Outline: Psychosocial aspects of stress management/compassion fatigue

in the health care workplace. Elizabeth A. Pector, M.D.

I.  Four-step model to manage stress

  1. Claim it: all organisms have stress. Selye: stress response, stressors
  2. Name it
  3. ABC’s of personal needs
  4. TWERPS: Tasks-Time,Worries, Environment-Expectations-Events, Roles-Responsibilities, People, Situations (the rest combined)
  5. Reframe it (III.)
  6. Tame it (IV.)

II.  Specifics of Job Stress

  1. Job stress model
  2. Definitions & signs: Burnout and compassion fatigue
  3. Burnout
  4. Withdrawal, emotional exhaustion, low effectiveness
  5. 6 elements: Overload, Lack of control, Little reward, Unfairness, Value conflict, Lost sense of community
  6. Gradual loss of idealism, energy, purpose
  7. Related to unsupportive work environment
  8. Compassion fatigue= secondary traumatic stress, “cost of caring”
  9. Exposure to client’s trauma, preoccupation with it
  10. Less able to show empathy
  11. Symptoms like post-traumatic stress disorder (see chart p. 2)
  12. Gradual or rapid, depending on amount & type of trauma
  13. Related to client’s traumatic experiences
  14. General workplace and worker factors that contribute to job stress
  15. Occupation-specific stressors in health care workplace & workers

III.  Reframe it: Looking at stress in a new way

  1. Worker factors that decrease risk
  2. Hardiness: commitment, control, challenge
  3. Coping styles & strategies: adaptive, maladaptive
  4. Hardiness, attitude, adjusting expectations, humor

IV.  Tame it: Coping with stress

  1. Prepare for the expected & the unexpected
  2. Self-care:“Balance PIES”
  3. Balance Work/Life
  4. Personal
  5. Intellectual
  6. Emotional
  7. Spiritual
  8. Dare to Dream, Decide & Act: stages of change.
  9. Share burdens that are overwhelming
  10. Cognitive behavioral therapy face-to-face
  11. E-therapy for anxiety & stress
  12. Face-to-face support groups in & outside work
  13. Online support groups: pros & cons
  14. Compassion fatigue: trauma-focused CBT, relaxation, EMDR.
  15. Be aware: Journaling, mindfulness, ongoing review of coping skills.

V.  Alternative medicine strategies for self-care: evidence for effectiveness.

  1. Includes: Music, yoga, Meditation/relaxation strategies, biofeedback.

VI.  Communication strategies: interpersonal and corporate

  1. Characteristics of effective teams
  2. Discussions after crisis; mutual respect and forgiveness.


Books, websites, and scholarly articles on stress & burnout:

Books:

1.  Figley, Charles R, Ed. Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel, 1995.

2.  Figley, Charles R, Ed. Treating Compassion Fatigue. New York: Brunner/Mazel, 2002.

3.  Kabat-Zinn, Jon. Wherever You Go There You Are: Mindfulness meditation in everyday life. New York: Hyperion, 1994.

4.  Leiter, Michael P. and Maslach, Christina. Banishing burnout: Six strategies for improving your relationship with work. San Francisco, CA: Jossey-Bass, 2005.

5.  Maddi, Salvatore R. and Deborah M. Kohshaba. Resilience at Work: How To Succeed No Matter What Life Throws At You. New York: Amacom Books, 2005.

6.  Maslach, Christina and Leiter, Michael P. How organizations cause personal stress and what to do about it. San Francisco, CA: Jossey-Bass, 1997.

Alternative medicine: Mind-body practices http://nccam.nih.gov/health/backgrounds/mindbody.htm

Meditation: http://nccam.nih.gov/health/meditation/overview.htm

Biofeedback: bcia.org, Aapb.org, isnr.org

Compassion fatigue

http://www.ace-network.com/cfspotlight.htm

friedsocialworker.com

synspectrum.com/healself.html

Counseling, psychology (general)

psychcentral.com

apa.org

EMDR: emdr.org

Hardiness/Resilience

http://www.psychologymatters.org/hardiness.html, hardinessinstitute.org

http://psychcentral.com/lib/2007/what-is-resilience/

Humor

http://www.jesthealth.com/arthmrskills.html#anchor8109474

aath.org

humormatters.com

Online counseling

Metanoia.org/imhs (an older view by an e-therapy client.)

Ismho.org, http://www.ismho.org/suggestions.html suggestions for clients re: therapy online.

Onlineclinics.com

Peer support (including online)

http://www.ciap.health.nsw.gov.au/hospolic/stvincents/1995/a06.html

synspectrum.com/support.html

http://mentalhelp.net/selfhelp/selfhelp.php?id=863

Relaxation exercises

allaboutdepression.com/relax/index.html (free, choice of techniques, no music)

healingchronicpain.org/content/relax/default.asp From Beth Israel. Guided Imagery. Choose type of imagery, male, female.

relax-online.com/imageryonline.htm (music, imagery, mind-body (progressive muscle) relaxation, breathing)

e-help.com/free_e-z_load_big_screen_relaxation_videos_online.htm

learningmeditation.com

http://www.learningmeditation.com/reduc1.htm

Healthjourneys.com: Free 15-min. guided imagery audio

Wilddivine.com Healing Rhythms: biofeedback hardware & sensors, $299.00. Andrew Weil demo wilddivine.com/content/HR_Demo1B_WD_QT384K.mov

Stress at work

Stress. http://www.osha.gov/SLTC/etools/hospital/hazards/stress/stress.html

Stress at Work. NIOSH Publ. 99-101. http://www.cdc.gov/niosh/stresswk.html

Coping with disaster or traumatic event: http://www.bt.cdc.gov/mentalhealth/.

Stress in organizational settings. http://www.cdc.gov/niosh/87-111.html

NIOSH/Health care worker guidelines http://www.cdc.gov/niosh/hcwold5g.html

NIOSH safety & health for health care workers: http://www.cdc.gov/niosh/topics/healthcare/

JCAHO on workplace violence, recognizing & managing angry client http://dev.jcrinc.us/12490/

Journal articles:

1.  Aasa U, Brulin C, Angquist KA, Barnekow-Bergkvist M. Work-related psychosocial factors, worry about work conditions and health complaints among female and male ambulance personnel. Scand J Caring Sci. 2005 Sep;19(3):251-8.

2.  Antai-Otong D. Creative stress management techniques for self-renewal. Dermatol Nurs 2001 Feb;13(1):31-2, 35-9.

3.  Barak A, et al. A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions. J Technol and Hum Serv, in press, 2007.

4.  Beckering R, Brunner R. The lab shortage crisis: a practical approach. MLO-Med Lab Obs 2003 Jun;35(6):48-50.

5.  Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2005, issue 2.

6.  Boscarino JA, Figley CR, Adams RE. Compassion fatigue following the September 11 terrorist attacks: a study of secondary trauma among New York City social workers. Int J Emerg Ment Health. 2004 Spring;6(2):57-66.

7.  Boudreaux E, Mandry C. The effects of stressors on emergency medical technicians (Part II): A critical review of the literature, and a call for further research. Prehosp Disaster Med. 1996 Oct-Dec;11(4):302-7; discussion 307-8.

8.  Boudreaux E, Mandy C. Sources of stress among emergency medical technicians (Part I): What does the research say? Prehosp Disaster Med. 1996 Oct-Dec;11(4):296-301.

9.  Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA 2007 Oct 10;298(14):1685-7.

10.  Demmer C. Burnout: the health care worker as survivor. AIDS Read 2004;14(10):522-537.

11.  Desselle SP, Holmes ER. Structural model of certified pharmacy technicians' job satisfaction. J Am Pharm Assoc 2007 Jan-Feb;47(1):58-72.

12.  Dowie R, Stoykova B, Desai M. Assessing the wellbeing of cytoscreeners: experience in two NHS cytology laboratories. Cytopathology. 2006 Dec;17(6):366-73.

13.  Eysenbach G, Powell J, Englesakis M, Rizo C, Stern A. Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions. BMJ 2004 May 15;328(7449):1166.

14.  Felton JS. Burnout as a clinical entity: its importance in healthcare workers. Occup Med 1998;48(4):237-50. (discusses different occupations within health care).

15.  Gaither CA, Nadkarni A, Mott DA, Schommer JC, Doucette WR, Kreling DH, Pedersen CA. Should I stay or should I go? The influence of individual and organizational factors on pharmacists' future work plans. J Am Pharm Assoc (2003). 2007 Mar-Apr;47(2):165-73.

16.  Heuer L, Bengiamin M, Downey VW, Imler NJ. Neonatal intensive care nurse stressors: an American study. British J of Nursing, 1996;5(18):1126-1130.

17.  Jonsson A, Segesten K, Mattsson B. Post-traumatic stress among Swedish ambulance personnel. Emerg Med J. 2003 Jan;20(1):79-84.

18.  Judkins S, Furlow L. Creating a hardy work environment: can organizational policies help? Texas J of Rural Health 2003;21(4):11-17.

19.  Lafer, Gordon et al. Listening to Nurses: Dissatisfaction and Burnout on the Job. In : Solving the Nursing Shortage, AFSCME. Accessed at: http://www.afscme.org/publications/2208.cfm, 10/28/07.

20.  Lahad M. Darkness Over the Abyss: Supervising crisis intervention teams following disaster. Traumatology 2000 6(4):273-293.

21.  Lapane KL, Hughes CM. Baseline Job Satisfaction And Stress Among Pharmacists And Pharmacy Technicians Participating In The Fleetwood Phase III Study. Consultant Pharmacist 2004 Nov;19(11):1029-1037.

22.  Maher L. Careers in the lab: an open door or a shut case? MLO- Med Lab Obs 1996 Apr;28(4):34-40.

23.  Maher L. Is the door half open or half closed on the laboratory’s future—survey of laboratorians and pathologists MLO- Med Lab Obs 1996 Jun;28(6):60-3.

24.  Marine A, Ruotsalainen J, Serra C, Verbeek J. Preventing occupational stress in healthcare workers. Cochrane Reviews, October 2006. Abstract accessed at: http://www.cochrane.org/reviews/en/ab002892.html

25.  Martin BG. Burnout in the lab: symptoms, stages, strategies. Medical Laboratory Observer, 1986.

26.  Martin RA. Sense of humor and physical health: theoretical issues, recent findings, and future directions. Humor 2004;17(1/2):1-19.

27.  McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs. 2003 Dec;44(6):633-42. accessed at: http://www.journalofadvancednursing.com/docs/0309-2402.2003.02853.x.pdf.

28.  Mott DA, Doucette WR, Gaither CA, Pedersen CA, Schommer JC. Pharmacists' attitudes toward worklife: results from a national survey of pharmacists. J Am Pharm Assoc (2003). 2004 May-Jun;44(3):326-36.

29.  Murphy LR. Stress management in work settings: a critical review of the health effects. Am J Health Promot. 1996 Nov-Dec;11(2):112-35.

30.  Oates RK, Oates P. Stress and mental health in neonatal intensive care units. Arch Dis Child 1995;72:F107-F110.Pector EA. Internet health support groups: their uses, formats, benefits, risks, facilitation, and research approaches. Presented December 5, 2003 at MedNet 2003, Geneva, Switzerland.

31.  Pector EA. How bereaved multiple-birth parents cope with hospitalization, homecoming, disposition for deceased, and attachment to survivors. J Perinatol 2004;24(11):714-22.

32.  Pector EA. Professional burnout: detection, prevention, and coping. The Clergy Journal 2005;81(9):19-20.

33.  Pector EA. Views of bereaved multiple-birth parents on life support decisions, the dying process, and discussions surrounding death. J Perinatol 2004;24(1):4-10.

34.  Reddick, Catlin & Jellinek, Crisis within Crisis: Recommendations for Defining, Preventing, and Coping with Stressors in the NICU, J. Clinical Ethics, Fall 2001; 12(3):254-65.

35.  Reineck C, Furino A. Nursing career fulfillment: statistics and statements from registered nurses. Nurs Econ 2005;23(1):25-30.

36.  Reiner B, Siegel E, Carrino JA, McElveny C. SCAR Radiologic Technologist Survey: analysis of the impact of digital technologies on productivity. J Digit Imaging. 2002 Sep;15(3):132-40. Epub 2002 Dec 17.

37.  Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Reviews 2000, Issue 1.

38.  Siebert DC. Personal and occupational factors in burnout among practicing social workers: implications for researchers, practitioners,and managers. J Soc Serv Res 2005;32(2):25-44.

39.  Smith, M. K. 'Bruce W. Tuckman - forming, storming, norming and performing in groups, the encyclopaedia of informal education, www.infed.org/thinkers/tuckman.htm 2005. Last updated: 10/23/07.

40.  Spickard A, Gabbard G, Christensen JF. Mid-career burnout in generalist and specialist physicians: definitions, risk factors and prevention. JAMA 2002;288(12):1447-50.

41.  van der Klink JJ, Blonk RW, Schene AH, van Dijk FJ. The benefits of interventions for work-related stress. Am J Public Health. 2001 Feb;91(2):270-6. Accessed at: http://www.ajph.org/cgi/reprint/91/2/270.

42.  van der Ploeg E, Kleber RJ. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med. 2003 Jun;60 Suppl 1:i40-6.

43.  Wagner SL. Emergency response service personnel and the critical incident stress debriefing debate. Int J Emerg Ment Health. 2005 Winter;7(1):33-41.

Self-assessment tests: These are NOT meant for formal psychological or psychiatric diagnosis. They may help you reflect on how you are currently dealing with work stress, and may help you either alone or in consultation with a counselor or coach determine how to better understand and cope with your stress. Dr.Pector.

1. Brief COPE

Reference: Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the Brief COPE.International Journal of Behavioral Medicine, 4, 92-100.

Downloaded & modified from: http://www.psy.miami.edu/faculty/ccarver/sclBrCOPE.html.

These items deal with ways you've been coping with work stress in your life. There are many ways to try to deal with problems. These items ask what you've been doing to cope with work stress. Obviously, different people deal with things in different ways, but I'm interested in how you've tried to deal with it. Each item says something about a particular way of coping. I want to know to what extent you've been doing what the item says. How much or how frequently. Don't answer on the basis of whether it seems to be working or not—just whether or not you're doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true FOR YOU as you can.

1 = I haven't been doing this at all
2 = I've been doing this a little bit
3 = I've been doing this a medium amount
4 = I've been doing this a lot

1. I've been turning to work or other activities to take my mind off things.
2. I've been concentrating my efforts on doing something about the situation I'm in.
3. I've been saying to myself "this isn't real."
4. I've been using alcohol or other drugs to make myself feel better.
5. I've been getting emotional support from others.
6. I've been giving up trying to deal with it.
7. I've been taking action to try to make the situation better.
8. I've been refusing to believe that it has happened.
9. I've been saying things to let my unpleasant feelings escape.
10. I’ve been getting help and advice from other people.
11. I've been using alcohol or other drugs to help me get through it.
12. I've been trying to see it in a different light, to make it seem more positive.
13. I’ve been criticizing myself.
14. I've been trying to come up with a strategy about what to do.
15. I've been getting comfort and understanding from someone.
16. I've been giving up the attempt to cope.
17. I've been looking for something good in what is happening.
18. I've been making jokes about it.
19. I've been doing something to think about it less, such as going to movies,
watching TV, reading, daydreaming, sleeping, or shopping.
20. I've been accepting the reality of the fact that it has happened.
21. I've been expressing my negative feelings.
22. I've been trying to find comfort in my religion or spiritual beliefs.
23. I’ve been trying to get advice or help from other people about what to do.
24. I've been learning to live with it.
25. I've been thinking hard about what steps to take.
26. I’ve been blaming myself for things that happened.
27. I've been praying or meditating.
28. I've been making fun of the situation.

Scales are computed as follows (with no reversals of coding):

Self-distraction, items 1 and 19
Active coping, items 2 and 7
Denial, items 3 and 8
Substance use, items 4 and 11
Use of emotional support, items 5 and 15
Use of instrumental support, items 10 and 23
Behavioral disengagement, items 6 and 16
Venting, items 9 and 21
Positive reframing, items 12 and 17
Planning, items 14 and 25
Humor, items 18 and 28
Acceptance, items 20 and 24
Religion, items 22 and 27
Self-blame, items 13 and 26


2. Burnout/Compassion fatigue

Copyright Information

© B. Hudnall Stamm, 1997-2005. Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales, R-IV (ProQOL). http://www.isu.edu/~bhstamm. This test may be freely copied as long as (a) author is credited, (b) no changes are made other than those authorized below, and (c) it is not sold. You may substitute the appropriate target group for [helper] if that is not the best term. For example, if you are working with teachers, replace [helper] with teacher. Word changes may be made to any word in italicized square brackets to make the measure read more smoothly for a particular target group.