I’m a big fan of boundaries for hospice nurses. I have written BLOG POSTS and recorded PODCAST EPISODES dedicated to the subject.

There are limits to a nurse’s ability to remain completely neutral when doing this work. We do this work because we think it is important. Anyone doing this for a year or more is doing it because we feel it is our calling.

I’m not sure there is another area of nursing that demands as much emotionally from nurses as working in hospice. We insert ourselves into the end of someone’s story. We provide education and support as aunts, uncles, sons, daughters, husbands and wives stand watch over their dying loved ones.

While we try so hard to not fall in love with our patients and their families, we still inevitably end up with a hand full of people we just connect with in a special way. There are many ways this can happen. Most often it is because they remind us of someone in our own lives. Maybe even someone we lost to death at one point. We connect in a deep way, and friendship blossoms. We can’t help it. We are human, and we were created to love other people.

Then there is this abrupt ending to the relationship for us. A patient we truly enjoyed spending time with dies over the weekend or during the night. For us, a deep relationship comes to a crashing end. Imagine being so close to someone that you have stopped even knocking on the door when you show up to visit? We became close friends without even trying. It was just the result of visiting them multiple times a week for what can sometimes be more than a year. Now they are completely yanked out of our lives and we didn’t even get to say goodbye. Sometimes we are able to reach out to the family following the death. Maybe we even stay connected for a while. Even then, eventually, that relationship comes to an end. It’s not on purpose, but life for everyone moves on.

Then we might meet a family member in the community somewhere. We may be in the line of a grocery store, or tying to find a new pair of shoes. We make eye contact and, after a second or two, one or both of us will recognize the other. Someone starts crying and asks the other how they are doing. It’s awkward and generally short lived to minimize the awkwardness. We part ways and, for me, I sit in my car and relive some of the memories. There is no doubt the family member I just met is REALLY living the memories. Sometimes, I can hear them telling the person they are with who I was, and what I mean to them. It’s a heavy moment.

So what do we do next? We go to work the next day and risk our hearts all over again for complete strangers.

This is what we do, and we love it. Sometimes we just love it a little to much, and it hurts. It hurts because our friends keep dying.

A former coworker messaged me recently to let me know she had taken her first clinical director position. She asked if I had any advice for her. I can get pretty wordy when asked these types of questions, so I decided to share my thoughts with……everyone!

I have been in hospice leadership since the fall of 2017 which is four-and-a-half years as of this writing. My first leadership position was as a clinical director. The official title was PCM or Patient Care Manager. I don’t look back on those 16 months with a lot of affection. I do feel I learned a lot. Much of the advice I plan to offer in this article is a direct result of my first two years in hospice leadership.

1. Don’t be afraid to make mistakes

You are going to mess up. Just accept it now. The fear of making a mistake can become detrimental to your success. Letting the fear of making mistakes control you will result in a toxic environment for your staff. When mistakes happen, those who fear them will look for an outlet. They will start to blame their own supervisors, or even worse, blame their staff.

When things go well, give credit to your staff. When things go poorly, look at yourself first. Mature leaders are always concerned with their own growth in the role. They are quick to examine themselves when things are not going well. They don’t look for excuses or blame others. They realize that leadership comes with a certain level of accountability, and they don’t take that responsibility for granted.

Leaders who never mess up are not adventurous enough. Be an authentic and adventurous leader. Your team will love you for it.

2. Establish boundaries early

Okay, this really got the best of me in my first couple of leadership positions. I wish I could say that I have mastered healthy boundaries. I have come to the conclusion that healthy boundaries are a continual challenge for all of us in hospice. When your job is literally about life and death, with death as the expected outcome, boundaries will always be a challenge. Especially if you operate with your heart first, as I tend to do.

The boundaries you will need to implement as a clinical director are more staff related than patient related. This isn’t to say that a clinical director doesn’t make patient visits anymore. If you work for a smaller hospice, then you will likely still make your share of patient visits. The boundaries I’m talking about revolve around how your clinical staff treat you.

I like to create a relaxed more casual environment. I love sarcastic humor. I like to make self-deprecating jokes to help the room relax. My issue was that I allowed my staff to create nick names for me that I felt eventually caused a certain level of disrespect. Eventually, my laid back style resulted in my staff treating me with a level of disrespect. My “nice guy” persona turned into more of a ”we can just run over him” type of environment.

Since then, I have learned where to draw my boundaries. I no longer tolerate being called ”Jimmy” by my staff. This has made a huge difference in my most recent position. My current boss knows all too well about my previous challenges with my lax environment. She won’t call me Jimmy. She might joke in private about it, and we will have a laugh over it, but she knows it won’t serve me well. She makes sure I get the respect I deserve. She’s the absolute best.

There are plenty other boundaries to have with your staff. I can’t list them all here. The first place to start is making sure you are given the appropriate amount of respect. You earned this role. It’s okay to stay confident.

3. Protect your staff

I am so proud of my current director. Just like so many other hospice providers across the country, we suffered some staffing problems in the last few weeks. Smartly, my administrator put a pause on admissions until we could hire the needed help. Many hospice providers will not do this. They will force leadership to get out into the field and take a caseload. This is a dangerous activity. When leadership is out in the field, there is no support for the staff. When the administrator and clinical director are out in the field, their work does not get done. There is no backup for administrators. When they don’t do their work, nobody does.

The other side of the coin is this: Patients who are currently on service deserve excellent care. This means that leadership must make sure patients get the visits they need. To do this, leadership will have to get out from behind the desk and make visits when situations dictate. If leadership is going to allow admits during a staffing crisis, they will need to get out into the field and make visits. Long days and nights come with the job sometimes. Don’t let your staff drown in visits because you are in leadership and somehow that means you don’t have to get out from behind your desk.

The best way to get respect from your team is to get out there in the field and deal with the same challenges they face every day. They will respect you for it.

4. Pursue excellence not perfection

This is not an easy concept to assimilate. When reading the headline, the first response is, ”of course, that makes perfect sense,” but the more you think about it, the harder it is to define the difference. We can quickly agree that excellence is a good thing, but how is it different than perfection?

To do this we need to examine our own imperfections. We have to realize that perfection is a place while excellence is an activity. Nobody will ever achieve perfection, but we can all be excellent. This means that we can strive every day to just be better than we were yesterday.

“Striving for excellence motivates you; striving for perfection is demoralizing.”

Harriet Braiker

As you settle into a new position as a clinical director, it will become real tempting to be critical of field staff. As the months progress, it’s easy to forget how busy the days can become in the field. It’s easy to forget about the phone calls. It’s easy to forget about the emotional drain field staff experience every day. The family anxiety. The infighting between family members, and how field staff can easily get drawn in. The rooms full of crying family members as they adjust to the idea that someone they love is nearing the end of their life.

When sitting behind a desk, it’s easy to just start focusing on what isn’t getting done. Nobody is going to end every day getting 100% of everything done. Be ready to eccept a little bit of imperfection. The days can get really long. Don’t expect perfection from yourself or those you are responsible for. Realize we are all imperfect. The goal is to make sure we are all just trying to get better every day. That is excellence, and we should all attempt to be excellent.

5. Be consistent

This may be the hardest thing of all. This requires we keep track of all our decisions to make sure we aren’t wishy-washy.

What does this mean? This means everyone gets the same amount of PTO. If someone needs to take a half day off, they have to use their PTO. We can’t just let them bail on half the caseload for the day and run a few errands because, ”They work hard and I really like them.” Sorry, we have PTO for a reason.

This means everyone is expected to follow the rules set forth by leadership. If your company requires all documentation be done within 24hrs that goes for everyone. Even the ones who like to snap at you when you hold them accountable.

I’ll be honest with you. I have the hardest time with this one. I generally don’t like confrontation. The more irritable someone is, the more tempted I am to let them get away with stuff. I just don’t want the fight, so I can tend to let people misbehave.

Don’t be the old James. Be the new James. Be consistent.

6. Don’t gossip

Gossip is death and destruction for any organization. I would encourage you to follow the advice Tom Hanks gives his team in Saving Private Ryan when they ask him about complaining. He explains that complaints go up the command chain and never down.

For clinical directors, this means you discuss your frustrations with your own superiors. You never share your frustrations with your clinical team. You need to show your whole team that you trust and believe in them. If you share your frustrations with other staff, you are sending them the message that you will also talk about them when they aren’t in the room.

You will also have a lot of private information about your staff. You will likely know private problems and health issues your staff are facing. It is your moral and legal obligation to keep it to yourself.

It can feel powerful to have lots of little secrets. It’s tempting to share those secrets. Don’t do it. Your staff deserve better, and it will just create problems you won’t be able to solve.

7. Support your superiors publicly

Passing on bad or unpleasant news to your staff is not fun. As clinical director this is going to happen. Someone in leadership is going to require you to implement something that you know your staff is not going to like. It is going to be real tempting to deliver the news and villainize your boss hoping it will lessen the heat your team will put back on you. This is a horrible plan. It will not help you take your team where you want them to go. Instead, take the following advice from Andy Stanley.

Public loyalty buys you private leverage. Criticize privately, praise publicly. Your boss and colleagues will respect you. Flip it and they’ll fire you or never trust you.

Andy Stanley

There is an important strategy to the quote above. The more you support your superiors publicly, the more influence you will have with them privately. If you are critical of your leadership to your staff, it will get back to your direct supervisor one way or the other. They will stop trusting you, and when you take ideas to them, they will wonder what your alterior motives are. They will wonder how you got to your conclusion. They may discount you out of hand because you might have gotten the idea while bashing them to your team.

Support your leaders publicly, and they will be more likely to listen to you in private.

Welcome to the middle. It’s not easy and it isn’t always very glamorous. Your goal is to have as much influence and trust with everyone as you possibly can. The only way to build a healthy organization is through these two concepts. Without building influence and trust, your office will be unsteady and full of turmoil. This is bad for you, bad for your staff and ultimately bad for your patients.