4.2 (4.16) burnout, compassion fatigue, and moral distress in PC Flashcards
Palliative care providers can face personal, emotional, organizational challenges in the workplace. List three syndromes that arise from stress and limited support in the workplace and describe what causes them
burnout - results from stresses that arise form clinician’s interactions with the work environment
compassion fatigue - evolves specifically from the relationship between the clinician and patient
moral distress is related to situations where clinicians are asked to carry out acts that run contrary to their moral compass
Burnout is a well recognized phenomenon in health care providers. What are three core features of burnout?
emotional exhaustion - losing enthusiasm for work
depersonalization - treating people as if they were objects
low personal accomplishment - sense that work is no longer meaningful
List 3 factors needed for job engagement ( = energy, involvement, efficacy in the workplace)
- Feeling professionally competent and able to cope with challenges
- Sustainable workload with sense of choice/control
- Perceiving appropriate recognition/award
- Supportive work environment
- Being treated fairly
- Strong appreciation of the meaning and value of one’s work
Different types of burnout have been identified. What are the three types?
frenetic - over invested and works extremely hard (to the sacrifice of other personal needs) and is frusterated and distressed by the lack of proportionate satisfaction: success, reward, appreciation
underchallenged - indifferent as a result of insignificant challenge, stimulation, or meaning from work
worn out - neglectful as a result of being overwhelmed by too much work stress and lack of proportionate satisfaction, success, reward, appreciation for the stresses endured
List six symptoms of burnout that might be seen in an individual
Box 4.2.1
Overwhelming physical, emotional exhaustion
feeling of cynicism and detachment from job
sense of ineffectiveness and lack of accomplishment
avoidance of emotionally difficult clinical situations
irritability and hypervigilence
Interpersonal conflicts: overidentification or over involvement
perfectionism and rigidity
poor judgment: professional and personal boundary violations
social withdrawal
numbness and detachment
difficulty in concentrating
questioning the meaning of life
questioning prior religious beliefs: sleep problems, intrusive thoughts, and nightmares
addictive behaviours
frequent illnessness: headaches, GI disturbances, immune system impairment
List three indicators of burnout in a team
low morale
high job turnover
impaired job performance (decreased empathy, increased absenteeism)
List six factors that can contribute to burnout in medical staff
workload
control (and training) - when clinicians are expected to take responsibility with inadequate training they may experience extreme lack of control
interprofessional and team issues
values - evidence demonstrating that degree of congruence between personal values and values central to work environment predict for feelings of energy, involvement, and efficacy which are essential for job engagement
reward - limited or inadequate financial rewards
emotion-work variables - feelings of grief due to constant death
extrinsic factors - personal sources of pressure outside of work environment
personality factors - overinvested, highly motivated health professionals are at greater risk for development of burnout
List four indicators of a poorly functioning interdisciplinary team which can contribute to burnout
lack of collaborative practice among professionals
strong hierarchical characteristics
lack of shared philosophy of care
stifled expression of concerns
strong professional territoriality
List three domains that are affected by burnout and provide an example of each:
- clinicians and their families
- decreased empathy/compassion
- depression/suicide, substance use, intent to leave practice
-lack of professionalism - patients
- alters patient-physician relationship
- affects patient trust/confidence in MD/team - health care setting
- increased risk medical errors
List six factors that are protective against burnout
attitudes and values - clinicians who identify with the attitudes and values in PC; recognize need for flexibility and compromise
good team work
personality factors - high emotional intelligence, conscientiousness
resilience and coherence of one’s life
control and training (sense of control)
use of wellness strategies
spirituality and meaning
List four personal strategies to manage burnout
- Adequate sleep
- Daily relaxation techniques
- Non-work related activities
- Develop personal relationships
- Personal time for reflection/grief
- Self-awareness techniques (i.e. reflective writing)
- Rely on psychotherapy / spiritual care
- Attend to spiritual needs
List 4 professional strategies to manage burnout
- Remember, you don’t own the problem
- Effective conflict management
- Communication skills training
- Familiarity with established guidelines/standards of practice
- Engage in peer consultation
- Develop assertiveness skills
- Set good boundaries and maintain sustainable workload
- Diversify workload
- Continuing educational activities
List four organizational strategies to manage burnout
- Adequate resources for the job
- Ensure schedules accommodate work-life balance
- Comfortable physical settings for breaks and meetings
- Encourage and support choice and control
- Appropriate reward and recognition
- Develop a supportive work community
- Adequate supervision and mentoring
- Provide space for personal items anchoring clinicians to lives outside of work
- Atmosphere of respect
- Acknowledge that compassion fatigue is an expected occupational hazard
- Develop team with ethos of collaborative practice
- Regularly discuss and debrief challenging cases
- Mindfulness based stress reduction for team
- Meaning centred intervention for team
Describe the relationship between compassion fatigue and burnout
(*Compassion fatigue comes from effort to maintain continuous compassion for persons in crisis)
while compassion fatigue may be one of the factors that contribute to burnout, one can have compassion fatigue whilst at the same time maintaining engagement and enthusiasm for one’s work with no sign of burnout
What are the three major domains that can be impacted by compassion fatigue
interpersonal - withdrawal from larger team, withdrawal from personal relationships, becoming easily irritated with others, detachment from emotional situations, difficulty trusting others
psychological - strong emotions, intrusive throughs, numb or frozen, avoiding patient/family, somatic complaints, anxiety/agitation, compulsive or addictive behaviour
cognitive - mistrust of others, increased personal vulnerability or lack of safety, increased cynicism, increased or decreased sense of power or control, belief others are not competent to handle problem
see box 4.2.3.
List four psychological impacts of compassion fatigue
strong emotions - sadness, anger, guilt
intrusive thoughts or images/nightmares
feeling number or frozen
avoiding the patient /family/situation
Somatic complaints
anxiety or agitation
compulsive or addictive behaviours
feeling isolated or personally responsible with no back up
inability to make self protective measures leading to maladaptive or harmful behaviours such as overworking, difficulty in decision making and loss of sensitivity to one’s own needs
List four cognitive impacts of compassion fatigue
mistrust of others
increased personal vulnerability or lack of safety
belief that others are not competent enough to handle problem
increased or decreased sense of power or control
increased cynicism
increased sense of personal responsibility or blame
belief that others do not understand the work that you do
List four interpersonal impacts of compassion fatigue
withdrawal from the larger team
withdrawal from personal relationships
difficulty trusting others personally and professionally
over-identifying with the distress of others leading to skewed boundaries of the relationship
detachment from emotional situations or experiences
becoming easily irritated with others
compassion fatigue can lead to three well identified syndromes. What are they?
Splitting - good-bad polarization (patients or team)
so-called saviour syndrome - avoid tragedy by trying to save patients
detachment - clinicians withdraw as emotional intensity increases
List four factors that mitigate against compassion fatigue
- exquisite empathy
- resilience and coherence
(compassion satisfaction, post-traumatic growth) - grieving strategies
debriefing, bereavement follow up - mindfulness strategies
- wellness strategies
List four external factors that may contribute to a sense of moral distress
power imbalances between members of health care team
patient or family preferences
poor communication between team members
pressure to reduce costs
fear of legal action
lack of administrative support
hospital policies that conflict with patient needs
List three sources of moral distress in PC. Give an example of each
clinical decisions - ie. continued life support even if not in best interest of patient
communication issues - inadequate info about EOL care between providers, patients, families
resources - when interests of organization outweigh interests of particular patient because of limited resources or staffing issues
lack fo staff time - distress caused by needing to devote increased time to administrative tasks at the expense of patient care
rules and regulations - conflict between regulations and what the clinician regards as best for the patient
List 3 consequences of experiencing moral distress in the workplace. What is moral residue?
produces feelings frustration, anger, anxiety
leads to nightmares, headaches, depression
contributing factor for burnout
moral distress and the feeling that one has seriously compromised oneself or allowed oneself to be compromised tend to linger and can impact self worth - moral residue
List three organizational approaches to the management of moral distress
provide forum for discussing ethically troubling situations
development of institutional /departmental culture of moral sensibility and commitment
open and iterative approach to moral conflicts
development of ethics infrastructure including availability of ethics consultation
Historic strategies for preventing burnout, compassion fatigue and moral distress included the establishment of professional boundaries and self-care strategies outside the work place. A. What is the issue with these strategies in isolation? B. What newer strategies are recommended?
A. Lead to emotional detachment by clinician and less job satisfaction, less patient centred care, less satisfied patients
B. developing greater mindfullness and self awareness
What are the four cardinal skills of self awareness practices?
ability to notice and observe sensations, thoughts, and feelings even though they may be unpleasant
ability to lower one’s tendency to respond reactively to emotionally charged experiences
An enhanced ability to react with awareness and intension rather than being on reactive autopilot
Focussing on experience, not labels or judgements we apply to them (feeling an emotion rather than wondering if it is okay to feel the emotion)
What are the four qualities of exemplary clinicians?
attentiveness - capacity to observe without making judgments
critical curiosity - refers to the ability to open up possibilities rather than premature closure and discarding new info/insights
informed flexibility - ability to adopt fresh perspective or consider more than one perspective simultaneously
presence - involves being there physically, mentally and emotionally for patients
you are at a symposium on self care in the workplace. A medical trainee asks you how they can improve self care on a day to day basis at work. What are four examples you might be able to provide of workplace strategies for self care?
Box 4.2.4
- As you walk at work, attend to contact between feet/ground.
- Set alarm for midday each day. Use this as a prompt to perform some simple act of centering
- Reward yourself after the completion of a task, i.e. coffee break.
- Call a few min ‘time out’ to deal with emotional flooding after traumatic event
- Stop at a window in your workplace & give attn to nature
- Take half a minute of silence or take turns to choose and read a poem at the beginning of weekly interdisciplinary team meetings.
- Before going into next patient’s room, pause/attn to the sensation of your breathing for two to five breaths.
8.Take a snack before the end of clinic to prevent neuroglycopenia.
9.Stay connected to the outside world during the day, i.e. check in with loved ones.
- Multitask self-care, for example, dictate or meditate while using office treadmill
- Use the suggested 20 seconds of hand washing to pay attention to water on your skin; acknowledge to yourself ‘I am worthy of my own time’; or repeat a favourite line from a poem or prayer; or sing yourself ‘Happy Birthday!’
- Don’t be afraid to ask the question, ‘Is it time for a break?’
- Deliberately make connections during the day with colleagues/patients, i.e. humour
- Keep a notebook and write ‘field notes’ on traumatic or meaningful encounters and events; share at team meetings
- Deliberately develop a ‘role-shedding ritual’ at the end of the day. i.e. pay attention to putting away stethoscope/ hanging up coat; use the drive home from work deliberately (music/news etc).
List 4 aspects of palliative care practice that are improved with practicing self-reflection.
Reduces burnout and compassion fatigue
Enhances potential for job engagement
Greater empathy
Improved communication with patients and families
Improved communication with interprofessional team
