10 Older Adults 279status. When the hallmark of good practice is connection with the individual
and family, it is nearly impossible not to be affected by the experience. The
grief can feel disenfranchised, not legitimate due to their professional role
(Doka, 2002). Legitimizing the feelings, and giving forum to the expression
of those uncomfortable feelings, is one of the key interventions to minimiz-
ing unproductive countertransference and reducing compassion fatigue and
burnout. It also supports the potential for increased insight into and under-
standing of the work.
Although the exposure to grief experiences is intensely connected to
the griever and the patient, hospice clinicians are largely remote (indepen-
dent) workers. While hospice care is provided by an interdisciplinary team
(comprised of nurses, social workers, chaplains, music therapists, bereave-
ment counselors, volunteers, and home health aides), the actual interaction
with patients and families is individual. The team meets weekly to discuss
patient care and family coping capacity, but beyond that weekly interaction—
each team member operates independently. This is a part of the work that
many clinicians enjoy, but also can contribute to feelings of isolation—particu-
larly when they have a powerful experience with a family. With much sicker
patients coming on to service so late in their disease progression, the work can
be emotionally challenging. Unchecked and unprocessed work can impact a
clinician’s ability to provide authentic empathetic care and may contribute to
symptoms associated with compassion fatigue and burnout.
As an administrator, I am charged to not only provide quality compre-
hensive services to our patients and families, but also to tend to the clinicians’
practice while juggling the financial realities of being a hospice provider. The
hospice financial environment has been impacted by decreasing reimburse-
ments, increased scrutiny (routine chart audits by Medicare which suspends
payment until the audit is complete), shorter lengths of stay, and the reevalu-
ation of hospice eligibility criteria (particularly with patients with terminal
neurological disorders, such as dementia—which financially penalizes the
provider when the patient is on service too long, or is discharged). Baumrucker
(2002) acknowledged that the ever increasing pressures of paperwork, regula-
tory demands, and late referrals add stress to the frontline clinician. Shrinking
resources coupled with increased demands heightens management’s respon-
sibility to create a work environment that promotes engagement and renewal.
In my experience working with hospice clinicians, the first relationship
to suffer when clinicians are approaching compassion fatigue and/or burnout
is the relationship with the agency itself. The clinician begins to express dis-
satisfaction with administration. In a perceived unsafe environment, clinicians
will express intolerance to organizational changes necessitated by regulatory
demands and perceive any change as devaluing their role. The relationship
with the work is enhanced when the workload is perceived as reasonable while
feeling valued and supported by the organization (Vachon, 2011). Recovering
from disengagement can be a long and arduous process.
So, how do you sustain a compassionate workforce with so many obsta-
cles and barriers? One way is by promoting the opportunity for clinicians to
be reflective and self-aware. If compassionate care is delivered through the
medium of relationship, then it stands to reason that the relationship between
administration and frontline staff is essential to that goal. Building a trusting