphasize the importance of self-care and mental and physical wellness.
“In the palliative care/hospice setting it is important that the staff get to process the emotions and secondary trauma they are experiencing through talking with coworkers or the individual support of their supervisor,” Waldrop said. “Self-care through exercise and self-assessment techniques are also effective to prevent burnout. It’s important that the staff feel valued and the work they do is appreciated and recognized.”
Both organizations utilize Employee Assistance Programs (EAPs) through their corporate insurance providers. EAPs can help palliative care clinicians receive support for their mental health needs, usually at no additional cost to the employee.
Houston Hospice also launched a mental wellness program in February as a free benefit for employees and their families to access. The personalized service includes confidential therapy, wellness exercises, personalized care, medication management, care navigators and digital tools to help clinicians navigate their mental health journey, the executive team said.
Frequent check-ins can also help mitigate symptoms of burnout, addressing concerns sooner rather than later, and allowing managers to recommend employees access the resources available.
“We are implementing a strategy to be more intentional about checking in with employees,” McClelland told Palliative Care News. “We are conducting ‘stay’ interviews to measure how staff are faring in the early stages of employment so we can mitigate any issues sooner rather than later.”
At Hospice of Health First, the palliative care department has created self-motivating events for staff to join, including fun runs and walks for charity, exercise of the month challenges and volunteer opportunities.
The company also has an associated-led Engagement through Positive & Intentional Culture (EPIC) committee focused on championing the company’s culture. The EPIC committee leverages compassion champions in times of personal or professional support needs, Waldrop said.
Waldrop added that sometimes, all a nurse needs is a change of scope to help them regain their love of the profession.
“Within the hospice realm, I’ve seen several amazing nurses that were burnt out that were able to swap, like a field nurse placed in the inpatient unit. It was like a new person,” Waldrop said. “Or an inpatient nurse and make her a floater. Just changing the role around a little bit and giving them a fresh start.”