Care for the Caregiver: Assessing and Addressing the

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Care for the Caregiver Assessing and Addressing
the Cost of Caring 

• Mary Lou OGorman, MDiv, BCC
• Executive Director of Pastoral Care and CPE
• Saint Thomas Health
• Nashville, Tennessee
• mogorman_at_stthomas.org

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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. 

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The Schwartz Center April 2013

• Burnout suffered by
• More than a third of nurses
• More than a quarter of physicians
• Numbers are increasing
• Caregivers need
• Support, opportunities to share
• Joys and challenges
• Time for patient/family interactions
• Their health and wellbeing to be valued

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Continuum?
Moral Distress
Compassion Fatigue
GriefOut
PTSD
Burn Out
Vicarious Traumatization
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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, RNCS
• In Nursing World, July 28, 2002

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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.
  NJPrentiss-Hall. 1984

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moral distress defined

• 1993 Jameton distinguished
• Initial frustration, anger and anxiety due to
• Institutional obstacles
• Interpersonal 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 judgment
• Personal failing
• Circumstances beyond control
• May feel cherished beliefs violated
• Compromised integrity

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distress

• Burn out
• Individual or group stress related to ones
  relationship with the work environment.
• Feel overwhelmed.
• Compassion fatigue
• Gradual lessening, over time of ability to be
  compassionate.
• The price one pays for caring.
• Emotional stress experienced from exposure to the
  suffering of others.

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distress

• Secondary 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

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It's possible I am pushing through solid rockin
flintlike layers, as the ore lies, aloneI 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 inthen
your great transforming will happen to me,and my
great grief cry will happen to you.
-Rilke
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Other/Related Distress

• Grief out
• Repeated, sustained and often unresolved grief
  and loss.
• Jading
• Process leading to exhaustion from being
  overdriven to perform long, continued labor
  and/or severe or tedious tasks. Leaves one angry,
  even mean.

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Continuum?
Moral Distress
Compassion Fatigue
GriefOut
PTSD
Burn Out
Vicarious Traumatization
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Caregiving A Moral Endeavor

• Practice
• Fundamentally ethical
• Roots of the caring professions
• Hotel Dieu House of God
• Nursing The Finest Art. An Illustrated History
• Promotion of ideal patient care
• Respect for persons
• Role as advocate
• Safe and best care
• Caregiver-patient relationship is complex
• Patient focused caring
• Some distress is unavoidable

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Constraints/Barriers

• Organizational
• Professional
• Personal

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Organizational Barriers

• Hospitals/other settings
• Biomedical focus
• Technology
• Lack of time
• Failure of team
• Leadership dynamics
• Lack of collaboration
• Conflict
• Patient/client with sudden, critical illness
• Wishes unknown
• Sustained proximity when others walk away

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Contributing Factors

• Cure orientation
• Technology
• Death a failure
• Discomfort with own mortality
• Belief doing everything a sign of faithfulness
• Staffing
• Insufficient
• Novice staff
• High patients acuity

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Professional Barriers

• Staffing
• So low, care is inadequate
• Lack of time, skill
• Novice staff
• Multiple deaths in close succession
• High patient/client acuity
• Organizational change
• Quality, safety
• Cost-cutting Doing more with less
• Leadership dynamics
• Effectiveness of team
• Power imbalance
• Lack of collaboration

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.professional

• Role and relevance questions
• Limited role in decision making
• Belief that decisions contradict best interests
• Confusion about plan
• Communication failures
• In team, between teams
• Too many partners or consultants
• Patient and/or family
• Technological imperative/futility
• Doing everything vs. the right thing
• Belief doing everything a sign of faithfulness
• Death a failure
• Discomfort with own mortality

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.professional

• Nature of relationships
• Closeness/identification
• Dynamics with patient and/or family
• Conflict
• Assertive/aggressive patients/clients and
  families
• Intra or interdisciplinary conflict
• Outside pressures
• Organizational, professional, personal
• Economy
• Politics
• Sustained proximity when others walk away

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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

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personal

• Grief and Loss
• Lack of time to process
• Accumulated grief and loss
• Lack of closure
• Compromise of ones standard of care
• Inadequate staffing
• Inability to meet perceived needs of patient
• Lack of resources, services
• Futility

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Symptoms of Distress

• Fatigue
• Emotional, physical
• Somatic concerns
• Diet, sleep, physical illness
• Absenteeism
• Poor or inappropriate care
• Recipients of care
• Self
• Feelings of inadequacy
• Personal, professional
• Feeling victimized

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symptoms of distress

• Irritability, anger, insults, resentment,
  conflicts
• Anxiety
• Frustration
• Depression
• Blaming others
• See self as having lost
• Integrity
• Authenticity
• Distancing oneself
• Isolation
• Friends, family
• Colleagues
• Loss of meaning
• Crisis of faith

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Addressing Distress

• Cause analysis
• Self awareness/self monitoring
• Limits, issues
• Address issues in real time
• Debriefing
• Talk about it
• Ethical decision-making
• Referral
• Skill-building
• Grief work

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addressing distress

• Engage in work of letting go
• At the bedside
• Funerals, journal, phone calls
• Sacred/holy
• Story telling
• Self-care
• Balance
• Spiritual practice
• Therapy
• Find own voice/Advocacy
• Courage
• Develop sources of support
• Professional relationships
• Social relationships
• Play

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Resources to Address StaffDistress

• Spiritual nurture provided on a regular basis
• Staff follow-up
• Support Groups
• CISM
• Schwartz Rounds
• Provide places of sanctuary

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

• -Abraham Heschel

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Healing Teams/Environments

• Interdisciplinary/Collaborative
• Role modeling
• Mentoring
• Skill building and education
• Conversation
• Affirmation of positive
• Encouraging when negative
• Flexible and creative
• Trusting environment
• Safe place to talk
• Bereavement
• Strong leader

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Effective Organizations
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Organizational Obligations

• Recurring issues/systemic causes of moral
  distress identified and monitored
• Corrective action
• Adequate financial and people resources
• Ethics resources
• Palliative care
• Conflict resolution
• Interdisciplinary forums to discuss complex
  situations
• Mechanisms to address futile care
• Accountability for practice and behavior
• Skill building, education, mentoring
• Bereavement mechanism
• Areas where death is frequent
• Opportunities for breaks and places of Sanctuary

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Chaplains

• Needed skills to address staff distress
• Are involved in clinical arena
• Accessible
• Part of the team
• Incarnate the presence of the Source of all Hope
• Ministry to care providers is part of the job
  description

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Pastoral Leadership

• Advocates for patients 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

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QUESTIONS?