Stress And The Professional Caregiver 0.9

Uploaded on

3rd Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentation

3rd Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentation

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads


Total Views
On Slideshare
From Embeds
Number of Embeds



Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

    No notes for slide
  • OHPPC – 5,6,75,8,9
  • Discuss the difference between distress and eu-stress, can pressure be a good thing. Can challenge or being presented with more than you can feasibly deal with be and advantage. Yes in the short term stress can make you more productive, collect more resources to do the task at hand
  • Table 16.1 form OHPPC
  • Lack of Resources – information/tools/timeWork Overload
  • PredisposingPersonalityWork conditionsPrecipitatingViolence with ptsSuicidal patientsOn call dutiesPerpetuatingHow one perceives and responds to stressKumar 2005
  • A Traumatic event occurred in which the person experienced, witnessed, or was confronted by actual or threatened serious injury, death, or threat to the physical integrity of self or other and, as a response to such trauma, the person experienced intense helplessness, fear, and horrorThe person Reexperiences such traumatic events by intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images.Avoidance and emotional numbing emerge, expressed as detachment from others; flattening of affect; loss of interest; lack of motivation; and persistent avoidance of activity, places, persons, or events associated with the traumatic experienceSymptoms are distressing and cause significant impairment in social, occupational, and interpersonal functioning (patients are Unable to function)These symptoms last more than 1 MonthThe person has increased Arousal, usually manifested by startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance
  • 69


  • 1. Stress and Burnout in the Professional Caregiver in Hospice & Palliative Care
    Christian Sinclair, MD, FAAHPM
    Kansas City Hospice & Palliative Care
  • 2. Objectives
    1. Identify risk factors associated with stress and burnout for professional caregivers in hospice and palliative care
    2. Define the psychological and relationship characteristics which can prevent or accelerate caregiver stress
    3. Perform a self-assessment of professional caregiver burnout
  • 3. Overview
    Death and dying
    “That must be depressing?!”
    ≈25% of palliative care staff *
    report symptoms leading to psychiatric morbidity and burnout
    Lower than that of other specialties†
    Like oncology and critical care
    Emotionally charged environment
    *Ramirez 1995; Turnipseed 1987, Woolley 1989
    †Mallett 1991, Bram 1989
  • 4. Definitions
    Compassion fatigue
  • 5. Stress
    Demands from the work environment exceed the employee’s ability to cope with or control them
    Relationship between employee and environment
    Consider stress at multiple levels
    Team (formal or ad hoc)
  • 6. Signs and Symptoms of Burnout
    Physical exhaustion
    Emotional exhaustion
    GI disturbances
    Weight loss
    Low morale
    Job turnover
    Impaired job performance
    decreased empathy
    increased absenteeism
    Vachon 2009
  • 7. Burnout
    Progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work
    Need to believe in meaningful work/life
    Chronic interpersonal stressors
    Lack of accomplishment
  • 8. Components of Burnout
    Burnout as a psychological syndrome
    Exhaustion – individual
    Cynicism – relationship
    Lack of accomplishment – self-eval
    Not due to an individuals disposition
    Maslach 2001
  • 9. Burnout
    Work Overload
    Lack of Resources
  • 10.
  • 11. Characteristics of Burnout
    No gender diff
    Personal char
    Low hardiness
    Lo self-esteem
    Strongest association with job characteristics
    Chronically difficult job demands
    Imbalance of high demands, low resources
    Presence of conflict (people, roles, values)
    Maslach 2001
  • 12. How Does Burnout Start?
    Kumar 2005
  • 13. Is Burnout just Depression?
    Overlapping constructs
    If you have severe burnout higher risk of major depressive disorder
    If you have major depressive disorder higher risk of burnout
  • 14. Compassion Fatigue
    Secondary traumatic stress disorder
    Identical to post-traumatic stress disorder
    Except the trauma happened to someone else
    Bystander effect
    No energy for it anymore
    Emptied, no
  • 15. Post-Traumatic Stress Disorder
    Traumatic event
    Experienced/witnessed serious injury, death of self or other
    As a response, the person experienced intense helplessness, fear, and horror
    Intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images.
    Avoidance and emotional numbing
    Detachment from others; flattening of affect; loss of interest; lack of motivation
    Persistent avoidance of activity, places, persons, associated with the traumatic experience
    Unable to function
    Impairment in social, occupational, and interpersonal functioning
    Symptoms > 1 month
    startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance
  • 16. Countertransference
    Alchemical reaction between patient and caregiver at the most vulnerable time in ones life – thru the experience both can be transformed
    Whole person care
    The social brain is wired to help others in distress
  • 17. Physician Burnout
    UK study of phsyicians*
    Burnout associated with being under age 55
    Increased job satisfaction with older age
    Emotional sensitivity increases with age^
    Married with children mixed results
    *Ramirez 1995; ^Cattel 1970, Gambles 2003
  • 18. Hardiness
    Sense of commitment, control and challenge
    Helps perception, interpretation, successful handling of stressful events
    Prevents excessive arousal
    Oncology docs and nurses
    Kobasa 19789, Kobasa 1982, Kash 2000, Papadatou 1994
  • 19. Resilience
    Not avoidance of stress
    But stress that allows for self-confidence thru mastery and appropriate responsibility
    Hardiness versus coherence
  • 20. Emotional Sensitivity
    Hospice Nurses 38
    Group oriented
    Cautious with new ideas
    Potentially naïve in dealing with those more astute
    Lacking objectivity
    Gambles 2003
  • 21. Genetics
    5-HTT short alleles
  • 22. Social Support
    Early identified as important
    Similar to critical nurses*
    Buffer to stress in workplace and associated with optimism
    Lack of social support predicted anxiety and psychosomatic complaints
    *Mallett 1991; ^Hulbert 2006; #Cooper 1990
  • 23. Attachment Style
    84 UK nurses
  • 24. Stressful life events
  • 25. MD comparisons
    Htable 16.2
    Deporsonilzation associated with work overload
  • 26. Religiosity, Spirituality, Meaning making
    Hospice staff more deeply religious (1984)
    Religious associated with decr risk of burnout in onc staff (2000) 44
    230 NZ MD correlation between religion and vicarious traumitzation higher compassion fatigue but a negative one with spirituality and burnout 11
  • 27. Engagement v. Burnout
    Workload – associated with deprsonalization
    Control – performing without training/outside epxertise
    Reward – Intrinsic and extrensic
    Money, care, touch, stories, love
    Lo ,though I walk through the valley of the shadow of death, it is never my turn
    Community – group v. team
    Values – individual moral agent, professional role and team
    Engagement: nrg, involvement, efficiency
    Compassion satisfaction
  • 28. Emotional Work Variables
    Closenss vs. distance
    Controlled closeness
    Patient rotation
    Choosing when and where closeness
    Rational reflection of internal process
    Concentrating on one’s own role
    Anticipating patient death
    Maintaining appropriate composure
    “No, within love” avoid being destroyed in the process of caring
  • 29. Inability to live up to one’s own standards
    Good or better death haunt our field
    Expectation of an unattainable ideal
    No pain therapy, symptom control support in psycho social and spiritual dimension can take the horror away from death. Avoid dramatisation of ideals and practice modesty and humbleness
  • 30. Death acuity/volume
    Rarely studied
  • 31. Evidence Based Interventions
    Few studies
    Poorly powered
    Mindfulness fully present without judgement
    Narrative driven workshops
    Dot theory
    Abcd of dignity conserving care
    Attitude, behavior, compassion dialogue
  • 32. Bibilography
    Amenta MM. Traits of hospice nurses compared with those who work in traditional settings. J Clin Psychol. 1984 Mar;40(2):414-20.
    Bram PJ, Katz LF. A study of burnout in nurses working in hospice and hospital oncology settings. OncolNurs Forum. 1989 Jul-Aug;16(4):555-60.
    Cooper CL, Mitchell S. Nursing the Critically III and Dying. Human Relations 1990 43: 297-311
    Gambles M, Wilkinson SM, Dissanayake C. What are you like?: A personality profile of cancer and palliative care nurses in the United kingdom. Cancer Nurs. 2003 Apr;26(2):97-104.
    Hawkins AC, Howard RA, Oyebode JR. Stress and coping in hospice nursing staff. The impact of attachment styles. Psychooncology. 2007 Jun;16(6):563-72.
    Hulbert NJ, Morrison VL. A preliminary study into stress in palliative care: optimism, self-efficacy and social support. Psychol Health Med. 2006 May;11(2):246-54.
    Kash KM, Holland JC, Breitbart W, Berenson S, Dougherty J, Ouellette-Kobasa S, Lesko L. Stress and burnout in oncology. Oncology (Williston Park). 2000 Nov;14(11):1621-33; discussion 1633-4, 1636-7.
    Kobasa SC. Stressful life events, personality, and health: an inquiry into hardiness. J Pers Soc Psychol. 1979 Jan;37(1):1-11.
    Kobasa SC, Maddi SR, Kahn S. Hardiness and health: a prospective study. J Pers Soc Psychol. 1982 Jan;42(1):168-77.
  • 33. Bibilography
    Kumar S, Hatcher S, Huggard P. Burnout in psychiatrists: an etiological model. Int J Psychiatry Med. 2005;35(4):405-16.
    Mallett K, Price JH, Jurs SG, Slenker S. Relationships among burnout, death anxiety, and social support in hospice and critical care nurses. Psychol Rep. 1991 Jun;68(3 Pt 2):1347-59.
    Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
    Papadatou D, Anagnostopoulos F, Monos D. Factors contributing to the development of burnout in oncology nursing. Br J Med Psychol. 1994 Jun;67 ( Pt 2):187-99.
    Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, Snashall DC, Timothy AR. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995 Jun;71(6):1263-9.
    Sinclair S, Raffin S, Pereira J, Guebert N. Collective soul: the spirituality of an interdisciplinary palliative care team. Palliat Support Care. 2006 Mar;4(1):13-24.
    Turnipseed DL Jr. Burnout among hospice nurses: an empirical assessment. Hosp J. 1987 Summer-Fall;3(2-3):105-19.
    Vachon MLS. The stress of professional caregivers. Oxford Textbook of Palliative Medicine 3rd edition (2004). p992-1004.
    Vachon MLS, Muller M. Burnout and symptoms of stress in staff working in palliative care. Oxford Handbook of Psychiatry in Palliative Care (2009). p236-264.
    Woolley H, Stein A, Forrest GC, Baum JD. Staff stress and job satisfaction at a children's hospice. Arch Dis Child. 1989 Jan;64(1):114-8.