Burnout in Palliative Care Palliative Regional Rounds January 16, 2015 Craig Goldie
Overview of discussion Define burnout and compassion fatigue Review prevalence of burnout in palliative care Complete self-reflective burnout inventory Discuss local concerns about burnout and recognize areas of strength and weakness
Burnout Form of mental distress manifested in normal individuals who experience decreased work performance resulting from negative attitudes and behaviours. Stronger predictor than depression for lower satisfaction with career choice Associated with poorer health Associated with suboptimal patient care practices and medical errors. Emotional exhaustion Feeling overextended Depletion of one s emotional and physical resources Cynicism/depersonalization Negative, callous, or excessively detached responses to various aspects of the job Ineffectiveness Lack of personal accomplishment Feeling of incompetence or underachievement at work May arise from lack of resources and/or above domains
Compassion Fatigue Cost of caring for others in emotional pain Felt by some to be similar to PTSD except trauma experienced by another Secondary or vicarious traumatization Can still care/be involved but in compromised way May lead to burnout Hyperarousal Disturbed sleep, irritability Anger, hypervigilance Avoidance Not wanting to go there again Avoid thoughts, feelings, conversations associated with patient s pain and suffering Re-experiencing Intrusive thoughts/dreams Psycho- or physiological distress in response to reminders of working with the dying
Symptoms and signs of Burnout: Individual Overwhelming physical/emotional exhaustion Feelings of cynicism/detachment from job Sense of ineffectiveness and lack of accomplishment Over-identification or overinvolvement Irritability and hypervigilance Sleep problems (including nightmares) Social withdrawal Professional or personal boundary violations Poor judgement Perfectionism and rigidity Questioning the meaning of life Questioning prior religious beliefs Interpersonal conflicts Avoidance of emotionally difficult clinical situations Addictive behaviours Numbness and detachment Difficulty concentrating Frequent illness (headache, GI, immune system)
Symptoms and signs of Burnout: Team Low morale High job turnover Impaired job function (decreased empathy, increased absenteeism) Staff conflicts
Burnout prevalence Variably reported in literature Usually higher in oncology than general medicine or surgery Rates from ~20% to ~60%
Burnout prevalence Grunfeld,E. 2000.
Burnout in palliative care Studies have reported that clinicians involved in palliative care have neither more or less stress and burnout than their medical and nursing colleagues. Two international studies (UK and Japan) showed palliative specialists have less stress/burnout than oncologists.
Burnout in palliative care Swetz,K. 2009.
Burnout in palliative care Swetz,K. 2009.
Burnout in palliative care Balance between: Environmental stressors Disease, patient/family, occupational role, work environment Personal stressors Demographic, personality, social supports, previous or concurrent stressors Coping strategies Personal and environmental Age Younger caregivers perceive and report more stressors, are more prone to burnout Socioeconomic status Better financial status = better adaptive stance Family status Marriage typically protective Dependents (children/elderly parents) lead to more stress Gender / Race No differences noted Duration of work Variable sometimes unchanged, sometimes increasing with length of employment. Spirituality Religious affiliation is protective against burnout
Burnout in palliative care Major palliative care stressors: Constant exposure to death Inadequate time with dying patients Growing workload and increasing number of deaths Inadequate coping with one s own emotional response to dying patients Communication difficulties with patients/relatives Identification with or developing friends with patients Inability to live up to one s own standards Internalized responsibility to provide a good death Feelings of depression, grief, and guilt in response to loss
Burnout tool Most commonly used is Maslach Burnout Inventory (MBI) 22 questions Answers range from: Never, few times per year, once a month A few times per month, a few times per week Once a week, every day
Protective Measures Kearney,M. 2009.
Group Discussion What do we do well? What could we do better? How can we improve?
Strengths Connected, small group of palliative care providers in Kingston Reasonably good support from institutions, colleagues Teaching environment (Residents/Med Students) Patient load generally reasonable
Weaknesses No patient registry No good awareness of patient course after leaving us Not always/often notified of patient death No process for memorializing or honoring patients at CCSEO / KGH
How can we improve? Communication Support each other Recognize burnout in ourselves and our colleagues
All go here from January March
Thank you Questions / comments?
References Vachon, M. Staff stress in hospice/palliative care: a review. Palliative Medicine 1995;9;91-122 Kearney, M et al. Self-care of Physicians Caring for Patients at the End of Life. JAMA 2009; 301:11; 1155-1164 Swetz, K et al. Strategies for Avoiding Burnout in Hospice and Palliative Medicine: Peer Advice for Physicians on Achieving Longevity and Fulfillment. JPallMed 2009; 12:9; 773-777 Grunfeld et al. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. CMAJ 2000;163-2:166-169