Staff stress in cancer Staff stress in cancer and palliative careand palliative care

Professor Robin DavidsonProfessor Robin DavidsonConsultant Clinical PsychologistConsultant Clinical Psychologist

Hon Lecturer, Faculty of Medicine Hon Lecturer, Faculty of Medicine (QUB)(QUB)

LIVERPOOL, SUMMER 2010LIVERPOOL, SUMMER 2010

The NHS Workforce The NHS Workforce InitiativeInitiative

(12,000 NHS Staff sampled)(12,000 NHS Staff sampled)

1.1. Mental health of staff in NHS Trusts was Mental health of staff in NHS Trusts was substantially poorer than other public substantially poorer than other public sector employees.sector employees.

2.2. 28.5% of nurses had minor psychiatric 28.5% of nurses had minor psychiatric disorders as assessed by the GHQ.disorders as assessed by the GHQ.

3.3. Palliative care particularly difficultPalliative care particularly difficult

Stress League (Health)Stress League (Health)

OccupationOccupation Stress ScoreStress ScoreDentistDentist 7.37.3DoctorDoctor 6.86.8NurseNurse 6.56.5Social WorkerSocial Worker 6.06.0PharmacistPharmacist 4.54.5PhysiotherapistPhysiotherapist 4.24.2Speech TherapistSpeech Therapist 4.04.0RadiographerRadiographer 4.04.0Occupational Occupational TherapistTherapist

3.73.7

DieticianDietician 3.43.4

What is Stress?What is Stress?

““A stressful circumstance is one A stressful circumstance is one which you cannot cope successfully, which you cannot cope successfully, or believe you cannot cope or believe you cannot cope successfully, and which results in successfully, and which results in unwanted physical, mental or unwanted physical, mental or emotional reactionsemotional reactions””..

Approaches To StressApproaches To Stress

1.1. Stress is Adaptive / Non-AdaptiveStress is Adaptive / Non-Adaptive

0

5

10

15

20

25

30

35

40 Optimum performance

Arousal

Task Performance

Approaches To StressApproaches To Stress 1.1. Individual DifferencesIndividual Differences

Type A / B PersonalitiesType A / B Personalities State / Trait AnxietyState / Trait Anxiety Neurotic / StableNeurotic / Stable Inner directiveness, self acceptanceInner directiveness, self acceptance Developmental/attachment differencesDevelopmental/attachment differences

2.2. External EventsExternal Events Impact Of Life Events e.g. unresolved griefImpact Of Life Events e.g. unresolved grief Impact of Organisation Structure / ClimateImpact of Organisation Structure / Climate Interface Between Work / HomeInterface Between Work / Home Type of JobType of Job

3.3. Personal InterpretationPersonal Interpretation Cognitive Style/coping strategyCognitive Style/coping strategy Learned HelplessnessLearned Helplessness Expectations/attributionsExpectations/attributions Transcendental beliefsTranscendental beliefs

Behavioural signs of stressBehavioural signs of stress Reduced concentrationReduced concentration Do too many things at onceDo too many things at once Don’t finish tasksDon’t finish tasks Indecision and poor concentrationIndecision and poor concentration Loss of memoryLoss of memory TATTTATT Fear of outsidersFear of outsiders IrritabilityIrritability Tend to overactTend to overact NightmaresNightmares

The Components of BurnoutThe Components of Burnout Emotional exhaustionEmotional exhaustion

– wearing out, depletion of emotional wearing out, depletion of emotional resources, loss of energy, debilitation, fatigue.resources, loss of energy, debilitation, fatigue.

DepersonalisationDepersonalisation - Negative, callous, excessively detached - Negative, callous, excessively detached

towards other people, loss of idealism, towards other people, loss of idealism, irritability.irritability.

Reduced personal accomplishmentReduced personal accomplishment - reduction in self-confidence, low productivity, - reduction in self-confidence, low productivity,

poor morale, inability to cope.poor morale, inability to cope.

Stages in BurnoutStages in Burnout 1.1. Stress Arousal StageStress Arousal Stage

-- Persistent irritability / AnxietyPersistent irritability / Anxiety -- InsomniaInsomnia -- Concentration lapsesConcentration lapses

2.2. Stress Resistance StageStress Resistance Stage -- AbsenteeismAbsenteeism - Fatigue- Fatigue - Indecision- Indecision - Cynicism- Cynicism - Resentful / Defiant- Resentful / Defiant

3.3. Severe Exhaustion StageSevere Exhaustion Stage -- Chronic depressionChronic depression - Chronic stress related illness- Chronic stress related illness - Self destructive thoughts- Self destructive thoughts

Job Related Stress DimensionsJob Related Stress Dimensions A) RelationshipsA) Relationships

B)B) TasksTasks

C)C) System System management management

communication problems communication problems with managerswith managers

lack of team worklack of team work conflict with colleaguesconflict with colleagues

difficult patient groupsdifficult patient groups role ambiguityrole ambiguity role conflictrole conflict low sense of autonomylow sense of autonomy

inadequate resourcesinadequate resources poor physical environmentpoor physical environment old equipmentold equipment work overloadwork overload

Additional stress for palliative care Additional stress for palliative care and cancer staff and cancer staff

Accumulated loss phenomenaAccumulated loss phenomena Ideal versus reality conflictIdeal versus reality conflict Incremental griefIncremental grief Problems with intimacy and staff Problems with intimacy and staff

patient interface e.g. special /difficult patient interface e.g. special /difficult patient, mutilation, death and dying patient, mutilation, death and dying (survivor guilt), adjustment to poor (survivor guilt), adjustment to poor outcome.outcome.

Staff stress in the NI cancer Staff stress in the NI cancer centrecentre

120 test batteries administer to 120 test batteries administer to doctors, nurses, PAMs and doctors, nurses, PAMs and radiographers.radiographers.

Response rate 57%Response rate 57% PsychmetricsPsychmetrics…..GHQ, Sources of …..GHQ, Sources of

Pressure Scale, Attitude to Work Pressure Scale, Attitude to Work Questionaire AWQ (junior doctors Questionaire AWQ (junior doctors and consultant versions)and consultant versions)

QuestionairesQuestionaires

GHQ-12GHQ-12. can be scored as a Likert scale . can be scored as a Likert scale or a dichotomous response format to or a dichotomous response format to assess casesness.assess casesness.

Sources of Pressure ScaleSources of Pressure Scale has 7 has 7 subscalessubscales

i.e. workload, patient related difficulties, i.e. workload, patient related difficulties, organisational structure and processes, organisational structure and processes, relationships and conflicts with other staff, relationships and conflicts with other staff, lack of resources, professional self doubt , lack of resources, professional self doubt , home/work conflictshome/work conflicts

Main findings (1)Main findings (1) CasenessCaseness Therapeutic radiographers (42%)Therapeutic radiographers (42%) Consultant oncologists (33%)Consultant oncologists (33%) Nurses (16%)Nurses (16%) PAMS (11%)PAMS (11%)

Key predictors of GHQKey predictors of GHQ workloadworkload professional self doubtprofessional self doubt

Main findings (2)Main findings (2)

Source of stressSource of stress

WorkloadWorkload top for all groups top for all groups except nurses who had except nurses who had lack of lack of resourcesresources top top

Organisational S and POrganisational S and P next top next top for radiographersfor radiographers

Conflicts with othersConflicts with others next top for next top for medical staff but bottom for PAMsmedical staff but bottom for PAMs

but wait………..but wait………..

Jenny Firth Cozins found the Jenny Firth Cozins found the methodology employed skewed the methodology employed skewed the data in sourse of stress research on data in sourse of stress research on cancer doctors and nurses!cancer doctors and nurses!

andand Vachon warns that occasionally some Vachon warns that occasionally some

studies demonstrate less burnout studies demonstrate less burnout among palliative nurses than those among palliative nurses than those working in IT and mental health.working in IT and mental health.

Stress InoculationStress Inoculation Adoption of multiple rolesAdoption of multiple roles,, e.g: - partner, parent, worker, e.g: - partner, parent, worker,

volunteervolunteer

Social SupportSocial Support,, e.g: - family, friends, colleagues e.g: - family, friends, colleagues

Personal VariablesPersonal Variables,, e.g: - type B, low state anxiety, internal e.g: - type B, low state anxiety, internal locus of controllocus of control

Coping StrategiesCoping Strategies,, e.g: - low avoidance, problem focused e.g: - low avoidance, problem focused coping, religious faithcoping, religious faith

Organisational StrategiesOrganisational Strategies - Staffing policies, education - Staffing policies, education programmes, support groups, confidential counselling, clear programmes, support groups, confidential counselling, clear communication systemscommunication systems

Work VariablesWork Variables - Role clarity, role conflict, lack of good - Role clarity, role conflict, lack of good working conditions, appropriate workload.working conditions, appropriate workload.

Skills required to deal with stressSkills required to deal with stress Stressor response chairStressor response chair Relaxation strategiesRelaxation strategies Appropriate assertivenessAppropriate assertiveness Time management - PrioritiseTime management - Prioritise Positive self talkPositive self talk Recovery periodsRecovery periods Stability zonesStability zones Support / DelegationSupport / Delegation Regular exerciseRegular exercise HumourHumour Good dietGood diet

Staff Support OptionsStaff Support Options

Access to professional mentor for nursesAccess to professional mentor for nurses

Informal peer support groupsInformal peer support groups

Quality circles that assist in the Quality circles that assist in the involvement in decision making and team involvement in decision making and team workwork

An individual counselling service for those An individual counselling service for those needing more in depth supportneeding more in depth support

Training initiatives to increase awarenessTraining initiatives to increase awareness

ReferencesReferences

Davidson, R (2006). Stress issues in Davidson, R (2006). Stress issues in palliative care palliative care inin Stepping into Stepping into Palliative Care: Relationships Palliative Care: Relationships and Responses. and Responses. Jo Cooper (Ed). Jo Cooper (Ed). Ratcliffe Medical Press Ltd. Oxford.Ratcliffe Medical Press Ltd. Oxford.

Davidson R (2008 ) Maintaining Davidson R (2008 ) Maintaining Mental Health. p319-332. (in) Mental Health. p319-332. (in) Rehabilitation in Cancer CareRehabilitation in Cancer Care. . Robb, K and Rankin, J (eds).Wiley-Robb, K and Rankin, J (eds).Wiley-Blackwell, London.Blackwell, London.