stress and the professional caregiver ver 1.0

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


  • 1.Stress and Burnout in the Professional Caregiver inHospice & 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
Moral Distress
Compassion fatigue
7. Stress
Demands from the work environment exceed the employees ability to cope with or control them
Relationship between employee and environment
Consider stress at multiple levels
Team (formal or ad hoc)
8. Signs and Symptoms of Burnout
Physical exhaustion
Emotional exhaustion
GI disturbances
Weight loss
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
Lack of accomplishment
Vachon 2009
10. Burnout
Work Overload
Lack of Resources
11. Characteristics of Burnout
No gender difference
Personal characteristics
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 As
Ask, Affirm, Assess, Act
Jameton 1993;
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
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
Symptoms > 1 month
startle reaction, poor concentration, irritable mood, insomnia, and hypervigilance
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
Emotional sensitivity
Social support
Workplace resources
Helping others
Secure attachment style
Emotion work-variables
Accelerate or Sustain
Stressful life events
Emotional sensitivity
Overwhelming demands
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
Group oriented
Cautious with new ideas
Potentially nave 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
27. Stressful Life Events
Death of spouse
Marital separation
Jail term or death of close family member
Personal injury or illness
Loss of job due to termination
Marital reconciliation or retirement
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
Patient rotation
Choosing when and where closeness
Rational reflection of internal process
Concentrating on ones 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 Ones 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:
33. Chochinov Dignity Model
34. Burnout Recognition - Individual
Physical exhaustion
Emotional exhaustion
GI disturbances
Weight loss
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
36. ProQOL Results
37. 38. 39. 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. AWHONNS ClinIssues PerinatWomens Health Nurs. 1993;4(4):542-551.
Kash KM, Holland JC, Breitbart W, Berens