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Compassion fatigue. Caregiver burnout. Stress-related exhaustion. Ineffective coping. Excessive grief processing.  

There are many names for what some hospice employees experience throughout year, and especially during the holidays. Whether it’s due to over a year in a pandemic-fraught world that has forever changed the post-acute health care setting, or simply the nature of the job, the grief is there.

How you respond to the grief that your employees are holding on to is vital. What programs do you have in place for your bereaved hospice staff? How do you help your employees decompress after particularly difficult deaths? Are you able to recognize signs of unprocessed grief in your employees who may be suffering?

Dealing With Death: A Story of a Hospice Nurse With Compassion Fatigue

Irene was a hospice nurse for nearly 30 years. I managed her and relished in her knowledge as the most seasoned hospice nurse on my team. She was confident. She was always willing to pick up extra shifts and tasks, and she served as a top mentor for new orientees.

Irene was also tough. She handled every patient passing with the strength and grace of a true hospice professional – until she didn’t.

Irene experienced a difficult death of a patient who was suspected to have given himself an overdose of insulin. The death of this patient hit her like a ton of bricks, but she hid it. I touched base with her frequently due to the difficult nature of the death. She was on call just a few days following the passing and refused to give up her scheduled weekend shift. She told me that she was “fine.”

It was nearly Christmas, and she had several packages of Christmas cookies that she had made for a few of her favorite patients and families. Irene would not give up her holiday plans to drop them off during visits over that weekend. She seemed jolly about it; the spirit of the holiday season seemed to be with Irene, and she really did seem “fine.” I would never have suspected what happened next.

During her weekend shift, she had several more deaths occur – more than usual for a moderately-sized hospice agency. She was busy, which she usually enjoyed. I saw through her schedule how busy she was and reached out to her to offer to help, send more staff, go myself and assist with tasks, or anything to decrease her stress level. She declined, saying again she was “fine.” Irene claimed she only had a few hours of charting left and that she was home watching a movie. I remember thinking, “What a great nurse! Such a value to the agency!”

The Result of Unrecognized Compassion Fatigue

I received a hysterical phone call on Monday afternoon, on Irene’s day off. Irene, who was seemingly made of stone, was completely breaking down. She sobbed that she just felt “burnt,” as she described it. She could not stop thinking of the recent deaths that she had experienced. She canceled her standing playdate with her granddaughter and was instead sitting home and sobbing to me on the phone.

I had only been Irene’s manager for a few months, but I was not new to administration. What did I miss? Irene had had busier shifts, had handled more stress, and had never reacted in this way. Was I not recognizing her grief?

Irene admitted that she not only had seasonal depression, despite her outward positive attitude and cookie baking, but was also diagnosing herself with compassion fatigue. I concurred, and we spent 42 minutes on the phone while she vented her feelings and we made a plan.

I was able to assist Irene in getting free telehealth counseling through our agency. She was later referred for weekly in-person sessions and continued them for several months. I also knew that Irene had a great relationship for many years with our chaplain. While Irene did not want me to go to her physically that day, she let our chaplain bring her lunch and sit and talk.

The Warning Signs of Compassion Fatigue

After a few days off, Irene returned and functioned well. She thanked me for helping set up her counseling many times following that weekend.  

The experience of how Irene crumbled is something that stuck with me. As a manger, I felt like I failed her because she had a breakdown. Irene later told me, “I really felt like you were the only one who cared.”  

Do you know the signs of impaired grief processing? Do you think you could have saved Irene from crumbling before it occurred? Now, with stressors intensified by the holiday season, it is even more important to recognize the signs of impaired grief processing in your hospice employees. Warning signs include: 

  • Irritability or Anger – Oddly negative behaviors or attitudes that are uncharacteristic for the employee 

  • Obsessive Thoughts – Rumination over certain patients or issues that is constantly brought up and seems to never be resolved 

  • Hyperalertness or Overreactive Behaviors – Intense, erratic behaviors or excess attention to work that is unwarranted or outside of the normal response 

  • Self-Harming Behaviors – Gravitation to overworked, exhaustive behaviors; e.g. refusing to take breaks, taking on added tasks unnecessarily 

  • Apathy or Numbness – lack of reaction to items that would normally cause a response, decrease in emotions, or refusal to address difficult emotions


Preventing Compassion Fatigue

Just as every family processes the grief of a dying loved one differently, so does every employee. Hospice is a special type of care that carries an array of emotions for patients, families, and your employees. It is the nature of caring for people. Home care and home health employees also feel this pain when they lose a favorite patient, particularly after they have cared for them in their own homes.

No matter what kind of agency you may manage, know the signs of impaired grief processing, and use some of these tips with your team to hopefully avoid the level of grief that Irene experienced:

  • Encourage your staff to say goodbye – Staff are on an emotional journey with hospice patients and families. Encourage your staff to not only help families say goodbye, but to let go themselves. Whether it is saying the words of farewell at the bedside, or later attending a memorial service, be supportive. 

  • Balance the workload – If you notice an employee has had particularly difficult deaths or other stressful events and may be overwhelmed, pull in other resources to provide assistance. Encourage your employees to use their paid time off to give themselves much needed breaks. 

  • Make space to share grief – Give every employee a journal to write down thoughts about their work life, their favorite patients, or any topic that helps them process their feelings. Set aside time during team meetings to discuss personal emotions regarding patients. Consider a separate, optional grief support meeting for your staff. 

  • Promote teamwork – Offer team-building activities so your employees and their peers know they can rely on each other. Encourage employees to openly communicate with each other and be supportive, no matter what the need may be.  

  • Share resources – Make sure that every team member knows what resources your agency offers if they’re experiencing impaired grief processing. If your agency is limited in options, can you create a list of free community resources for counseling, grief support groups, and other interventions? Don’t wait until something happens, like with Irene, to tell your staff about the plans you can make to support them in a difficult situation.


This holiday season, show appreciation for you hospice employees and make sure they are more than “fine.” Recognize the potential signs of impaired grief processing in your employees and make a contingency plan for how you will help. Work to keep those bricks from crumbling, and keep your hospice team’s foundation strong. 

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