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

Burnout

• Progressive loss of 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 disturbances• 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 accomplishment – 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

Bibilography• Vachon MLS. The stress of professional caregivers. Oxford Textbook of Palliative Medicine 3 rd 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.• 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.• Turnipseed DL Jr. Burnout among hospice nurses: an empirical assessment. Hosp J. 1987 Summer-Fall;3(2-3):105-19.• 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.• 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.• Bram PJ, Katz LF. A study of burnout in nurses working in hospice and hospital oncology settings. Oncol Nurs Forum. 1989 Jul-

Aug;16(4):555-60.• 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.• 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.• 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.• 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.• Amenta MM. Traits of hospice nurses compared with those who work in traditional settings. J Clin Psychol. 1984 Mar;40(2):414-20.• 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.• 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.