We’re celebrating the return of heart-based/heart-centered care - it was never completely gone, but let’s revisit the basics.

When I first started working in hospice, we had regulations, but there was more space to care. To spend time. To reminisce and connect and develop relationships. We were definitely practicing the concept of meraki. 

Today, there is more pressure than ever to meet productivity standards, document well, and prove eligibility. We still put our souls into it, but we do so feeling more pressured and rushed.

Whether you are just starting in the hospice industry or you are an experienced hospice professional, we can't help feeling that pressure to perform, do more, be more. We don't have time to waste.

That's why it's so important to make the most of your time with the patients and their families. As we talk to our customers, the overarching theme always comes back to the stresses of the job mentioned above. 

Hospice nursing turnover rates are 19%. That means one year from now, 1 out of 5 of your nurses will no longer work with you. Industry experts say that it costs between 1-2 years for new employees to be fully productive in their role.  

The solution? Well-trained, highly engaged employees can reduce a company's turnover rate by 25-59%.

While employee education is a challenging, never-ending job, we'd like to give you a resource for training your staff to make it easier on your education coordinator and easier on your staff, too. The best part? It’s free!

Often, there is a chasm between a hospice professional's intentions to teach and actually teaching. Not because they aren’t doing their job - but because they are focused on the whole of their job - meeting everyone’s needs, all of the visits, the meds, the equipment, the caregiver issues - and it’s difficult to settle in and focus on educating the caregiver when the whole of their job is calling.

We set out to help the end-of-life professional practice heart-centered care. What does that mean? It means that we take the time to teach, support, encourage, listen, answer questions, connect, and be emotionally available. It means that you are transforming those heart-based words into action that benefits the patient and caregiver.

Then what happens? Your patient/family satisfaction rate and caregiver confidence increases. Caregiver anxiety decreases. And if your team member is trained well, she knows exactly how to deliver and highlight the important parts of end-of-life care.

That’s where Nature Gave Us Butterflies comes in. We’ve known for a long time that Nature Gave Us Butterflies, Hospice Edition is a game-changer when it comes to educating the patient and family. It is a touchstone in heart-centered care, serving as a reference that your professionals can return to over and over to reinforce their teaching between visits. 

We want our customers to get every ounce of value and meaning from this booklet - part of the end-of-life professional’s toolkit. So we developed our new training guides that will be included in every order of Nature Gave Us Butterflies, Hospice Edition. 

The training guides are designed to help your Orientation/Education/Inservice Coordinator train new and existing staff on how to use this booklet to effectively educate caregivers and reinforce their teachings. Here are some highlights of the training guide, which is yours for the asking! The training guides:

• Highlight when to teach from the booklet: at admission, each visit, teachable moments, when the caregiver has questions, status changes, and the active dying process
• Describe how to introduce hospice goals (which are related to the hospice quality initiatives) on the first page 
• Explain the organization of the booklet (Part 1 addresses specific symptoms; Part 2 is a chronological timeline. Both sections are designed for findings topics easily and quickly.
• Detail the specific symptoms and issues within the booklet
• Describes the contents of Part 2, which includes the Caterpillar to Butterfly metamorphosis and what to expect as death nears
• Focuses on the quality of the visit and ensuring that all needs were met by the end of each visit by providing suggestions for questions that can be asked 

Imagine the peace of mind in knowing all of your team members are maximizing the use of this teaching resource while checking in with caregivers on the quality of their visit - each visit. It’s all available to you, free for the asking!

You can request your training guides right here.

You can see Nature Gave Us Butterflies, the touchstone tool for end-of-life teaching right here.

When used as the touchstone that they were developed to be, the training guides will ensure that everyone on your team is using Nature Gave Us Butterflies consistently. Training guides are available free to those who purchase Nature Gave Us Butterflies, Hospice Edition because we want you to squeeze every ounce of value out of our resources.

You can help your team members be consistent, reinforce their teaching, and improve your CAHPS survey results and patient satisfaction by using the training guides to maximize the benefit of Nature Gave Us Butterflies. 

We’re in this with you. Let us know what you think!

Sources: www.builtin.com/employee-turnover-statistics

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May 2, 2018 is emblazoned in my mind. My dad was being released from the hospital after suffering a low sodium-low potassium episode and his ability to care for himself was markedly diminished. His dementia was progressing quickly, and his needs went from mild to major within the period of a week. My mom was his caregiver every now and then; it was clear that this had shifted into a full-time job, and none of us were able to hide from my dad’s decline. It was front and center.

One of the gems of our Michigan trips was some father-daughter

My otherwise (proudly) independent parents, who were planning a move and the sale of their house in June to be closer to me in a neighboring state, were faced with the need to move earlier than planned so I could be their support person nearby. 

My mom grabbed their most basic needs from their home and we pulled up to the hospital drive, loaded up my dad, and high-tailed it to my home 6 hours away.  They moved in with us for 6 weeks until their apartment was ready. 

My parents were lovely house guests. They would sit on the porch when my husband was mowing the lawn and watch the activity of the neighborhood. Even in the midst of caregiving for him - along with all of the sadness and frustration - we will also cherish the funny moments.  My dad would tell my mom that my husband was “the landlord” and they needed to watch themselves because he didn’t want to get “kicked out.” He stuffed his pockets with cookies for breakfast. He still wanted a beer every now and again. His sweet tooth which never existed prior to his Alzheimer’s diagnosis was in full force, requiring us to keep a lot more ice cream and cookies in the house than we did when the kids were small.. 

He also pocketed his prized coffee cup coaster he received from his last job at a war museum, proudly showing it off to the hospice staff. There were still glimmers of who he was peeking through the cloud of confusion and decline. 

My parents at our wedding reception, 2017.  

He talked to my mom’s pig figurines and called them “police dogs.” He conversed with people on television. He offered to share his meals with “the others” in the “hospital." He thought my mother was his mother at times, and then at other times he would sweetly reflect on how good his wife was to him. 

 There were, of course, many moments that felt like years. He clung to my mom and felt safer when she was within his field of vision. If she would go outside, he would shuffle throughout the house looking for her - she was his safety and security. He forgot how to use a fork. He lost the ability to understand simple commands like “sit down” or “stand up.” As many of you know, one never knows what to expect next, and I feel fortunate to have a mom who copes well and is able to find the humor in the midst of what is really, well . . . the loss of a human being right before your eyes. My sweet little dad, disintegrating and regressing, was slipping away.

As a writer, I knew I was in my own personal version of a topic incubator, especially writing for the end-of-life care industry. While I thought it would be difficult to face these topics, my overwhelming takeaway from the experience with my dad is this: caregivers of persons with dementia need support. Not just a little support, not just a check-in - but real, consistent presence. 

Healthcare professionals who provide services to those living with dementia and their caregivers know this. They teach it often. During our experience with my dad, it became clear to me that this information - though taught - needed a way to stick. 

There were times where we were so overwhelmed, we were unable to retain it. There were times when we felt no one understood the depth of our pain. There were times when people in stores and restaurants, not understanding his dementia, looked the other way not knowing how to respond. There were times of isolation, sadness, and hopelessness. My mom, in her 70s, functioned on very little sleep.

Experience tends to map out our next steps in life, so I set out to write a booklet that was a companion to those caring for their loved one who has dementia. The result is The Whisper of the Fallen Oak:  A Family’s Guide to Early, Middle, Late and End-stage Dementia. Using the life cycle of the oak tree metaphor to explain the stages of dementia, the booklet gently guides caregivers through the decisions and emotions of the caregiver experience. 

In every stage of life, our loved ones have value and worth. When the challenges of caregiving are intense, this booklet offers hope and understanding in the midst of overwhelm and exhaustion. The booklet gives step-by-step suggestions for action items that need to be taken care of each step of the way. Covering topics such as anticipatory grief, legal and financial planning, advance directives, nursing home placement By knowing what to expect, we can decrease caregiver anxiety and increase caregiver confidence.

It is my hope that this booklet can ease the pain of others during a sometimes lonely, exhausting, and overwhelming time in the lives of caregivers. Visit our new booklet here to see how it may help you, your clients, or someone you know who is caregiving for someone with dementia. Be sure to send us your thoughts on the booklet, too. 

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Have you ever had a visit with a patient or their family member where you just can’t reach them? Where you can feel them walling off, staying safe, not sharing?  

Awkward, right? I don’t know anyone who works in healthcare who can answer “no” to this question.

In providing hospice care, we are pressed to meet regulations, sending multiple professionals to the patient’s home within a week of signing onto hospice or palliative care - and understandably so - they are a bit overwhelmed by the number of people coming to meet them to provide services. 

The shock of limited life expectancy, the burden of caregiving and feelings of overwhelm sometimes leave those who are experiencing the terminal illness and their loved ones in a state of constant protection. Many people find that they search for and still lack the vocabulary to adequately describe their emotions, and many use denial and avoidance to protect themselves from the pain. Even though this is an understandable attempt to help themselves feel better, not speaking of the emotions associated with the grief (or anticipatory grief) may leave them feeling isolated and misunderstood.

That said, there will always be those who don’t want to open up about their emotions, and our job is not to force conversation, but to be a willing participant who can hold emotional space for them - by just being present, reminiscing, discussing current events, sharing things in common, and building rapport and trust. 

There are times when we feel we aren’t “getting anywhere” with a patient or family member - but each time we visit, we are building a relationship of consistency, trust, familiarity, and rapport. 

So for all of those times when you thought you didn’t get very far in the visit with your patient or their family member - rest easy. Establishing trust and rapport is the foundation of a therapeutic relationship. 

It doesn’t make sense to build a house without pouring a foundation. Most people don’t openly share without trusting the person they speak to. Take the time to pour your foundation first (It also helps to share this concept with your coworkers and supervisors who need help understanding what you do during your visits. Service is built on relationships and trust.)

So how do we assess their needs and meet them when they clearly aren’t ready to open up? We aren’t there to change communication patterns used for decades at the end of life - that’s not our goal. Our goal is to create a safe space where sharing could happen should they choose.

When someone is “shut down” how do we create that safe space for them - so that when and if they choose to share their feelings - they feel supported and heard? 

Metaphors to the rescue.

What is a Metaphor? 

According to literarydevices.net, a metaphor is a figure of speech that makes an implied comparison between two things that are unrelated but share some common characteristics. In therapy, the use of metaphors can help the patient or family find a language or vocabulary to talk about difficult topics comfortably. Almost every culture has metaphors and stories that provide an alternative way of seeing something. Accessing the client’s language creates trust and rapport and allows the client to see that you “get it” by joining in on the use of their word choice, phrasing, and language. 

For example, I was seeing a client named Dave who sought grief therapy when his son died. Dave was a carpenter, and I noticed his choice of words related to construction, so to develop rapport, I used the phrase “you hit the nail on the head” to affirm his understanding of the grief process. I made reference to “building resilience” and “tearing down old internal negative messaging  and constructing new positive internal messaging.” Any chance I received to mirror and relate to him with his personal choices of language, I would do so. 

By the time he left our first session, he had shared that his wife couldn’t understand how he could go back to work so soon after the death, and opened up by explaining that the only way he could actually get in touch with his emotions was through physical work, i.e. swinging a hammer and lifting lumber. This allowed me to explain the difference between intuitive and instrumental grief, and he was able to go home and explain to his wife that they are both grieving - but they are doing so in different ways.   

What Can We Achieve by Using Metaphors?

The use of metaphor can be  a guiding light in your work with patients, caregivers, and clients. End-of-life care requires us to build trust and rapport quickly. We are in patient and caregiver homes, in a time that is overwhelming/traumatic, and we are usually complete strangers to them. We visit with the best intentions, but those intentions aren’t always met with open arms.  While it may seem foreign to you initially, with some reflection you may find that you are already using metaphors in your daily work with your own hospice patients and families. With intentional application of a few basic concepts, you can increase your use of metaphors to build connection and trust, which is crucial at a time when most caregivers are feeling very alone with low levels of confidence that they can survive the caregiving process.

Metaphors use words, visualization, and experience to create a deeper sense of understanding and connection. 

Metaphors can:

• create a connection between the known and the unknown by helping the patient or caregiver; absorb new ideas into a framework that is already familiar;
• highlight similarities between you and the patient or caregiver, establishing connection;
• clarify an idea and help the patient or caregiver understand an idea more clearly;
• diminish resistance to psychosocial/spiritual/medical care;
• encourage new ways of thinking;
• use story and illustration to see something in a different way;
• remind and reinforce earlier connections and teachings;
• help the patient or caregiver retain important information;
• create a language that feels safe so they may express emotions and feelings.

How Do You Begin Using Metaphors?

Start by listening and observing the patient and caregiver. Does he enjoy fishing, hunting, or the outdoors? Does the caregiver relate to a particular family role, like mother, or family household manager? Perhaps the caregiver is a career-minded person who refers to technology often? These are all clues in how to relate to them. Did they grow up on a farm? Do they enjoy travel? Start listening carefully and getting to know them as their core level. Metaphors will evolve from knowing your patient and caregivers.

What are some examples of metaphors?

• It hit me like a ton of bricks.
• I’m a puddle of tears.
• You hit the nail on the head.
• They had a stormy relationship.
• He was like a fish out of water.
• She would play outside until the cows come home.
• Her tears were flowing like a river.
• He is my sunshine.
• Her temper is a volcano.
• We were two peas in a pod.
• You are a true angel.
• She let the cat out of the bag.

Metaphors can also be used by assigning meaning to a physical item. For example, suggest carrying a stone in the client’s pocket to remind them of their strength, or a poem or letter in their wallet to remind them of their connection with a deceased loved one to give them solace and courage. 

Using metaphors in the therapeutic or supportive process comes from listening well. Your client will give you, over time, the language to reach them. 

How Metaphors Help Patients & Caregivers at the End of Life

Over here at Wings of Change Publications, we craft our words carefully. We put a lot of planning and research into our topics, our style, and our intended purpose.

If you lean on what you know from your experience as a clinician, you undoubtedly have observed, at some point, as an end-of-life professional:

1. Patients, and families, experiencing shock due to the poor prognosis, the number of changes they are experiencing, and the emotional energy involved in digesting the new information of a terminal illness, and
2. The overwhelmedness and inability to retain information.

Neurobiologically, we know that when we are functioning in fight or flight mode, we are primarily being guided by our limbic system. We physiologically cannot be in touch with our prefrontal cortex, which is the center of reason and logic in the brain. As EOL professionals, we must remember that we are supporting and educating people who are highly stressed, overwhelmed, and trying their best to digest the information you are offering - but they cannot fully comprehend it if they are being managed by their limbic system.

This is the primary reason we write our booklets using nature metaphors. Metaphors are memorable, helping the patient retain information and hear the support. Metaphors soften the message with understandable similarities to which everyone can relate. And nature metaphors are universal, providing comfort, connection, and information to people of all religions, cultures, and backgrounds.

If you haven’t experienced our booklets in your EOL professional practice, we offer free samples to EOL professionals. We encourage you to read them yourself, and offer them to those who are part of the life transition, grief, or loss experience. Let the power of the metaphor start working with you in your practice.

Questions? We’re here to help you help them. Reach out anytime.

We don't want you to miss out on anything. Sign up for the TEND eLetter and be the first to hear about:

• discounts only available to TEND subscribers
• Hygge for Hospice Professionals Giveaway
• New Product Releases
• Blog posts to help you as an EOL professional
• Team member recognition ideas

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