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www.nccosc.navy.mil
Bart Jarvis, PhDHeidi Kraft, PhD
Monique Beauchamp, MFT
Caregiver Occupational Stress Control
(CgOSC) Training <DRAFT>
Introduction
HM3(FMF) Smith's infantry unit is deployed to Afghanistan. They
have lost many comrades to injury and death over the
deployment. Recently, HM3 has battled insomnia and night
sweats. He is increasingly edgy and easily irritated with people.
Despite this, he prides himself on his ability to handle many of his
Marines' medical concerns on deployment, including helping two
of them through significant home-front stressors.
After a grueling string of days for his platoon, HM3 suddenly
notices his friend, CPL Jones, acting differently. The corporal is
not sleeping, and his speech is racing and difficult to understand.
The Marine often paces, seems agitated, and talks of emailing the
Commandant to share thoughts on platoon leadership.
Why CgOSC?
• Increasing demands – Caregivers are facing
• Knowledge and tools
• Mediate risk-of negative outcomes
• Burnout-prevent or address
• Compassion Fatigue-Prevent or address
• Support resilient caregivers
Course Objectives
• Provider Ethics and Risk Management- in relation to CgOSC Principles
• Combat & Operational Stress Continuum Model
• Combat and Operational Stress First Aid (COSFA) Model
• 5 Core Leader Functions
• Resilience, Compassion Satisfaction and Caregiver Growth
• Duties of CgOSC Teams
Ethics of Caregiver Self-Care
• Self-care and buddy-care are foundations of caregiver ethics
• Deep connections-Caregivers have with their patients
• Increasing demand-to provide specialized care
• Poor judgment-Result from Burnout, Secondary Traumatic Stress (STS), Compassion Fatigue
• Risk-lapses in judgment, negligence, malpractice
Fallacy of Caregiver Self-Care
• High value for Self-Sacrifice
• Focus on others
• Tendency to ignore own issues
• Elevated substance abuse rates
• Elevated suicide rates
• Intrinsic Rewards-For caregiving, not self-care
• Extrinsic Rewards-Not persuasive for self-care
Initial Stress Symptoms
DiminishedSelf
Awareness
PoorConcentration
SocialWithdrawal
IrritabilityIncreased
SelfSoothing
Potential Caregiver Difficulties Burnout- Cumulative, predictablesubtle, mental fatigue, low energy, exhaustion, de-personalization
Compassion Fatigue (CF) or STS Anxiety, re-experiencing trauma, avoidance/numbing of reminders of trauma, sudden onset, unmet desire to help
Shared Trauma Caregiver and patient have gone through same or similar experience
Risk Factors: STS/CF and Burnout
HIGHER RISK LOWER RISK
High Caseload Reasonable Caseload, Ask for Help
High Exposure to ST Material Use of Active Coping, Humor, Active Optimism, Mindfulness
More than 40 Hours Work Per Week Reasonable Work Hours, Regular Down Time, Ask for Help
Personal Trauma History Positively Address, Cope with Trauma History
Isolation and Withdrawal, Poor Social Network
Utilize Positive Social Network
Minimal or Negative Supervision Positive Supervision
Substance Use/Abuse Awareness, Positively Address
Low Resilience Learn, Utilize Positive Resilience Factors
Caregiver Burnout Scenario HMC Brady is an IDC assigned to a busy clinic at a large MTF.
Due to high-op tempo and recently deployed staff in the clinic,
his patient load increased significantly, leading to long hours, no
breaks and minimal supervision. His wife has regularly said that
he needs to get help because he has been withdrawing from her
and their 12-year-old daughter. In addition, a staff member
recently approached HMC and told him he is becoming
distracted and appears indifferent to his patients.
Negative Ethical OutcomesSTS/CF Burnout
Practice Beyond Competency
Boundary Violations
Poor Risk Management
Lapses in Judgment
Negligence or Malpractice
Stress Continuum• Green – “Ready” Zone – Optimal functioning despite stressors;
leadership responsibility
• Yellow – “Reacting” Zone – Mild temporary symptoms; leadership and individual responsibility
• Orange – “Injured” Zone – Severe and lasting distress, decrease in productivity. See “Four Sources Of Stress Injury”; individual and leadership responsibility
• Red – “Ill” Zone – Danger! Severe symptoms that do not improve without intervention; need professional intervention
ReactingReady Injured Ill
Adaptive coping
Optimal functioning
Wellness
FeaturesWell trained and prepared
Fit and focused
In control
Optimally effective
Behaving ethically
Mild and transient distress or loss of optimal
functioning
Temporary & reversible
Low risk for illness
FeaturesIrritable, angry
Anxious or depressed
Physically too pumped up or tired
Reduced self-control
Poor focus
Poor sleep
Persistent and disabling distress or loss of function
Unhealed stress injuries
Mental disorder
TypesPTSD
Major Depression
Anxiety
Substance abuse
FeaturesSymptoms and disability persist over many weeks
Symptoms and disability get worse over time
More severe and persistent distress or loss
Higher risk for illness
CausesLife threat, Loss,
Inner conflict, Wear and tear
FeaturesPanic or rage
Loss of control of body/ mind
Can’t sleepRecurrent nightmares/ bad
memoriesPersistent shame, guilt
or blameLoss of moral values
and beliefs
STRESS
Unit Leader Responsibility
Caregiver Responsibility
Individual, Shipmate, Family Responsibility
www.nccosc.navy.mil
Life Threat
A trauma injury
Due to events provoking terror,
helplessness, horror, shock
Loss Wear and Tear
A fatigue injury
Due to the accumulation of stress over time
Inner Conflict
A beliefs injury
Due to conflict between
moral/ethical beliefs and
current experiences
A grief injury
Due to loss of people who are
cared about
Four Sources of Stress Injury
Combat & Operational Stress First Aid (COSFA)
• Flexible, multi-step psychological first aid process
• Used for assessment and pre-clinical care
• Designed to help self and others
COSFAGOALS
PreserveLife
Prevent FurtherHarm
Promote Recovery
www.nccosc.navy.mil
Seven Cs of Stress First AidContinuous Aid 1. Check Assess, Observe and Listen 2. Coordinate Get Help, Refer as Needed
Primary Aid 3. Cover Get to Safety ASAP 4. Calm Relax, Slow Down, Refocus
Secondary Aid 5. Connect Get Support from Others 6. Competence Restore Effectiveness 7. Confidence Restore Self-Esteem and Hope
Combat and Operational Stress First AidCOSFA
Actions of COSFA
Reduce Anxiety, Distress, Arousal
Assess Current Status
Ensure Safety
Correct Negative Self-Talk, Normalize Reactions
Facilitate Social Connectedness
Foster Short & Long Term Resilience
Provide Resources, Refer as Needed
Augment & Promote Repair of Support Structures
Reacting Injured
Where COSFA Falls on the Stress Continuum
Promotes a Sense of Safety Promotes Calming Promotes Connectedness
COSFA VIDEO
COSFA Scenario
HM3 Banks is asked to escort the body of one of the Marines to Mortuary Affairs. He is
overcome with grief at the loss of his friend. He doesn’t know that this Mortuary Affairs unit
has been processing remains for several months without a break, during a time of very heavy
casualties. The Marine that Banks escorts MA is sent there prematurely. Banks and the
Marines of MA learn this when the medical officer who comes to officially pronounce the
Marine deceased informs them that his heart is still beating. The group – now including the
young corpsman – rallies around the seriously injured Marine, desperately hoping that he will
survive, despite the medical officer’s assessment that he will not. When the Marine’s heart
finally stops beating, the group is devastated. HM3 Banks is particularly affected, which
becomes obvious when he returns to his company. He is angry, irritable and experiences
frequent belligerent outbursts around his comrades and leadership. When confronted by
superiors, he becomes sullen and withdrawn, talking to almost no one for weeks.
Why the Five Core Leader Functions?
*The Five Core OSC Leader Functions were developed to reinforce a leader’s commitment to Sailors, families and overall command health
TWO C/OSCOBJECTIVES
MAINTAIN INDIVIDUAL
HEALTH & WELL-BEING
PRESERVEFORCE
READINESS
Five Core Leader FunctionsStrengthen• Leadership that is Firm, Fair, a Source of
Courage, Communicates Plans and Listens
• Expose to Tough, Realistic Training
• Foster Unit Cohesion
• Hardiness
• Remove Unnecessary Stressors
• Ensure Adequate Sleep and Rest
• Conduct After-Action Review (AAR) in Small Groups
Identify• Know Crew Stress Load
• Recognize Reactions, Injuries and Illness
Treat• Self
• Buddy Aid (Peers)
• Chain of Command
• Chaplain
• Medical
Reintegrate• Keep with Unit if at all Possible
• Expect Return to Full Duty
• Don’t Allow Retribution or Harassment
• Communicate with Treating Professionals (Both Ways)
Mitigate
Five Core Leader Scenario
HN Robertson recently returned from deployment with a Marine unit and was
assigned to an inpatient nursing unit at a large MTF. ENS Graves, his charge nurse,
began to assign HN Robertson patient care tasks, such as emptying bed pans,
changing beds and helping pass out patient food trays. HN thought these tasks were
menial and he began to get agitated and angry. He was adversarial in his interactions
with not only his charge nurse, but all his co-workers. He started telling everyone that
his life was over, he didn’t trust anyone, he should have died instead of several of his
Marines and that his girlfriend broke up with him. He also said he bought a car even
though he cannot afford the upkeep. He began to withdraw from his co-workers.
Resilient Caregivers• Resilience: The ability to overcome, adapt, grow and function
competently in the face of adversity and stressful situations
• Promote self- and buddy-care
• Associate with maintaining a balanced and healthy lifestyle
• Not a fixed state, can be strengthened and taught
• Less likely to experience burnout
• Less likely to experience compassion fatigue
• Maintain high-quality ethical practice
Values
• Foundation of individual and organizational resilience
• Foundation of individual and organizational guiding principles
• Life compass to help one navigate the storms and stay on course
Low Resilience High
Stress
High
Low
Leader effort
Individual effort
Optimal functioningMild distr
essModerate distr
essSevere distr
ess
Resilience Continuum
Sailor 1
Sailor 2
Factors That Contribute To Resilience
Behavior Control
Control and Confidence
Optimism
Positive Coping
Flexible Thinking
Values
Resilience
Awareness
Thoughts
Behavior Feelings
Awareness
• Interrelationship-among thoughts, feelings and behavior • Interact-feedback loop which can go
in both directions • Awareness-Key element, thoughts, feelings and behaviors
A-B-C Model
A = “Activating Event” is a life experience that has the potential to affect one in a particular manner
B = “Belief” is the interpretation or appraisal that one makes in response to
“A”
C = “Consequence” is the feelings and behaviors as a result of “B”
A B C
Flexible Thinking
• Ability to consider other alternatives
• Essential component of resilience
• Refrain from rigid beliefs
• Three flexible thinking skills:
– Positive reframing
– Disputing unhelpful thought patterns
– Meaning-making
Optimism
• Positive-thoughts, beliefs, attitudes, emotions and expectations
regarding life and being flexible about change
• Hope and positive expectations-when under periods of stress
• Sense of humor-and recognizing that difficult situations are temporary
• Identifying-“silver” lining of unfortunate or stressful situations
Resilience
--Henry Ward Beecher
‘‘’’
A person without a sense of humor
is like a wagon without springs.
It’s jolted by every pebble on the road.
Increasing Provider Resilience• Leaders – Teach, inspire, focus, instill confidence, exhibit
model ethical and moral behavior, communicate effectively, provide regular supervision
• Unit Cohesion – Mutual and supportive trust, important protective factor
• Caregiver Buddy-care– Encourage, support, watch for changes, ask hard questions
• Caregivers Self-care – Know self, know environment, monitor stress, know protective factors, monitor behavior, monitor physical, know resources
Compassion Satisfaction & Growth
• Chosen field can be very rewarding and self-fulfilling
• Scope of practice can be stretched
• Increased autonomy and responsibility
• Treatment allows for growth after trauma
CgOSC TEAM RESPONSIBILITIES• Teams: Master trained leader & co-leader, trained team
members. Adequate size to meet training & support needs
• Conduct CgOSC trainings & awareness briefs
• Provide referral information for healthcare professionals
• Execute ongoing caregiver stress related command assessments
• Provide command consultation, evaluation & staff support following stress-related work center event
• Align with SPRINT Team, establish referral procedures
QUESTIONS?
Bart Jarvis, PhDHeidi Kraft, PhD
Monique Beauchamp, MFT
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