4.2 (4.16) burnout, compassion fatigue, and moral distress in PC

Question 1

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

Answer 1

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

Question 2

Burnout is a well recognized phenomenon in health care providers. What are three core features of burnout?

Answer 2

emotional exhaustion - losing enthusiasm for work

depersonalization - treating people as if they were objects

low personal accomplishment - sense that work is no longer meaningful

Question 3

List 3 factors needed for job engagement ( = energy, involvement, efficacy in the workplace)

Answer 3

1. Feeling professionally competent and able to cope with challenges
2. Sustainable workload with sense of choice/control
3. Perceiving appropriate recognition/award
4. Supportive work environment
5. Being treated fairly
6. Strong appreciation of the meaning and value of one’s work

Question 4

Different types of burnout have been identified. What are the three types?

Answer 4

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

Question 5

List six symptoms of burnout that might be seen in an individual

Answer 5

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

Question 6

List three indicators of burnout in a team

Answer 6

low morale

high job turnover

impaired job performance (decreased empathy, increased absenteeism)

Question 7

List six factors that can contribute to burnout in medical staff

Answer 7

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

Question 8

List four indicators of a poorly functioning interdisciplinary team which can contribute to burnout

Answer 8

lack of collaborative practice among professionals

strong hierarchical characteristics

lack of shared philosophy of care

stifled expression of concerns

strong professional territoriality

Question 9

List three domains that are affected by burnout and provide an example of each:

Answer 9

1. clinicians and their families
   - decreased empathy/compassion
   - depression/suicide, substance use, intent to leave practice
   -lack of professionalism
2. patients
   - alters patient-physician relationship
   - affects patient trust/confidence in MD/team
3. health care setting
   - increased risk medical errors

Question 10

List six factors that are protective against burnout

Answer 10

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

Question 11

List four personal strategies to manage burnout

Answer 11

1. Adequate sleep
2. Daily relaxation techniques
3. Non-work related activities
4. Develop personal relationships
5. Personal time for reflection/grief
6. Self-awareness techniques (i.e. reflective writing)
7. Rely on psychotherapy / spiritual care
8. Attend to spiritual needs

Question 12

List 4 professional strategies to manage burnout

Answer 12

1. Remember, you don’t own the problem
2. Effective conflict management
3. Communication skills training
4. Familiarity with established guidelines/standards of practice
5. Engage in peer consultation
6. Develop assertiveness skills
7. Set good boundaries and maintain sustainable workload
8. Diversify workload
9. Continuing educational activities

Question 13

List four organizational strategies to manage burnout

Answer 13

1. Adequate resources for the job
2. Ensure schedules accommodate work-life balance
3. Comfortable physical settings for breaks and meetings
4. Encourage and support choice and control
5. Appropriate reward and recognition
6. Develop a supportive work community
7. Adequate supervision and mentoring
8. Provide space for personal items anchoring clinicians to lives outside of work
9. Atmosphere of respect
10. Acknowledge that compassion fatigue is an expected occupational hazard
11. Develop team with ethos of collaborative practice
12. Regularly discuss and debrief challenging cases
13. Mindfulness based stress reduction for team
14. Meaning centred intervention for team

Question 14

Describe the relationship between compassion fatigue and burnout

(*Compassion fatigue comes from effort to maintain continuous compassion for persons in crisis)

Answer 14

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

Question 15

What are the three major domains that can be impacted by compassion fatigue

Answer 15

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.

Question 16

List four psychological impacts of compassion fatigue

Answer 16

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

Question 17

List four cognitive impacts of compassion fatigue

Answer 17

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

Question 18

List four interpersonal impacts of compassion fatigue

Answer 18

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

Question 19

compassion fatigue can lead to three well identified syndromes. What are they?

Answer 19

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

Question 20

List four factors that mitigate against compassion fatigue

Answer 20

1. exquisite empathy
2. resilience and coherence
   (compassion satisfaction, post-traumatic growth)
3. grieving strategies
   debriefing, bereavement follow up
4. mindfulness strategies
5. wellness strategies

Question 21

List four external factors that may contribute to a sense of moral distress

Answer 21

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

Question 22

List three sources of moral distress in PC. Give an example of each

Answer 22

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

Question 23

List 3 consequences of experiencing moral distress in the workplace. What is moral residue?

Answer 23

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

Question 24

List three organizational approaches to the management of moral distress

Answer 24

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

Question 25

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?

Answer 25

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

Question 26

What are the four cardinal skills of self awareness practices?

Answer 26

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)

Question 27

What are the four qualities of exemplary clinicians?

Answer 27

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

Question 28

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?

Answer 28

Box 4.2.4

1. As you walk at work, attend to contact between feet/ground.
2. Set alarm for midday each day. Use this as a prompt to perform some simple act of centering
3. Reward yourself after the completion of a task, i.e. coffee break.
4. Call a few min ‘time out’ to deal with emotional flooding after traumatic event
5. Stop at a window in your workplace & give attn to nature
6. Take half a minute of silence or take turns to choose and read a poem at the beginning of weekly interdisciplinary team meetings.
7. 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.

10. Multitask self-care, for example, dictate or meditate while using office treadmill
11. 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!’
12. Don’t be afraid to ask the question, ‘Is it time for a break?’
13. Deliberately make connections during the day with colleagues/patients, i.e. humour
14. Keep a notebook and write ‘field notes’ on traumatic or meaningful encounters and events; share at team meetings
15. 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).

Question 29

List 4 aspects of palliative care practice that are improved with practicing self-reflection.

Answer 29

Reduces burnout and compassion fatigue
Enhances potential for job engagement
Greater empathy
Improved communication with patients and families
Improved communication with interprofessional team