Stress and Burnout in the Professional Caregiver in

Hospice & Palliative Care

Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care

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

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

Definitions

• Stress• Burnout• Compassion fatigue• Countertransference

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

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

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

Components of Burnout

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

– Not due to an individuals disposition

Maslach 2001

Burnout

CynicismExhaustion

Lack of Ac-complishment

Work Overload

Lack of Resources

Characteristics of Burnout

• 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 resources– Presence of conflict (people, roles, values)

Maslach 2001

How Does Burnout Start?

Kumar 2005

Predisposi

ng

•Personality

•Work conditions

Precipitati

ng

•Violence with pts

•Suicidal patients

•On call duties

Perpetuating

•Perception of stress

•Response 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

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

Countertransference

• Alchemical reaction between patient and caregiver at the most 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

Physician Burnout

• UK study of phsyicians*– Burnout associated with being under age 55– Increased job satisfaction with older age

• Emotional sensitivity increases with age^• Married with children mixed results

*Ramirez 1995; ^Cattel 1970, Gambles 2003

Hardiness

• Sense of commitment, control and challenge• Helps perception, interpretation, successful

handling of stressful events• Prevents excessive arousal • Oncology docs and nurses

Kobasa 19789, Kobasa 1982, Kash 2000, Papadatou 1994

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

Gambles 2003

Genetics

• 5-HTT short alleles

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

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

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