Joanne Goldbort, PhD, RNBurnout, Compassion Fatigue, STSD

• General belief of “this is a happy place to work.”

• Bringing life into the world is a miraculous event, met with joy and awe

• However, there are risks and challenges

Intrapartum Setting

• Situations similar to any life altering event that occurs in an ER

• Occasions when joy is replaced with sadness

• The entire health care team and the family can be affected by distressing events

Inherent Challenges:

Emergency Birthing Situations

• Can be devastating for the woman/family

• Literature replete with reports of women who develop post-traumatic stress disorder after a traumatic birth experience

• Ayers & Pickering, 2001; Soet, Brack, & Dilorio, 2003; Beck, 2004a, 2004b; Leeds & Hargreaves, 2008.

One Woman’s Story

I really think part of it was the position, all these people in there, and the total lack of connection that there was a human being on the table going through this! It’s like, I was a body, I was a piece of meat that needed to have a procedure done to get this child out and when that was over then it’s fine, and it’s done. But to me who was going through it, nobody was talking to me. It’s not a natural position to be laid, filleted opened naked in front of all these men and people that didn’t, that really don’t even know your name.

Burnout

• Evolves when expectations of the individual and the organization are in conflict (Aycock & Boyle, 2010)

• Cumulative stress from the demands of daily life—a state of physical, emotional, & mental exhaustion (Potter, et al 2010)

• Arises when assertiveness goals are not met in the work place (Boyle, 2011)

• Associated with high work loads, unsupportive work settings, & failure to achieve personal goals (Yoder, 2010)

Symptoms of Burnout

• Physical: Rapid pulse, fatigue, hypertension, head, back or muscle aches

• Behavioral: Chemical abuse, medication errors, poor record keeping, cynicism

• Emotional: Critical of others, apathy, depression, hopelessness, irritability

• Spiritual: Doubt concerning beliefs, urgency to change job, marriage, relocation

(Aycock & Boyle, 2009)

Compassion Fatigue

• Compassion—Latin means “co-suffering” • Deep physical, emotional, & spiritual

consumption accompanied by significant emotional pain (Aycock & Boyle, 2009)

• Emerges suddenly & without warning and

includes a senses of helplessness and confusion (Potter, et al 2010)

CF-cont’

• Stems from emotional engagement & interpersonal intensity associated with witnessing tragedy within the work setting

• Occurs when rescue-caretaking strategies are not met

• Similar to Secondary Traumatic Stress Disorder (STSD)

(Boyle, 2010; Lester, 2010)

Risk Factors CF

• First Responders

• Soldiers

• Noted in caring professionals whose personal identity is closely associated with their professional role

• Inability to rescue patients

Symptoms of CF

Work Related:

•Avoidance or dread of working with certain patients; Dread going to work

•Reduced ability to feel empathy towards patients or families

•Frequent sick days

•Lack of joyfulness

•Error rate an issue

Symptoms of CF

Emotional:

•Mood swings, restlessness, anxiety

•Depression, anger, and resentment

•Poor concentration, focus & judgment

•Oversensitivities

•Memory issues(Lombardo, 2011; Douglas, 2010; Potter et al, 2010)

Symptoms of CF

Physical:

•Headaches

•Digestive problems

•Sleep disturbances

•Fatigue

•Cardiac—chest pain, palpitations

•Increase susceptibility to illness(Lombardo, 2011; Douglas, 2010)

More than one symptom must be present plus an assessment of the RN to include:

•Description/evaluation of the work setting

and working conditions

•Tendency to become overinvolved

•Usual coping strategies

•Replenishing strategies

•Openness for learning new skills (Lombardo, 2011)

Secondary Traumatic Stress Disorder(STSD)

The natural consequent behaviors and emotions resulting from knowing about a traumatizing event experience by a significant other [or] the stress resulting from helping or wanting to help a traumatized or suffering person (Figley, 1995)

STSD

• A natural consequence of caring between two people, one of whom has been initially traumatized and the other whom is affected by the first’s traumatic experiences (Figley, 1999)

• Figley redefined CF as STSD

• Symptoms nearly identical to PTSD

(Devilly, et al 2009)

STSD symptoms

• Recurrent recollections

• Distressing dreams

• Psychological distress—anxiety

• Reminders of the events

• Anger, depression, hopelessness

• Feeling on the edge

• Irritability, difficulty concentrating, and insomnia

Qualitative Phenomenological Study

• What effect, if any, does participating in and/or witnessing a traumatic birth have on the intrapartum nurse caring for the woman?

Qualitative cont’

• Nine intrapartum nurses recruited • 8 female, 1 male• Age range: 31-60 years• Mean age: 46 years• 27 stories shared• Occurred at different stages of the nurses’ career• Similar in impact regardless of the stage of their career

STSD expressed

• “And it was very traumatic for [me]. I didn’t know what to do. I was brand new. The only thing I knew was that I wasn’t supposed to have a cord in my hand. And so I started yelling for other nurses to come help me. “

STSD expressed

• “I had nightmares for several weeks after that, wondering about . . . how that could happen and what it was . . . It was very difficult from the first few weeks afterwards to come to work.”

• “But it took me years of seeing that visualization over and over and over again before I could finally move on and not continue to think about it every minute of every day. . .”

Makes you want to withdraw. Makes you not want to deal with things. I can remember how we all kept talking . . . to try to find out, ‘is there anything elsewe could have done? Could we have done anything differently? Could we have had a different outcome?’ But as a woman, as a nurse, it still makes you feel like you failed.

Unexpected Consequences

• Directly correlated to nurse retention and turnover, to patient satisfaction, and to patient safety

(Potter et al, 2010)

Remen (1996)

The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able

to walk on water without getting wet.

Interventions

Provision 5 of the ANA Code of Conduct states:

The nurse owes the same duties to self as to others.

Resilience

• The ability to cope with or recover from the impact of stress and turn it into a positive learning experience.

• Latin—”to leap back” or “to spring back” • A dynamic process that can be learned• A cyclic process of uncovering, using, and

developing the innate self, motivating life force, human spirit

(Grafton et al, 2010)

Resilience cont’

• Emotional intelligence—the ability to sense, perceive, use, understand and effectively manage emotions

• Reflective thinking• Quiet Rooms • Guided teaching• Techniques for relaxation

(Sabo, 2011)

Interventions cont’

• Work life balance—Practicing responsible selfishness—diet, exercise, journaling, meditation, counsel for marital and child issues, adequate sleep, yoga, tai-chi

Interventions cont’

Education to:•Improve communication skills•Identify personal coping strategies•Develop caring communication styles•Establish boundaries with patients and families•Reframe “difficult” interactions

(Lombardo, 2011)

Interventions cont’

• Resolve interpersonal relationship problems in the workplace

• Cope with ethical conflict & dilemmas

• Utilize meditation and mindfulness

• Attend a conference

Interventions cont’

Work setting strategies:

•On-site counseling—EAP

•Seek out a mentor

•Staff support groups—retreats

•Debriefing

•Art Therapy

•Massage

Teamwork

“

Afterwards, the nurses that were involved, I think were really effected by the situation because it was a bad outcome. And luckily I was on a unit where we could all talk together, cry together, debrief together and get through it together and it was really supportive.”

Interventions cont’

• Bereavement interventions—sympathy cards, attending funerals, memorial services

• Become involved in a project of interest

• Meet own spiritual needs

Interventions cont’

Develop Nurse Residency Program

•One year for new graduates

•Monthly meetings with focused topics and to “reflect”

•Develop critical thinking skills

•Share thoughts and feelings

•Develop effective decision making skills

For the Love of OB

• “So you have to be able to have a personal satisfaction to want to keep doing it…we love what we do.”

• “Makes you feel so insignificant. So small and humble to be a part of that, to help these people out . . . but it’s, it’s been a blessing in my life...This lady and the people I work with, are all of them, are part of what makes it work and worthwhile.”

LET’S DO IT FOR OUR MOTHERS AND FOR OUR NEWBORNS! THEY NEED US TO BE HEALTHY TOO.