Taking Peer Visitation to the Next Level

By Dick Mooney

The slide on the screen reads in big print, "Taking Peer Visitation to the Next Level." In front, Liz Zemke energetically bounces around the room, looking every bit like the Emeril Lagasse of peer visitation. This was the scene that kicked off an extraordinary support group leaders' workshop at the Anaheim annual meeting.

At first blush, the title of Liz's presentation might have appeared to be a bit of easily forgiven hype. Indeed, parts of Liz's "formula" seem pretty mainstream. But other parts are extraordinarily inspired and innovative. These are the parts that kicked Liz's program to a higher level.

For the few who don't know, Liz Zemke is the registered nurse, below-knee amputee founder and driving force behind Fresno's Central California Amputee Education and Support Group, the centerpiece of which is its highly successful peer visitation program. The program has been implemented at two major Fresno hospital systems--one of which operates three comprehensive medical facilities--and is responsible for between 300 and 350 visits to new amputees each year.

So what makes Liz's program different? There are many things, but here's the major one.

The next time you are visiting a hospital go into the cafeteria. You will probably see a sign reading "Hospital Cafeteria." You will see employees behind steam tables and counters of sandwiches and salads. You will see employees at check-out stations. There are employees eating and employees clearing tables. But if you ask, you may very well find that the only employees who are truly hospital employees are the ones who are eating. The rest, including their supervisors and managers, and probably even the food itself, may be provided by one of the many private firms that specialize in staffing and managing hospital food service operations. The point is, the cafeteria looks like a hospital operation. The hospital clearly endorses it, provides management support and oversight, and most employees probably think of it as "our" cafeteria. The many ways in which both the hospital and the outside company benefit from this arrangement are probably obvious.

Similarly, Liz's peer visitors look like "insiders." They wear hospital volunteer badges and hand out peer visitation program brochures published by the hospital. If you go to the volunteer office and ask to see the peer visitation policy and procedure, you will be shown one published by the hospital and signed by hospital management personnel. This is the principal feature of Liz's peer visitation program that enables hers to flourish where others fail. The hospital benefits from being able to provide a specialized service that it couldn't provide for itself, and the peer visitation program benefits from receiving a greater number of referrals and the opportunity to bring support and encouragement to a greater number of new amputees.

So how can we all cash in on Liz's success? Here's her advice.

1. Select a hospital at which to start.

(Note: If your group is new to the peer visitation business, you will obviously need to have an appropriate number of well trained peer visitors and your own group's visitation policies and procedures in place first. It should be observed, however, that it is possible for one person to do this program with occasional help from other visitors--indeed, that's the way Liz does it.)

Choose a hospital that performs amputations and is a convenient distance from the visitors you will "assign" to that hospital. It will be best not to try to start with a major trauma center. The sheer numbers of amputee patients these facilities usually generate can easily overload a fledgling program.

2. Make telephone contact.

If you don't already have an established contact, call the hospital's main phone number and try to identify the person (or job title) who oversees the surgery schedule daily. Ask to speak to them. If you draw a blank, ask for the CEO's office. They will be able to refer you to the right person. As you will read below, this will be the key person to help you keep the program going.

When you reach the appropriate person, provide a brief overview of your peer visitation program, say that you are offering it to the hospital at no charge, and request them to set up a meeting with hospital personnel who have the authority to approve your program and who are in a position to commit to promoting it. These might include:

•  The surgery department coordinator or supervisor

Unlike many visitation programs that rely for referrals on the social services or nursing people who support many different clinical services and who tend to turnover rapidly, Liz's program recognizes that the people who schedule the operating rooms (and those who supervise them) are in a unique position to know every time an amputation is scheduled.

•  Someone involved in community and hospital education

This individual is needed because this department may become responsible for overseeing the peer visitation program. At one of the hospitals Liz's group serves, this department was instrumental in developing the hospital's peer visitation policies, procedures, and brochures; and is the focal point for transmitting visitation requests to Liz and for fielding amputation-related calls from both inside and outside the hospital.

•  The risk management or quality coordinator

This individual is needed because he or she will be concerned about confidentiality issues and any other parts of the program that could put the hospital and its volunteers at risk.

•  The volunteer office manager or supervisor

This individual is needed because you will request that your visitors become an official part of the hospital's volunteer program.

•  A representative of the CEO.

This individual is needed because you will request that your program become an official hospital-sponsored service and you will need top management support for that.

3. The meeting

Carefully prepare a presentation that will cover the following points. Remember, your goal for the meeting is to sell your visitation program to hospital management, so you will need to wear your management and marketing hat.

• Point out that amputation is a unique kind of surgery that makes a permanent and visible change in a person's body and to some extent will alter a person's life forever. Limb loss is a traumatic event and requires early intervention with a unique kind of support and encouragement.
• Stress that the kind of support and encouragement that is needed can only be provided by one who has been through it. No matter how much information and empathy healthcare professionals with a full complement of arms and legs can provide, only peers can provide the unique the insight into limb loss that new amputees need. Only another amputee can say, "I know how you feel."
• Stress that peer visitors also provide non-medical information and identification of resources with "first person" credibility
• Describe your peer visitation program in detail. Stress that your visitors have been trained and describe the training--the more rigorous the better. (Note: Here is where the training and "certification" that can be provided by the Amputee Coalition can be of real benefit.)
• Request that your visitors become an official part of the hospital's volunteer program, that they should undergo the established volunteer training and orientation, sign all the necessary forms, and carry volunteer badges. (Note: There's more on this below.)
• Request that the hospital publish a peer visitation brochure and the necessary policies and procedures, and that you will be available to help with this.
• Stress that this is a free program that will provide a services of significant benefit to the hospital not only in terms of the unique patient care involved, but also in terms of its beneficial effect during JCHO and other hospital certification reviews.

4. If you face resistance

Following are the kinds of objections Liz has faced and her suggested responses.

•  I don't think we do enough amputations to warrant this program.

Liz suggests asking for a records check. Her experience is that most hospitals do more amputations than they think. Also, you can say, "Let's try the program and see."

•  What about confidentiality?

Liz points out that her visitors have been trained not to discuss their visits with others and, anyway, they will be subject to the same confidentiality rules as all volunteers. In addition, she points out that having only one person privy to confidential patient information (i.e.,. the visitation coordinator) fixes responsibility and limits exposure.

•  I think we would have to ask the patients' permission first.

This is potentially a big trap and Liz takes a hard line on this subject. She wants to see all or none, and states. "If they don't want to talk to us, we'll leave." Non-negotiable. Her experience has been that if shortly after surgery a patient is asked if they want another amputee to visit them--especially when there is no control over how the question is asked--the answer will in all likelihood be "no." Another effective argument is that her way is more fair. Everyone gets a referral.

•  Are you going to be giving information that may contradict information given by our staff or physicians?

Liz says, "We don't give that kind of information," and reinforces that visitors are trained about what not to discuss. Liz follows up with a brief review of what is discussed. She emphasizes that visitors are there to listen and answer questions about living as an amputee. A list of prosthetists is provided but no recommendations are made. Sometimes visitors will suggest questions patients can ask their health care providers, but recommendations aren't made. Visitors will show their prosthesis if asked, will answer questions about activities, etc.

5. Once you've convinced them that this is a great idea--implementation.

•  Visitors go through the hospital's volunteer process.
•  The hospital writes and publishes policies and procedures.
•  The hospital designs brochures and announces and publishes the program.

To repeat, these steps are necessary to demonstrate that peer visitation is a hospital program, not an outside program. The theory being, of course, that the hospital will be more likely to support, nourish, and perpetuate its own program than it will an outside program.

6. Visitors go through the hospital's volunteer process.

Naturally, each hospital's volunteer process is likely to differ, but it will probably include:

•  Completing an application,
•  Attending an orientation class,
•  Fulfilling special requirements, such as having an annual TB test, attending a safety orientation, signing confidentiality and other required forms, submitting periodic hours or activity reports, and attending any special volunteer meetings, and
•  Receiving an identification badge that is to be worn during all visits.

Liz advocates stressing that your visitors are special-assignment volunteers rather than general volunteers like those who staff the gift shop or information desks. She also advises, since your visitors may come directly from their jobs or go from hospital to hospital, that you should get them exempted from the requirement to wear a volunteer uniform.

7. The hospital writes and publishes policies and procedures.

Although whoever ordinarily writes hospital policies and procedures will understand what format and "standard" information should be included, you will want to have an opportunity to suggest specialized peer visitation information and to approve the final product. Ordinarily, policies and procedures should include:

•  That it is the policy of the hospital to refer all patients who have had or will soon have amputations to a hospital-sponsored peer visitor who is a part of the hospital's volunteer department,
•  A brief statement of the purpose or mission of the program,
•  A list of procedures that detail:
  • who refers patients,
  • how patients are referred,
  • the time frame for visitor response,
  • duties of the visitor to coordinate with hospital personnel before and/or after each visit, to complete visitation reports, to report problems, to conduct follow-up or telephone visits, etc.,

8. The hospital designs brochures and announces and publishes the program.

Since there's no practical way to include brochure samples here, a description of a "pro forma" brochure will have to suffice.

•  The brochure should be printed on 8 1/2" by 11" paper of a durable weight, either two- or three-folded.
•  The brochure should be dual purpose; suitable both to explain and promote the program and to provide information for new amputees. Accordingly, copies should be made available to all visitors to be left with their visitees.
•  The front of the brochure should contain the hospital's name, the words "Amputee Peer Visitation Program," and, if appropriate, the hospital's logo. The color scheme and type style should conform to hospital standards.
•  The back of the brochure should include the hospital's name again, its address and all the necessary contact information.
•  Information for general consumption within the brochure should include an introduction about limb loss, and a description of the peer visitation program.
•  Information that will be useful to the visitee should include:
  • a space for the visitor to write his or her name and contact information;
  • a list of resources, such as the name and contact information for your support group and the Amputee Coalition, reference to independent living centers, adaptive materials catalogs, local adaptive driving equipment firms, vocational rehabilitation resources, and the like;
  • a space for the visitee to make notes; and
  • any inspirational or supportive words for which there is room.

In addition to printing a brochure, the hospital should be encouraged to promote the program through regular staff bulletins, the hospital newsletter, nursing and social services inservice training, and appropriate community outreach and public relations media.

Liz's final advice: "You've got to be in for the long haul and don't bite off more than you can handle."

There you have it. The road map to the next level. If you have any questions, feel free to contact Liz at lzemke@mail.intracorp.com or by telephone at 599-432-6035.

Have a great trip!

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Peer Visitation Q and A Forum

Dear Kathy,

Last spring I conducted a peer visit at a local hospital. As is routine, I left my name and telephone number with the new amputee. About a week later, I received a call asking if I would visit again and answer some additional questions. I arranged to do so, and visited at the rehabilitation center where the visitee was receiving ongoing therapy. Since then, I have heard from the visitee at least once a week and she has invited me on several occasions to do things socially with her.

Although she is a nice enough person, I am not interested in developing an ongoing relationship. How do I explain that my professional role as a peer visitor has run its course, and I would rather not be in regular contact? Is this an unusual situation for a visitor to find herself in?

Vicki

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Dear Vicki,

The situation you describe is not as uncommon as one may think. Sometimes, new amputees can identify closely with their peer visitor, requesting more time and attention than the visitor may have, or wants or is expected to share. As a peer visitor, your official role was fulfilled after your initial visit and perhaps first follow-up call. Staying in regular contact and/or communication is not a requirement that Amputee Coalition imposes on any peer visitor. Although sometimes friendships are garnered as a result of visitation, that is not generally the case. Your responsibility as a peer visitor does not continue on at the discretion of the visitee.

Here are some suggestions that may help alleviate your dilemma:

If there is a local amputee support group, provide the contact information and recommend that the new amputee become a member. Suggest that they might find other new and also seasoned amputees there, who would be able to offer them further support, information, and new insights. Additionally, suggest that the social support that could be found in this setting may be especially helpful and lead to friendships.

• If there is a local support group that relates to a different physical limitation or disability that the new amputee may have, i.e., diabetes, vascular, cancer, etc., provide the contact information. Explain same as above.
• Provide information on Internet support lists, like the St. John's List and AMP-L.
• Explain to the new amputee that you have a limited amount of time to be in contact with prior visitees and hope that they can understand your position.
• If all else fails (or even if all else doesn't fail) and the visitee doesn't take no for an answer, politely, but firmly, explain that you can no longer be in contact with them due to personal time constraints.
• If it becomes necessary to use this last approach, contacting your Amputee Coalition Regional Representative would be appropriate.

Remember that your responsibility as a peer visitor only goes so far. While it's important to take into account that you may have been the first person to really listen and understand what the new amputee was saying and feeling, it is also important to remain aware that they may develop an unhealthy dependence upon you in their recovery process. If you feel uncomfortable about offering or can't offer additional time to the visitee, remember that it is not part of your job description as a peer visitor to provide that type of ongoing support unless you so choose.

If other support group leaders or peer visitation coordinators have information, advice and/or questions to share, please forward them by email directly to Kathy Spozio at mermaid@usachoice.net.