The NHS Workforce Initiative

1. Staff stress in cancer and palliative careProfessor Robin DavidsonConsultant Clinical PsychologistHon Lecturer, Faculty of Medicine (QUB)LIVERPOOL, SUMMER 2010

2. The NHS Workforce Initiative (12,000 NHS Staff sampled) 1. Mental health of staff in NHS Trusts was substantially poorer than other public sector employees. 2. 28.5% of nurses had minor psychiatric disorders as assessed by the GHQ. 3. Palliative care particularly difficult

3. Stress League (Health)

4. What is Stress? “A stressful circumstance is one which you cannot cope successfully, or believe you cannot cope successfully, and which results in unwanted physical, mental or emotional reactions”.

5. Approaches To Stress • 1. Stress is Adaptive / Non-Adaptive Task Performance Optimum performance Arousal

6. Approaches To Stress • 1. Individual Differences • Type A / B Personalities • State / Trait Anxiety • Neurotic / Stable • Inner directiveness, self acceptance • Developmental/attachment differences • 2. External Events • Impact Of Life Events e.g. unresolved grief • Impact of Organisation Structure / Climate • Interface Between Work / Home • Type of Job • 3. Personal Interpretation • Cognitive Style/coping strategy • Learned Helplessness • Expectations/attributions • Transcendental beliefs

7. Behavioural signs of stress • Reduced concentration • Do too many things at once • Don’t finish tasks • Indecision and poor concentration • Loss of memory • TATT • Fear of outsiders • Irritability • Tend to overact • Nightmares

8. The Components of Burnout • Emotional exhaustion • wearing out, depletion of emotional resources, loss of energy, debilitation, fatigue. • Depersonalisation • - Negative, callous, excessively detached towards other people, loss of idealism, irritability. • Reduced personal accomplishment • - reduction in self-confidence, low productivity, poor morale, inability to cope.

9. Stages in Burnout • 1. Stress Arousal Stage • - Persistent irritability / Anxiety • - Insomnia • - Concentration lapses • 2. Stress Resistance Stage • - Absenteeism • - Fatigue • - Indecision • - Cynicism • - Resentful / Defiant • 3. Severe Exhaustion Stage • - Chronic depression • - Chronic stress related illness • - Self destructive thoughts

10. A) Relationships B) Tasks C) System management communication problems with managers lack of team work conflict with colleagues difficult patient groups role ambiguity role conflict low sense of autonomy inadequate resources poor physical environment old equipment work overload Job Related Stress Dimensions

11. Additional stress for palliative care and cancer staff • Accumulated loss phenomena • Ideal versus reality conflict • Incremental grief • Problems with intimacy and staff patient interface e.g. special /difficult patient, mutilation, death and dying (survivor guilt), adjustment to poor outcome.

12. Staff stress in the NI cancer centre • 120 test batteries administer to doctors, nurses, PAMs and radiographers. • Response rate 57% • Psychmetrics…..GHQ, Sources of Pressure Scale, Attitude to Work Questionaire AWQ (junior doctors and consultant versions)

13. Questionaires • GHQ-12. can be scored as a Likert scale or a dichotomous response format to assess casesness. • Sources of Pressure Scale has 7 subscales i.e. workload, patient related difficulties, organisational structure and processes, relationships and conflicts with other staff, lack of resources, professional self doubt , home/work conflicts

14. Main findings (1) • Caseness Therapeutic radiographers (42%) Consultant oncologists (33%) Nurses (16%) PAMS (11%) • Key predictors of GHQ workload professional self doubt

15. Main findings (2) • Source of stress Workload top for all groups except nurses who had lack of resources top Organisational S and P next top for radiographers Conflicts with others next top for medical staff but bottom for PAMs

16. but wait……….. Jenny Firth Cozins found the methodology employed skewed the data in sourse of stress research on cancer doctors and nurses! and Vachon warns that occasionally some studies demonstrate less burnout among palliative nurses than those working in IT and mental health.

17. Stress Inoculation • Adoption of multiple roles, e.g: - partner, parent, worker, volunteer • Social Support, e.g: - family, friends, colleagues • Personal Variables, e.g: - type B, low state anxiety, internal locus of control • Coping Strategies, e.g: - low avoidance, problem focused coping, religious faith • Organisational Strategies - Staffing policies, education programmes, support groups, confidential counselling, clear communication systems • Work Variables - Role clarity, role conflict, lack of good working conditions, appropriate workload.

18. Skills required to deal with stress • Stressor response chair • Relaxation strategies • Appropriate assertiveness • Time management - Prioritise • Positive self talk • Recovery periods • Stability zones • Support / Delegation • Regular exercise • Humour • Good diet

19. Staff Support Options • Access to professional mentor for nurses • Informal peer support groups • Quality circles that assist in the involvement in decision making and team work • An individual counselling service for those needing more in depth support • Training initiatives to increase awareness

20. References • Davidson, R (2006). Stress issues in palliative care in Stepping into Palliative Care: Relationships and Responses. Jo Cooper (Ed). Ratcliffe Medical Press Ltd. Oxford. • Davidson R (2008 ) Maintaining Mental Health. p319-332. (in) Rehabilitation in Cancer Care. Robb, K and Rankin, J (eds).Wiley-Blackwell, London.