Assessing and Managing Burnout in Hospital and Home Care Teams

1. Assessing and Managing Burnout in Hospital and Home Care Teams Serife Eti, MD Beth Israel Medical Center Mona S. Patel, DO MJHS Hospice and Palliative Care

2. According to the US Department of Health and Human Services Occupational stress has been a longstanding concern in the healthcare industry. CDC,2009

3. Physician Burn-out A recent survey showed that 1 in 2 US physicians has symptoms of burnout. This likely is rooted in the care delivery system rather than the personal characteristics of few susceptible individuals. Arch Internal Med, 2012

4. Burnout in Palliative Care The deleterious impact that terminal illness and its treatment can have on patients and their families’ quality of life has been well-documented. Caring for these patients may present both challenges and rewards for the entire health care team

5. Burnout in Hospital and Home Care Teams staff are deeply involved in people’s lives and have frequent exposure to death/dying multiple losses and high grief exposure leads to higher stress levels/feelings of guilt This is especially true in the pediatric palliative care population in which death is not expected to occur at such a young age Non specialists are more prone to burnout than palliative care specialists

6. Burnout ~ A closer look ~

7. What is Burnout First described in 1974 by Freudenberger In 1981, Maslach and Jackson defined occupational burnout syndrome as a syndrome of emotional exhaustion, depersonalization reduced personal accomplishment.

8. Burnout • Excessive prolonged stress • Feeling of overwhelm • Feeling of unable to meet constant demands

9. Job stressors excessive or high workloads, the emotional demands of dealing with sick patients and their families and with patients whose behaviors are difficult lack of staff support, uncertainty concerning treatment, conflict with other nurses, supervisors and medical staff, dealing with death and dying, management difficulties, issues involving patient care, concerns about technical knowledge and skills Kelly, J. G. & Cross, D. G. 1985. Research in Nursing and Health Podrasky, D. L. & Sexton, D. L. 1988. : Journal of Nursing Scholarship Robinson et al 2003

10. Stress versus Burnout stress is a long-standing problem for nurses irrespective of nationality, type of nursing training, area or type of clinical or non-clinical work Aiken et al., 2002b

11. Over engagement Over reactive Loss of energy Leads to anxiety Primary damage is physical Disengagement Blunted Loss of motivation, hope Leads to detachment, depression Primary damage is emotional Stress versus Burnout

12. Causes or of burnout job characteristics work demands / challenges, work relationships, employee-patient relationships, role ambiguity / conflict organizational characteristics workplace infrastructure, rewards/punishments linked to job performance, staff support personal characteristics such as age, gender, and coping skills.

13. Personal Characteristics and Burnout investigators noted that though both hospice and oncology nurse groups have high levels of self-transcendence, they also have high EE, which puts them at increased risk for burnout. Cashavelly, Oncologist, 2008

14. Stressors identified among palliative care nurses inappropriateness of medical treatment for the terminally ill patients, talking to patients about dying, lack of authority, coping with patient’s suffering. Georges et al, J of Clinical Nursing, 2002

15. Nurses who are empowered in their work are more likely to be effective. Work effectiveness includes, measures of achievement and success, respect, and co-operation in the work organization, and indicators of client satisfaction. Higher levels of job-related structural empowerment have been associated with greater psychological empowerment, lower levels of job strain, greater work satisfaction increased commitment among nurses [i] [i] Laschinger,Finegan2001b. Journal of Nursing Administration

16. Burnout was found to be significantly and negatively correlated with measures of autonomy variety facility effectiveness policy influence work sharing work relations Social support feedback Laschinger,Finegan2001b. Journal of Nursing Administration

17. Burnout was significantly and positively correlated with measures of overextension overload decision load guilt about not providing adequate service environmental pressures bureaucratic pressures administrative hassles social overextension conflicting demands Laschinger,Finegan2001b. Journal of Nursing Administration

18. Recognizing Burnout

19. Symptoms Physical: feeling tired, headaches, back pain, change in appetite and sleep habits Emotional: sense of failure, feeling helpless, trapped, detachment, loss of motivation, cynical and negative outlook, decreased satisfaction Behavioral: withdrawing, isolating from others, procrastinating, alcohol &drug use,

20. Maslach Burnout Inventory The 22 -item version MBI is a three component conceptualization of; feelings of emotional exhaustion [EE] (having no capacity left to offer psychological support to others), tendency to depersonalize others [DP] (having a negative or callous attitude toward colleagues or patients), diminished feelings of personal accomplishment[PA] (playing down or disregarding positive job performances and past achievements).

21. Preventing and ReversingBurnout

22. Preventing Burnout Cultivate Relationships Set Boundaries, priorities, education, keeping an open mind Take time out for yourself Eat/Exercise Ask for help Acknowledge your emotions Stress Reduction techniques( music, medication, journaling) Mentoring/Peer Support Group Support Promote self-awareness, create a place to retreat/unwind Explore professional and personal goals

23. Coping with Burnout Taking to peers, others Journaling Taking time off Balancing professional life with personal life Maintain a good team, promote teamwork Grieving for our patients, attending memorials David F. Giansiracusa MD, Palliative Care Update, Sustaining Our Ability to Provide Palliative Care

24. Individual/organization takes responsibility Individual counseling thru employee assistance programs Critical incident debriefings Staff support groups

25. Interventions Supportive verbal group modalities Psychodrama / play therapy / art therapy Recreational music Exercise

26. Caring for Oneself Identify ways to process intense emotions (share with another, meditate, exercise) Attend to one’s own emotions and spiritual needs Set boundaries Find; What aspects of work are most gratifying? (relationships, teaching, research, program development) How do professional demands affect us? How do we view the rewards of our work?

27. Developing Self Awareness/Coping Strategies Learn what causes you stress Learn how to recognize effects of stress in yourself Develop coping strategies and self care techniques to conquer stress Physical self care Emotional and Cognitive Self care Relational Self-Care Spiritual Self Care

28. Self Care and Self Awareness Practices in the Workplace Walking Meditation At scheduled times: 4 cleansing breaths, think of a loved one, recite poem/prayer Reward yourself after a task: coffee break Attend to nature out of a window Half minute of silence or read a poem before meeting Cleaning breaths before patient visit Keep field book/journal to write about meaning or traumatic encounters and share them Develop end of workday ritual Figure out a way to touch the patient Kearney M. et al. JAMA, 2009, 301

29. MBSR Mindfulness Based Stress Reduction training have been shown to reduce burnout or anxiety among nurses and nurses aides as well, sometimes with large reductions in burnout Shapiro SL, 2005

30. A 2009 study focusing on a nurse leader population used a brief mindfulness-based stress reduction education program which was designed to parallel the program and ideals of John Kabat-Zinn Pipe, TB et al 2009

31. Kabat-Zinn founded mindfulness meditation specifically intended to deepen capacity for attention and strengthen present-moment awareness.  

32. MBSR The study found significantly more improvement in self-reported stress symptoms relative to controls by nurse leaders, but called for additional randomized clinical trials Pipe, TB et al 2009

33. In Summary Healthcare professionals are at increased risk for professional burnout. Professional burnout is generally described as prolonged stress that impairs one’s ability to perform his or her job in demanding situations.

34. In Summary Precursors to professional burnout include, but are not limited to, Employee workload, chronic fatigue, compassion fatigue, balance between family and career, sickness absence, and loss of confidence.

35. In Summary Administrators must watch for early signs of professional burnout to improve retention and promote employee morale. To reduce professional burnout, administrators must implement strategies to reduce burnout while also promoting productivity.

36. In Summary There is a plethora of intervention modalities to reduce burnout among Health Care staff, research is lacking on systematic ways to determine which modalities are best suited for a given health care system or individual staff member

37. Care for your mind, care for your heart, the care for your patient will follow“ Jerome Stone author of Minding the Bedside: Nursing from the Heart of the Awakened Mind