2nd Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentation

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 Stress Burnout Compassion fatigue Countertransference

5. 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

6. Burnout Progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work Related to our need to believe in meaningful work/life Chronic interpersonal stressors Exhaustion Cynicism/detachment Lack of accomplishment

7. 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

8. Maslach Burnout as a psychological syndrome Exhaustion – individual Cynicism – relationship Lack of accomplishment – self-eval Not due to an individuals disposition

9. Maslach Burnout associated with: Demographics Single Younger No gender diff Personal char Neuroticism Low hardiness Lo self-esteem Strongest association with job characteristics Chronically difficult job demands Imbalance of high demands, low reources Presence of conflict (people, roles, values

10. Kumar et al - psychiatrists Predisposing Personality Work cond Precipitating Violence with pts Suicidal patients On call duties Perpetuating How one perceives and responds to stress

11. 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

12. 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

13. Countertransference Alchemical reaction between patient and caregiver at themost 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

14. Study 5 -age UK study of phsyicians - #5 Burnout associated with being under age 55 Increased job satisfaction with older age Emotional sensitivity increases with age-37-38 Married with children mixed results

15. Hardiness 42-43-44 Sense of commitmment, control and challenge Helps perception, interpretation, successful handling of stressful events Prevetns excessive arousal Oncology docs and nurses 46

16. resilience Not avoidance of stress But stress that allows for self-confidence thru mastery and appropriate responsibility Hardiness versus coherence

17. Emotional Sensitivity Hospice Nurses 38 Extroverted Empathic Trusting Open Expressive Insightful Group oriented Cautious with new ideas Potentially naïve in dealing with those more astute Lacking objectivity

18. Genetics 5-HTT short alleles

19. Social Support Early identified as important Similar to critical nurses Buffer to stress in workplace and assoicated with optimism Lack of social support predicted anxiety and psychosomatic complaints

20. Attachment Style 84 UK nurses Secure Preoccupied Fearful Dismissing

21. Stressful life events

22. MD comparisons Htable 16.2 Deporsonilzation associated with work overload

23. 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

24. 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 Fairness Values – individual moral agent, professional role and team Engagement: nrg, involvement, efficiency Compassion satisfaction

25. Emotional Work Variables Closenss vs. distance Controlled closeness 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

26. 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

27. Death acuity/volume Rarely studied

28. 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

29. Bibilography 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. 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. TurnipseedDL Jr. Burnout among hospice nurses: an empirical assessment. Hosp J. 1987 Summer-Fall;3(2-3):105-19. 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. MallettK, 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. 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. 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. KobasaSC. Stressful life events, personality, and health: an inquiry into hardiness. J Pers Soc Psychol. 1979 Jan;37(1):1-11. KobasaSC, Maddi SR, Kahn S. Hardiness and health: a prospective study. J Pers Soc Psychol. 1982 Jan;42(1):168-77. KashKM, 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. PapadatouD, 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. AmentaMM. Traits of hospice nurses compared with those who work in traditional settings. J Clin Psychol. 1984 Mar;40(2):414-20. 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. 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.