“In Memory of Those Who Left”: How “Thank You” Letters Are Perceived and Used as a Team Empowerment Motivational Factor by a Home-Based Palliative Care Team in the Azorean Islands

Dear Editor:

Family members of palliative care patients often express their gratitude toward healthcare professionals by writing “Thank You” letters. These letters are quite helpful when it comes to meaning building, empowerment, recognition, and organizational and societal impact.

To our knowledge, sending/receiving “Thank You” letters is common in several European countries (e.g., Portugal, Spain, United Kingdom, Belgium, and Germany). However, little is known about the meaning and use given to these letters by healthcare teams and professionals.

A qualitative single center study was conducted with a recently established home-based palliative care support team in the Azorean Islands, Portugal. The main objective was to understand the emotions, meaning, and use given to these letters by the professionals receiving them (Box 1).

The study shows that “Thank You” letters are positively perceived and illustrate the sense of gratitude from family members toward the care provided to their loved one at the end of life. Particularly in the Azorean tradition, it is considered desirable that patients die at home, surrounded by their related, loved ones, and neighbors. This cultural value becomes enhanced since families commonly live in small villages, where neighbors and friends provide extra support during the care process, ¹ and healthcare professionals are part of that local community. Being enmeshed within this community system can expand social and human capital, promoting job embeddedness, which affects job performance, organizational citizenship behavior, innovation, and satisfaction. ²

Through “Thank You” letters, professionals perceive how families recognize and value their work: helping patients to die more peacefully, contributing to patients' personal achievements, satisfying patients' last wishes, and supporting families through the journey of a life-threatening disease of their beloved ones and mourning.

Team members feel a sense of reward, satisfaction, and “mission accomplished” when receiving these letters. This shows letters' positive impact and symbolic potential on team empowerment. These empowering experiences foster the sense of both individual and teamwork meaning, despite the death of the patient. Defined as the value of work goal or purpose, judged in relation to an individual's own ideals or standards, ³ meaning is one of the core dimensions of empowerment. By having a meaningful work, professionals and teams feel and share a sense of personal connection to it, feeling more empowered, motivated, and effective.

This process can be explained by the Expectancy Theory of Motivation, ⁴ in which symbolic and verbal forms of recognition for good performance are considered to be very effective in terms of performance-to-reward expectancy and reward valence. As an example, the participant team carefully collected the “Thank You” letters into a meaningful dossier named “In memory of those who left,” used in moments of vulnerability and distress.

In conclusion, when receiving “Thank You” letters, professionals feel a sense of reward, recognition, satisfaction, and “mission accomplished.” As a team, professionals highly value these letters, using them for meaning building, burnout prevention, individual and team empowerment, and as a quality outcome. “Thank You” letters may help to understand micro-meso-macro linkages in home-based palliative care and to facilitate change in teams, services, and organizations' culture to enhance their effectiveness.