Pediatric Hospice and Palliative Clinicians Face High Burnout Risk

The unique needs of families and children facing life-limiting illness can wear pediatric palliative and hospice care clinicians especially thin, and the potential for burnout can leave providers even more short-staffed than many already are.

Pediatric subspecialists are at a higher risk of burnout than others, according to authors of a 2020 study from the journal of Pediatric Quality & Safety. This, coupled with the limited number of clinicians trained to provide pediatric hospice and palliative care, further complicates recruitment and retention in a very competitive labor market.

These factors often leave pediatrics-trained hospice and palliative care clinicians juggling a higher volume of cases than those who care for adults only. This can add to the strain of their work as they care for very different populations with different needs, according to Joan Harold, director of home care clinical services at Michigan-based Angela Hospice.

“[It] can be stressful when nurses are torn between the needs of pediatric and adult patients,” Harold told Hospice News in an email. “Burnout may be exacerbated when nurses feel they can’t meet all of the expectations of patients and caregivers.”

Even outside of hospice, caring for seriously ill children can take a mental and emotional toll.

Nearly half, or 45%, of pediatricians in a Medscape survey reported either experiencing symptoms of burnout and depression, or complete burn out last year.

A survey from Becker’s Hospital Review of more than 13,000 physicians across the United States yielded similar results, with 49% of pediatric clinicians reporting feelings of burnout. Pediatrics ranked seventh out of 29 clinical specialties that experienced burnout during 2021, according to the survey.

Coping with “anticipatory grief” can be amplified among pediatric palliative and hospice clinicians, which could be contributing to higher risk of burnout, according to Debbie Vallandingham, director of social work and grief care services at Angela Hospice.

“These families are experiencing the challenge of anticipating a loss that is outside the normal progression of life,” Vallandingham told Hospice News. “They face the death of dreams along with the loss of their child, as hopes for the future fade. Often, these families are more susceptible to guilt, self-blame, fear, and emptiness that make interacting with clinical staff challenging.”

Another factor that’s unique to the pediatric workforce in particular is a limited availability of supportive resources in place for seriously and terminally ill children and their families, according to Jennifer Mangers, director of pediatrics and serious illness services at Illinois-based Lightways Hospice and Serious Illness Care.

Pediatric populations have significant resource needs that are not always accessible, said Mangers. In comparison to those caring for adult patients, clinicians may not be able to quickly access equipment or services for their pediatric patients, she explained. This can create additional stress and in turn contribute to burnout.

“Some organizations that are not able to have a dedicated pediatric program and staff may have clinicians that are required to wear many different hats in order to meet the needs of a patient or family member,” Mangers told Hospice News. “[For example,] a registered nurse acting as a social worker, or a social worker acting as a chaplain, child life specialist, or complementary therapist. This can take a toll on work/life balance and increase stress of finding time to accomplish the needs of the patient and family.”

Without relief or support, some of these clinicians may be driven to leave the field.

It has become “increasingly rare” for clinical staff to stay in a position for more than a year before moving on, making it difficult for hospices to retain their clinical pediatric staff, according to Lee Hudson Teslik, founder and CEO of Reverence, a staff scheduling technology company that serves home-based care providers.

“At a most basic level these clinicians and health assistants can only provide that support if they stay in their roles,” Hudson Teslik told Hospice News in an email. “Simply asking practitioners to do more isn’t a viable solution. Sustainably meeting demand here requires innovating on staffing models — not just getting more people, but also being more thoughtful in how you deploy the precious resource you already have – your current practitioner base.”

In addition to ramping up recruitment and retention programs, some providers are expanding education and training to bolster the pediatric palliative and hospice workforce.

Others are also banding together to form collaborative partnerships. Providers across seven northwestern states recently formed the Northwest Pediatric Palliative Care Coalition. Among the coalition’s priorities is to build up clinical education programs around providing family and caregiver psychosocial support, having goals of care conversations and discussing symptom management.

Regional coalitions that share resources, including some staff, can help providers offer some of their employee’s workload and increase patient capacity, according to Mangers. However, once these coalitions cross state lines, they have to navigate differences in laws and regulations, regional insurance payers and care delivery practices — making competition for resources fierce, she added.

“If one coalition has better access to resources, this can be challenging for those who do not,” said Mangers.

But initiatives closer to home may be even more critical to keeping these clinicians in their jobs.

A positive and supportive workplace culture will attract and keep pediatric clinicians, according to Vallandingham. This would include collaborative guidance from management and tangible responses to staff feedback and concerns.

“The most important thing hospice leaders can do is stay connected with their pediatric clinicians and stay involved at the patient level, listening to any challenges along the way,” echoed Mangers. Leaders “must be able to find creative ways for staffing while keeping the patient and the family as the top priority,” she continued.