Stress And The Professional Caregiver Ver 1.0

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Final version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series

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Stress And The Professional Caregiver Ver 1.0

  1. 1. Stress and Burnout in the Professional Caregiver in Hospice & Palliative Care<br />Christian Sinclair, MD, FAAHPM<br />Kansas City Hospice & Palliative Care<br />November 19th, 2009<br />
  2. 2. Taking a Test<br />The Professional Quality of Life Scale-IV<br />
  3. 3. Two Readings<br />
  4. 4. Objectives<br />1. Identify risk factors associated with stress and burnout for professional caregivers in hospice and palliative care<br />2. Define the psychological and relationship characteristics which can prevent or accelerate caregiver stress<br />3. Perform a self-assessment of professional caregiver burnout<br />
  5. 5. Overview<br />Death and dying<br />“That must be depressing?!”<br /> Emotionally charged environment<br />≈25% of palliative care staff *<br />report symptoms leading to psychiatric morbidity and burnout<br />Lower than that of other specialties†<br />Like oncology and critical care<br />*Ramirez 1995; Turnipseed 1987, Woolley 1989<br />†Mallett 1991, Bram 1989<br />
  6. 6. Definitions<br />Stress<br />Burnout<br />Moral Distress<br />Compassion fatigue<br />Counter-transference<br />Self-Care<br />
  7. 7. Stress<br />Stress<br />Demands from the work environment exceed the employee’s ability to cope with or control them<br />Relationship between employee and environment<br />Consider stress at multiple levels<br />Individual<br />Team (formal or ad hoc)<br />Organizational<br />
  8. 8. Signs and Symptoms of Burnout<br />Fatigue<br />Physical exhaustion<br />Emotional exhaustion<br />Headaches<br />GI disturbances<br />Weight loss<br />Sleeplessness<br />Depression<br />Boredom<br />Frustration<br />Low morale<br />Job turnover<br />Impaired job performance<br />decreased empathy<br />increased absenteeism<br />Vachon 2009<br />
  9. 9. Burnout<br />“Progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work”<br />Need to believe in meaningful work/life<br />Chronic interpersonal stressors<br />Exhaustion<br />Cynicism/detachment<br />Lack of accomplishment<br />Vachon 2009<br />
  10. 10. Burnout<br />Work Overload<br />Lack of Resources<br />
  11. 11. Characteristics of Burnout<br />Demographics<br />Single<br />Younger<br />No gender difference<br />Personal characteristics<br />Neuroticism<br />Low hardiness<br />Low self-esteem<br />Maslach 2001<br />
  12. 12. Characteristics of Burnout<br />Strongest association with job characteristics<br />Chronically difficult job demands<br />Imbalance of high demands, low resources<br />Presence of conflict (people, roles, values)<br />Maslach 2001<br />
  13. 13. How Does Burnout Start?<br />Kumar 2005; Image from Flickr user itshideE<br />
  14. 14. Is Burnout Just Depression?<br />Overlapping constructs<br />If you have severe burnout higher risk of major depressive disorder<br />If you have major depressive disorder higher risk of burnout<br />
  15. 15. Moral Distress<br />You know the ethically appropriate action to take, but you are unable to act upon it.<br />You act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity<br />4 A’s<br />Ask, Affirm, Assess, Act<br />Jameton 1993; http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_Distress.pdf<br />
  16. 16. Compassion Fatigue<br />Secondary traumatic stress disorder<br />Identical to post-traumatic stress disorder<br />Except the trauma happened to someone else<br />Bystander effect<br />Strive for “Compassion Satisfaction”<br />
  17. 17. Post-Traumatic Stress Disorder<br />Traumatic event <br />Experienced/witnessed serious injury, death of self or other <br />As a response, the person experienced intense helplessness, fear, and horror<br />Re-experience<br />Intrusive thoughts, nightmares, flashbacks, or recollection of traumatic memories and images.<br />Avoidance and emotional numbing<br />Detachment from others; flattening of affect; loss of interest; lack of motivation<br />Persistent avoidance of activity, places, persons, associated with the traumatic experience<br />Unable to function<br />Impairment in social, occupational, and interpersonal functioning<br />Month<br />Symptoms &gt; 1 month<br />Arousal<br />startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance<br />DSM-IV<br />
  18. 18. Counter-transference<br />Whole person care<br />Not always a Freudian bad thing<br />“Alchemical reaction between patient and caregiver at the most vulnerable time in ones life. Thru the experience both can be transformed.”<br />Vachon 2009<br />
  19. 19. How Do We Achieve Engagement and Avoid Burnout?<br />
  20. 20. Values<br />
  21. 21. Engagement or Burnout?<br />Prevent or Control<br />Hardiness/ Resilience<br />Adaptability<br />Emotional sensitivity<br />Social support<br />Workplace resources<br />Helping others<br />Secure attachment style<br />Self-awareness<br />Emotion work-variables<br />Accelerate or Sustain<br />Stressful life events<br />Emotional sensitivity<br />Overwhelming demands<br />Genetics<br />Lack of education<br />Fearful/dismissing attachment style<br />Unresolved conflict<br />
  22. 22. Hardiness/Resilience<br />Sense of commitment, control and challenge<br />Helps perception, interpretation, successful handling of stressful events<br />Prevents excessive arousal <br />Not avoiding stress<br />Stress that leads to self-confidence<br />thru mastery and appropriate responsibility<br />Kobasa 19789, Kobasa 1982, Kash 2000, Papadatou 1994<br />
  23. 23. Emotional Sensitivity<br />Hospice Nurses<br />Extroverted<br />Empathic<br />Trusting<br />Open<br />Expressive<br />Insightful<br />Group oriented<br />Cautious with new ideas<br />Potentially naïve in dealing with those more astute<br />Lacking objectivity<br />Gambles 2003<br />
  24. 24. Genetics<br />
  25. 25. Social Support<br />Early identified as important<br />Similar to critical nurses*<br />Buffer to stress in workplace and associated with optimism^<br />Lack of social support predicted anxiety and psychosomatic complaints#<br />*Mallett 1991; ^Hulbert 2006; #Cooper 1990<br />
  26. 26. Attachment Style<br />Hawkins 2007<br />Others<br />+<br />-<br />+<br />Self<br />-<br />
  27. 27. Stressful Life Events<br />Death of spouse<br />Divorce<br />Marital separation<br />Jail term or death of close family member<br />Personal injury or illness<br />Marriage<br />Loss of job due to termination<br />Marital reconciliation or retirement<br />Pregnancy<br />Change in financial state<br />Citation ??<br />
  28. 28. Religiosity & Spirituality<br />Hospice staff more deeply religious*<br />Religious associated with decreased risk of burnout in oncology staff^<br />Really self-awareness and meaning making?<br />*Amenta 1984; ^Kash 2000<br />
  29. 29. Emotional Work Variables<br />Closeness vs. distance<br />Controlled closeness is the goal<br />Strategies:<br />Patient rotation<br />Choosing when and where closeness<br />Rational reflection of internal process<br />Concentrating on one’s own role<br />Anticipating patient death<br />Maintaining appropriate composure<br />“No, within love” avoid being destroyed in the process of caring<br />Pfeffer – “We Die Here Better Than Anywhere Else” (German)<br />
  30. 30. Inability to Live Up to One’s Standards<br />The ‘Good Death’ haunts palliative medicine<br />Expectation of an unattainable ideal<br />Avoid dramatization of ideals<br />Practice modesty and humbleness<br />
  31. 31. Death Acuity/Volume<br />Rarely studied in hospice<br />Few studies in oncology<br />Relationship between stress/burnout and volume<br />
  32. 32. Evidence Based Interventions<br />Few studies<br />Poorly powered<br />Mindfulness fully present without judgment<br />Narrative driven workshops<br />ABCD of dignity conserving care<br />Attitude, behavior, compassion, dialogue<br />Chochinov 2006: http://caonline.amcancersoc.org/cgi/reprint/56/2/84.pdf<br />
  33. 33. Chochinov Dignity Model<br />
  34. 34. Burnout Recognition - Individual<br />Fatigue<br />Physical exhaustion<br />Emotional exhaustion<br />Headaches<br />GI disturbances<br />Weight loss<br />Sleeplessness<br />Depression<br />Boredom<br />Frustration<br />Low morale<br />Job turnover<br />Impaired job performance<br />decreased empathy<br />increased absenteeism<br />Vachon 2009<br />
  35. 35. Burnout – Team/Organization<br />• High absenteeism<br />• Constant changes in co-workers relationships<br />• Inability for teams to work well together<br />• Desire among staff members to break company rules<br />• Outbreaks of aggressive behaviors among staff<br />• Inability of staff to complete assignments and tasks<br />• Inability of staff to respect and meet deadlines<br />• Lack of flexibility among staff members<br />• Negativism towards management<br />• Strong reluctance toward change<br />• Inability of staff to believe improvement is possible<br />• Lack of a vision for the future<br />http://www.compassionfatigue.org/pages/symptoms.html<br />
  36. 36. ProQOL Results<br />
  37. 37.
  38. 38.
  39. 39.
  40. 40. Bibilography<br />Amenta MM. Traits of hospice nurses compared with those who work in traditional settings. J Clin Psychol. 1984 Mar;40(2):414-20.<br />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.<br />Cooper CL, Mitchell S. Nursing the Critically III and Dying. Human Relations 1990 43: 297-311<br />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.<br />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.<br />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. <br />Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONN’S ClinIssues PerinatWomens Health Nurs. 1993;4(4):542-551.<br />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.<br />Kobasa SC. Stressful life events, personality, and health: an inquiry into hardiness. J Pers Soc Psychol. 1979 Jan;37(1):1-11.<br />Kobasa SC, Maddi SR, Kahn S. Hardiness and health: a prospective study. J Pers Soc Psychol. 1982 Jan;42(1):168-77.<br />
  41. 41. Bibilography<br />Kumar S, Hatcher S, Huggard P. Burnout in psychiatrists: an etiological model. Int J Psychiatry Med. 2005;35(4):405-16. <br />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.<br />Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.<br />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.<br />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.<br />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.<br />Turnipseed DL Jr. Burnout among hospice nurses: an empirical assessment. Hosp J. 1987 Summer-Fall;3(2-3):105-19.<br />Vachon MLS. The stress of professional caregivers. Oxford Textbook of Palliative Medicine 3rd edition (2004). p992-1004.<br />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.<br />Woolley H, Stein A, Forrest GC, Baum JD. Staff stress and job satisfaction at a children&apos;s hospice. Arch Dis Child. 1989 Jan;64(1):114-8.<br />

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