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

1. Stress and Burnout in the Professional Caregiver in Hospice & Palliative Care Christian Sinclair, MD, FAAHPM Kansas City Hospice & Palliative Care

2. 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

3. 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

4. Definitions Stress Burnout Compassion fatigue Countertransference

5. 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

6. 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

7. 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

8. 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

9. Burnout Work Overload Lack of Resources

11. 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

12. How Does Burnout Start? Kumar 2005

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Resilience Not avoidance of stress But stress that allows for self-confidence thru mastery and appropriate responsibility Hardiness versus coherence

20. 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

21. Genetics 5-HTT short alleles

22. 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

23. Attachment Style 84 UK nurses Secure Preoccupied Fearful Dismissing

24. Stressful life events

25. MD comparisons Htable 16.2 Deporsonilzation associated with work overload

26. 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

27. 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

28. 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

29. 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

30. Death acuity/volume Rarely studied

31. 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

32. Bibilography Amenta 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. OncolNurs Forum. 1989 Jul-Aug;16(4):555-60. Cooper CL, Mitchell S. Nursing the Critically III and Dying. Human Relations 1990 43: 297-311 Gambles 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. 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 Jan;37(1):1-11. Kobasa SC, Maddi SR, Kahn S. Hardiness and health: a prospective study. J Pers Soc Psychol. 1982 Jan;42(1):168-77.

33. Bibilography Kumar S, Hatcher S, Huggard P. Burnout in psychiatrists: an etiological model. Int J Psychiatry Med. 2005;35(4):405-16. Mallett K, Price JH, Jurs SG, Slenker S. Relationships among burnout, death anxiety, and social support in hospice and critical care nurses. Psychol Rep. 1991 Jun;68(3 Pt 2):1347-59. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422. Papadatou D, Anagnostopoulos F, Monos D. Factors contributing to the development of burnout in oncology nursing. Br J Med Psychol. 1994 Jun;67 ( Pt 2):187-99. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Leaning MS, Snashall DC, Timothy AR. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995 Jun;71(6):1263-9. Sinclair S, Raffin S, Pereira J, Guebert N. Collective soul: the spirituality of an interdisciplinary palliative care team. Palliat Support Care. 2006 Mar;4(1):13-24. Turnipseed DL Jr. Burnout among hospice nurses: an empirical assessment. Hosp J. 1987 Summer-Fall;3(2-3):105-19. Vachon MLS. The stress of professional 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 Psychiatry in Palliative Care (2009). p236-264. Woolley H, Stein A, Forrest GC, Baum JD. Staff stress and job satisfaction at a children's hospice. Arch Dis Child. 1989 Jan;64(1):114-8.