stress and the professional caregiver 0.5
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First Draft version of Presentation for 11/19/2009 - KU Palliative Care Fellowship Lecture Series. Uploaded to show the evolution of creating a slide presentationTRANSCRIPT
Stress and the Professional Caregiver
Christian Sinclair, MD, FAAHPMKansas City Hospice & Palliative Care
Nov 19, 2009
Objectives
Overview
• 25% of palliative care staff report symptoms– Indicates psychiatric morbidity and burnout
• Lower than that of other specialties– Like oncology
Definitions
• Stress– Relationship between employee and work environment– Demands from the work environment exceed the employee’s ability
to cope with or control them• Burnout
– Progressive loss if idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work
– Related to our need to believe in meaningful work/life– Chronic interpersonal stressors
• Exhaustion• Cynicism/detachment• Lack of accomplishment
Signs and Symptoms of Burnout• Fatigue• Physical exhaustion• Emotional exhaustion• Headaches• GI disturances• Weight loss• Sleeplessness• Depression• Boredom• Frustration• Low morale• Job turnover• Impaired job performance (decreased empathy, increased absenteeism
• Maslach– Burnout as a psychological syndrome• Exhaustion – individual• Cynicism – relationship• Lack of accomlishment – self-eval
– Not due to an individuals disposition
• Maslach– Burnout associated with:
• 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 reources• Presence of conflict (people, roles, values
• Kumar et al - psychiatrists– Predisposing• Personality• Work cond
– Precipitating• Violence with pts• Suicidal patients• On call duties
– Perpetuating• How one perceives and responds 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
Countertransference
• Alchemical reaction between patient and caregiver at themost 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
Study 5 -age
• UK study of phsyicians - #5– Burnout associated with being under age 55– Increased job satisfaction with older age
• Emotional sensitivity increases with age-37-38• Married with children mixed results
Hardiness 42-43-44
• Sense of commitmment, control and challenge• Helps perception, interpretation, successful
handling of stressful events• Prevetns excessive arousal • Oncology docs and nurses 46
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
Genetics
• 5-HTT short alleles
Social Support
• Early identified as important• Similar to critical nurses• Buffer to stress in workplace and assoicated
with optimism• Lack of social support predicted anxiety and
psychosomatic complaints
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
Bibliography
• Vachon MLS. The stress of profesisonal caregivers. Oxford Textbook of Palliative Medicine 3rd edition (2004). p992-1004.
• Vachon MLS, Muller M. Burnout and symptoms of stress in staff working in palliative care. Oxford handbook of Psychoatry in Palliative Care (2009). p236-264.