Stress And The Professional Caregiver Ver 1.0
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Transcript of Stress And The Professional Caregiver Ver 1.0
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Stress and Burnout in the Professional Caregiver in
Hospice & Palliative Care
Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care
November 19th, 2009
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Taking a Test
• The Professional Quality of Life Scale-IV
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Two Readings
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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
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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
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Definitions
• Stress• Burnout• Moral Distress• Compassion fatigue• Counter-transference• Self-Care
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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
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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
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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
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Burnout
CynicismExhaustion
Lack of Ac-complishment
Work Overload
Lack of Resources
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Characteristics of Burnout
• Demographics– Single– Younger– No gender difference
• Personal characteristics– Neuroticism– Low hardiness– Low self-esteem
Maslach 2001
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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
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How Does Burnout Start?
Kumar 2005; Image from Flickr user itshideE
Predisposi
ng
•Personality
•Work conditions
Precipitati
ng
•Violence with pts
•Suicidal patients
•On call duties
Perpetuating
•Perception of stress
•Response to stress
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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
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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
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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”
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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
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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
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How Do We Achieve Engagement and Avoid Burnout?
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Values
Workload
Control
RewardCommunity
Fairness
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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
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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
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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
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Genetics
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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
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Attachment Style
Hawkins 2007
Secure Dismissing
Preoccupied Fearful
Self
Others
+
+
-
-
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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 stateCitation ??
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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
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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)
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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
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Death Acuity/Volume
• Rarely studied in hospice• Few studies in oncology– Relationship between stress/burnout and volume
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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
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Chochinov Dignity Model
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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
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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
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ProQOL Results
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