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3rd Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentation
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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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