Stress and Burnout in the Professional Caregiver in

Hospice & Palliative Care

Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care

November 19th, 2009

Taking a Test

• The Professional Quality of Life Scale-IV

Two Readings

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?!”

• 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

Definitions

• Stress• Burnout• Moral Distress• Compassion fatigue• Counter-transference• Self-Care

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

Vachon 2009

Burnout

CynicismExhaustion

Lack of Ac-complishment

Work Overload

Lack of Resources

Characteristics of Burnout

• Demographics– Single– Younger– No gender difference

• Personal characteristics– Neuroticism– Low hardiness– Low self-esteem

Maslach 2001

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

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

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

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

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”

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

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

How Do We Achieve Engagement and Avoid Burnout?

Values

Workload

Control

RewardCommunity

Fairness

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

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

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

Genetics

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

Hawkins 2007

Secure Dismissing

Preoccupied Fearful

Self

Others

+

+

-

-

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 ??

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

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)

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

Death Acuity/Volume

• Rarely studied in hospice• Few studies in oncology– Relationship between stress/burnout and volume

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

Chochinov Dignity Model

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

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

ProQOL Results

BibilographyAmenta 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. Oncol Nurs

Forum. 1989 Jul-Aug;16(4):555-60.Cooper CL, Mitchell S. Nursing the Critically III and Dying. Human Relations 1990 43: 297-311Gambles 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. AWHONN’S Clin Issues

Perinat Womens Health Nurs. 1993;4(4):542-551.Kash KM, Holland JC, Breitbart W, Berenson S, Dougherty J, Ouellette-Kobasa S, Lesko L. Stress and burnout in

oncology. Oncology (Williston Park). 2000 Nov;14(11):1621-33; discussion 1633-4, 1636-7.Kobasa SC. Stressful life events, personality, and health: an inquiry into hardiness. J Pers Soc Psychol. 1979

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