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

1. Stress and Burnout in the Professional Caregiver in Hospice & Palliative Care Christian Sinclair, MD, FAAHPM Kansas City Hospice & Palliative Care November 19th, 2009

2. Taking a Test The Professional Quality of Life Scale-IV

3. Two Readings

4. 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

5. Overview Death and dying “That must be depressing?!” Emotionally charged environment ≈25% of palliative care staff * report symptoms leading to psychiatric morbidity and burnout Lower than that of other specialties† Like oncology and critical care *Ramirez 1995; Turnipseed 1987, Woolley 1989 †Mallett 1991, Bram 1989

6. Definitions Stress Burnout Moral Distress Compassion fatigue Counter-transference Self-Care

7. Stress 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 Individual Team (formal or ad hoc) Organizational

8. Signs and Symptoms of Burnout Fatigue Physical exhaustion Emotional exhaustion Headaches GI disturbances Weight loss Sleeplessness Depression Boredom Frustration Low morale Job turnover Impaired job performance decreased empathy increased absenteeism Vachon 2009

9. 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 Exhaustion Cynicism/detachment Lack of accomplishment Vachon 2009

10. Burnout Work Overload Lack of Resources

11. Characteristics of Burnout Demographics Single Younger No gender difference Personal characteristics Neuroticism Low hardiness Low self-esteem Maslach 2001

12. Characteristics of Burnout Strongest association with job characteristics Chronically difficult job demands Imbalance of high demands, low resources Presence of conflict (people, roles, values) Maslach 2001

13. How Does Burnout Start? Kumar 2005; Image from Flickr user itshideE

14. 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

15. Moral Distress You know the ethically appropriate action to take, but you are unable to act upon it. You act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity 4 A’s Ask, Affirm, Assess, Act Jameton 1993; http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_Distress.pdf

16. Compassion Fatigue Secondary traumatic stress disorder Identical to post-traumatic stress disorder Except the trauma happened to someone else Bystander effect Strive for “Compassion Satisfaction”

17. 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 Re-experience 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 Month Symptoms > 1 month Arousal startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance DSM-IV

18. Counter-transference Whole person care Not always a Freudian bad thing “Alchemical reaction between patient and caregiver at the most vulnerable time in ones life. Thru the experience both can be transformed.” Vachon 2009

19. How Do We Achieve Engagement and Avoid Burnout?

20. Values

21. Engagement or Burnout? Prevent or Control Hardiness/ Resilience Adaptability Emotional sensitivity Social support Workplace resources Helping others Secure attachment style Self-awareness Emotion work-variables Accelerate or Sustain Stressful life events Emotional sensitivity Overwhelming demands Genetics Lack of education Fearful/dismissing attachment style Unresolved conflict

22. Hardiness/Resilience Sense of commitment, control and challenge Helps perception, interpretation, successful handling of stressful events Prevents excessive arousal Not avoiding stress Stress that leads to self-confidence thru mastery and appropriate responsibility Kobasa 19789, Kobasa 1982, Kash 2000, Papadatou 1994

23. Emotional Sensitivity Hospice Nurses Extroverted Empathic Trusting Open Expressive Insightful Group oriented Cautious with new ideas Potentially naïve in dealing with those more astute Lacking objectivity Gambles 2003

24. Genetics

25. 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

26. Attachment Style Hawkins 2007 Others + - + Self -

27. Stressful Life Events Death of spouse Divorce Marital separation Jail term or death of close family member Personal injury or illness Marriage Loss of job due to termination Marital reconciliation or retirement Pregnancy Change in financial state Citation ??

28. Religiosity & Spirituality Hospice staff more deeply religious* Religious associated with decreased risk of burnout in oncology staff^ Really self-awareness and meaning making? *Amenta 1984; ^Kash 2000

29. Emotional Work Variables Closeness vs. distance Controlled closeness is the goal Strategies: 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 Pfeffer – “We Die Here Better Than Anywhere Else” (German)

30. Inability to Live Up to One’s Standards The ‘Good Death’ haunts palliative medicine Expectation of an unattainable ideal Avoid dramatization of ideals Practice modesty and humbleness

31. Death Acuity/Volume Rarely studied in hospice Few studies in oncology Relationship between stress/burnout and volume

32. Evidence Based Interventions Few studies Poorly powered Mindfulness fully present without judgment Narrative driven workshops ABCD of dignity conserving care Attitude, behavior, compassion, dialogue Chochinov 2006: http://caonline.amcancersoc.org/cgi/reprint/56/2/84.pdf

33. Chochinov Dignity Model

34. Burnout Recognition - Individual Fatigue Physical exhaustion Emotional exhaustion Headaches GI disturbances Weight loss Sleeplessness Depression Boredom Frustration Low morale Job turnover Impaired job performance decreased empathy increased absenteeism Vachon 2009

35. Burnout – Team/Organization • High absenteeism • Constant changes in co-workers relationships • Inability for teams to work well together • Desire among staff members to break company rules • Outbreaks of aggressive behaviors among staff • Inability of staff to complete assignments and tasks • Inability of staff to respect and meet deadlines • Lack of flexibility among staff members • Negativism towards management • Strong reluctance toward change • Inability of staff to believe improvement is possible • Lack of a vision for the future http://www.compassionfatigue.org/pages/symptoms.html

36. ProQOL Results

40. 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. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONN’S ClinIssues PerinatWomens Health Nurs. 1993;4(4):542-551. 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.

41. 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.