Stress and the Professional Caregiver

Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care

Nov 19, 2009

Objectives

Overview

• 25% of palliative care staff report symptoms– Indicates psychiatric morbidity and burnout

• Lower than that of other specialties– Like oncology

Definitions

• Stress– Relationship between employee and work environment– Demands from the work environment exceed the employee’s ability

to cope with or control them• Burnout

– Progressive loss if 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

Signs and Symptoms of Burnout• Fatigue• Physical exhaustion• Emotional exhaustion• Headaches• GI disturances• Weight loss• Sleeplessness• Depression• Boredom• Frustration• Low morale• Job turnover• Impaired job performance (decreased empathy, increased absenteeism

• Maslach– Burnout as a psychological syndrome• Exhaustion – individual• Cynicism – relationship• Lack of accomlishment – self-eval

– Not due to an individuals disposition

• 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

• 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

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

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

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

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

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

resilience

• Not avoidance of stress• But stress that allows for self-confidence thru

mastery and appropriate responsibility• Hardiness versus coherence

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

Genetics

• 5-HTT short alleles

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

Attachment Style

• 84 UK nurses– Secure– Preoccupied– Fearful– Dismissing

Stressful life events

MD comparisons

• Htable 16.2• Deporsonilzation associated with work

overload

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

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

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

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

Death acuity/volume

• Rarely studied

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

Bibliography

• Vachon MLS. The stress of profesisonal 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 Psychoatry in Palliative Care (2009). p236-264.