Care for the Caregiver: Assessing and Addressing

the “Cost” of Caring 

Mary Lou O’Gorman, MDiv, BCCExecutive Director of Pastoral Care and CPE

Saint Thomas HealthNashville, Tennessee

mogorman@stthomas.org

Objectives

Describe the causes, symptoms and impact of moral distress, compassion fatigue, burnout and other sources of staff distress.

Describe the cultural, organizational, professional and personal factors that contribute to that distress.

Identify strategies and “best practices” that provide care for the caregiver. 

The Schwartz Center April 2013

Burnout suffered by More than a third of nurses

More than a quarter of physicians

Numbers are increasing

Caregivers needSupport, opportunities to share

Joys and challenges

Time for patient/family interactions

Their health and wellbeing to be valued

Continuum?

CompassionFatigue

GriefOut

Moral Distress

PTSDBurn Out

Vicarious Traumatization

Moral Distress Defined…

“…the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing.”

Alvita Nathaniel MSN, RNCSIn Nursing World, July 28, 2002

…moral distress defined

“Painful feelings and/or the psychological disequilibrium that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”

Jameton A. Nursing Practice: The Ethical Issues. NJ:Prentiss-Hall. 1984

…moral distress defined

1993 Jameton distinguished:Initial: frustration, anger and anxiety due to

Institutional obstaclesInterpersonal conflict about values

Reactive: due to failure to address initial distress

2000 Webster and Baylis included:Failure to pursue “right” course of action due to

Error in judgmentPersonal failingCircumstances beyond control

May feel cherished beliefs violated Compromised integrity

…distressBurn out

Individual or group stress related to one’s relationship with the work environment.

Feel overwhelmed.

Compassion fatigueGradual lessening, over time of ability to be compassionate.The price one pays for caring.Emotional stress experienced from exposure to the suffering of others.

…distressSecondary Traumatic Stress (STS)

Presence of Post-Traumatic Stress Disorder (PTSD) in the caregiver.Due to relationship and/or proximity.

Both STS and CF are caused by exposure to patients who have been traumatized or are suffering, not to the traumatic event itself.

Vicarious traumatization

“It's possible I am pushing through solid rockin flintlike layers, as the ore lies, alone;I am such a long way in I see no way through,and no space: everything is close to my face,and everything close to my face is stone.

I don't have much knowledge yet in grief --so this massive darkness makes me small.You be the master: make yourself fierce,

break in:then your great transforming will happen to me,and my great grief cry will happen to you.”

-Rilke

Other/Related Distress…

Grief outRepeated, sustained and often unresolved grief and loss.

JadingProcess leading to exhaustion from being overdriven to perform long, continued labor and/or severe or tedious tasks. Leaves one angry, even mean.

Continuum?

CompassionFatigue

GriefOut

Moral Distress

PTSDBurn Out

Vicarious Traumatization

Caregiving: A Moral Endeavor

PracticeFundamentally ethical

Roots of the caring professionsHotel Dieu: “House of God”

Nursing : The Finest Art. An Illustrated History

Promotion of ideal patient careRespect for personsRole as advocateSafe and best care

Caregiver-patient relationship is complexPatient focused caringSome distress is unavoidable

Constraints/Barriers

Organizational

Professional

Personal

Organizational BarriersHospitals/other settings

Biomedical focusTechnologyLack of timeFailure of team

Leadership dynamicsLack of collaborationConflict

Patient/client with sudden, critical illnessWishes unknown

Sustained proximity when others walk away

Contributing Factors

Cure orientation Technology

Death a failureDiscomfort with own mortality

Belief “doing everything” a sign of faithfulness

StaffingInsufficient

Novice staff

High patients acuity

Professional BarriersStaffing

So low, care is inadequate

Lack of time, skill

Novice staff

Multiple deaths in close succession

High patient/client acuity

Organizational changeQuality, safety

Cost-cutting: Doing more with less

Leadership dynamics

Effectiveness of teamPower imbalance

Lack of collaboration

….professionalRole and relevance questions

Limited role in decision making

Belief that decisions contradict best interests

Confusion about plan

Communication failuresIn team, between teams

Too many partners or consultants

Patient and/or family

Technological imperative/futilityDoing everything vs. the right thing

Belief “doing everything” a sign of faithfulness

Death a failureDiscomfort with own mortality

….professional

Nature of relationshipsCloseness/identification

Dynamics with patient and/or family

ConflictAssertive/aggressive patients/clients and families

Intra or interdisciplinary conflict

Outside pressures Organizational, professional, personal

Economy

Politics

Sustained proximity when others walk away

Personal

Psychological/emotional

Closeness/identification with patient/client

Boundaries

Isolation

Feelings of powerlessness or helplessness

Feelings of failure or guilt

Inability to talk about feelings

…personal

Grief and LossLack of time to process

Accumulated grief and loss

Lack of closure

Compromise of one’s standard of careInadequate staffing

Inability to meet perceived needs of patient

Lack of resources, services

Futility

Symptoms of Distress

FatigueEmotional, physical

Somatic concernsDiet, sleep, physical illness

Absenteeism

Poor or inappropriate careRecipients of care

Self

Feelings of inadequacyPersonal, professional

Feeling victimized

…symptoms of distress

Irritability, anger, insults, resentment, conflictsAnxietyFrustrationDepression Blaming othersSee self as having lost

IntegrityAuthenticity

Distancing oneselfIsolation

Friends, familyColleagues

Loss of meaningCrisis of faith

Addressing Distress…

Cause analysis

Self awareness/self monitoringLimits, issues

Address issues in real timeDebriefing

“Talk about it”

Ethical decision-making Referral

Skill-building

Grief work

…addressing distressEngage in work of “letting go”

At the bedsideFunerals, journal, phone callsSacred/holy

Story tellingSelf-care

BalanceSpiritual practiceTherapy

Find own voice/AdvocacyCourage

Develop sources of supportProfessional relationshipsSocial relationships

“Play”

Resources to Address StaffDistress

Spiritual nurture provided on a regular basis

Staff follow-up

Support Groups

CISM

Schwartz Rounds

Provide places of sanctuary

“To heal a person, one must first be a person.”

-Abraham Heschel

Healing Teams/Environments

Interdisciplinary/CollaborativeRole modelingMentoringSkill building and education

ConversationAffirmation of positiveEncouraging when negative

Flexible and creativeTrusting environment

Safe place to talk

BereavementStrong leader

Effective Organizations

Organizational ObligationsRecurring issues/systemic causes of moral distress identified and monitored

Corrective action

Adequate financial and people resourcesEthics resourcesPalliative careConflict resolutionInterdisciplinary forums to discuss complex “situations”

Mechanisms to address futile careAccountability for practice and behaviorSkill building, education, mentoringBereavement mechanism

Areas where death is frequent

Opportunities for breaks and places of “Sanctuary”

Chaplains

Needed skills to address staff distress

Are involved in clinical arenaAccessible

Part of the team

Incarnate the presence of the Source of all Hope

Ministry to care providers is part of the job description

Pastoral LeadershipAdvocates for patient’s wishes and goals

Develops and maintains strong team relationships

Possesses strong communication skills

Possesses skill in ethical decision-making and in conflict resolution

Attends and participates in significant patient/family conferences

Uses appropriate referrals to address issues

Is courageous

QUESTIONS?