Missouri Oncology Society

Spring 2015 Membership Meeting

April 14, 2015

Compassion Fatigue:

Prevalence among

Oncology Nurses

Patricia Potter RN, PhD, FAAN

Director of Research, Patient Care Services

Barnes-Jewish Hospital

St Louis, Mo 1

Burnout The chronic condition

of perceived demands

outweighing perceived

resources*

Secondary Traumatic Stress Emotional distress

resulting from exposure to

another’s trauma

Compassion Fatigue

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3

Impact on the Healthcare Environment

o Burnout and Secondary Traumatic Stress are associated with: o Increased turnover or turnover intention o Absenteeism o Decreased work performance o Decreased patient satisfaction o Difficulty in recruiting and retaining staff

Garman, Corrigan and Morris, 2002; Vahey, et al.,2004; Jones 2004; Yoder, 2010; Sung, Seo, Kim, 2012).

o Both associated with patient satisfaction with nursing care - a significant predictor of overall patient satisfaction with hospital care

“That which is to give light must endure burning”. -Viktor Frankl

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2009 ________________________________________________2015

Our Journey

Compassion Fatigue – Oncology Nursing

o 2009 -oncology nurse managers identified behaviors characteristic of “compassion fatigue”

o Unknown concept o Surveyed RNs, Techs, MAs, Radiology Techs o ProQol IV – 3 Constructs: compassion satisfaction,

secondary traumatic stress, burnout. o Construct validity and reliability coefficients for the three

subscales range from 0.71–0.9 (Aycock & Boyle, 2009; Boscarino, et al., 2004).

Study of Oncology Healthcare Staff

o Participants (153) – 34% response rate

o Registered Nurses - 132

o Patient Care Technicians - 6

o Medical Assistants - 10

o Radiology Technicians – 5

o Age: M = 39.9 years (Range 21-63)

o Years in Healthcare: M = 14.8 years (Range 1-43)

o Years in Oncology: M = 8.9 years (Range 1-33)

Results o Comp Satisfaction - 38.3/37

o Burnout – 21.5/22 o Comparable to average scores reported by Stamm

(2005).

o Secondary traumatic stress score – 15.2/13 - higher than average score reported by Stamm (2005).

o Staff working on inpatient nursing units had the highest percentage of high risk compassion satisfaction scores (p=.008)

o High-risk scores for secondary traumatic stress were relatively

equal among inpatient (37%) and outpatient staff (35%).

Build a Professional Resiliency Program for Oncology Staff

o Trained 3 facilitators (pastoral care/MSW/PA) to present a compassion fatigue program for oncology nurses.

o Dr. Eric Gentry – consultant

o Program Elements o Education about Compassion Fatigue components, including

contributing factors

o Compassion Fatigue Prevention & Resiliency

Course Design – Oncology Staff

o 5 wk program – 90 minute sessions following day shift o 4th week – 4 hr retreat off site o A mixed model repeated-measures design - compared

outcome measures across four time points (before and immediately, 3-months, and 6-months after the program)

o Adjusted for covariates (age, years in nursing, and years in oncology).

Outcome Measures

o ProQol IV – 30 item measure (Stamm, 2005)

o Revised Impact of Events Scale (Beck et al., 2008) 22-items. Rates subjective distress caused by traumatic events experienced during the past week.

o RN Satisfaction (Hinshaw & Atwood, 1983) – 28 item scale (five-point Likert).

Table 4

Pilot program outcomes (N=13)

Instrument Pre (p) Post 0 mth (p) Post 3 mth (p) Post 6 mth (p)

ProQOL-R-IV

Compassion 39.53 39.92 (ns) 38.53 (ns) 40.76 (ns)

Satisfaction

Burnout 23.46 22.61 (ns) 23.69 (ns) 22.30 (ns)

Secondary 19.76 17.61 (ns) 17.92 (ns) 16.23 (p 0.04)

Traumatic Stress

Impact of Events Scale R

Avoidance 1.27 1.06 (ns) 0.57 (p.007) 0.90 (ns)

Intrusive 1.79 1.34 (ns) 0.75 (p.000) 1.03 (p.004)

Hyperarousal 1.38 0.80 (p.01) 0.58 (p.000) 0.74 (p.006)

Total score 4.45 3.21 (p .04) 2.05 (p.000) 2.68 (p.005)

Staff Program Evaluation

o “It was most helpful to get together with a group and have discussions, to know other people have the same kind of day I do and experience the same things”.

o “I learned how to relax a little bit about things. I learned to not take myself so seriously. I learned some relaxing techniques that kind of helped at home, too”.

o “I have a tendency to take all the work on myself. I know now that it's okay to make patients wait, so I take time and don't make stupid mistakes.”

Potter P, Berger, J, Clarke M, Deshields T, Chen L: (2013). Evaluation of a Compassion Fatigue Resiliency Program for Oncology Nurses,

Onc Nurs Forum, 40(2):180-187.

Hospital Wide Class Design

o Offered twice a month

o 8 hour class – participatory, small groups

o 2-3 facilitators – clinical and non-clinical

o Prior to class – complete ProQol IV – 3 dimensions

o Post class evaluation – ranges from 3 to 12 months

o YTD > 660 attended

Compassion Satisfaction

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

21.3%

13.0% 14.7% 18.2% 18.4% 19.1% 21.3% 21.3% 22.6% 23.8%

30.3% % A

t R

isk

Low Compassion Satisfaction - Risk by Specialty

Burnout

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

21.6%

9.1% 10.2% 11.8% 13.2% 14.8% 17.0% 23.4%

28.1% 31.5% 33.3% %

At

Ris

k

Burnout - Risk by Specialty

Secondary Traumatic Stress

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

100.0%

37.3%

14.3% 20.8%

27.7% 34.8% 38.2% 42.6% 42.6%

47.6% 48.3%

% A

t R

isk

Secondary Trauma - Risk by Specialty

Time on Unit

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Compassion Satisfaction

Burnout Secondary Trauma

24.1% 20.5%

42.9%

24.6% 28.0%

44.0%

18.7% 18.3%

32.1% % A

t R

isk

ProQOL Scores by Time on Unit

1 Year or Less (n=115) 1-5 Years (n=209) 5+ Years (n=306)

Follow-Up Evaluation

o Linked Surveys: n=130; 22%

o Time Since Class o <6 months ago: 65% (71%) o >6 months ago: 35% (29%)

o Demographics o Female: 94.6% (91.0%)

o Male: 5.6% (8.7%)

o Average age: 43.2 (42.0)

o Average number of years on unit: 10.0 (8.3)

o Average number of years at BJH: 11.9 (9.9)

• Roles – Nurse: 69.2% (69.2%)

– Physician: 0% (0.3%)

– Allied Health: 7.7% (7.9%)

– Tech/clerical: 8.5% (8.4%)

– Interpreters/Other: 14.6% (14%)

• Service – ED: 8.5% (8.3%)

– IP Services: 30.8% (29.6%)

– Oncology: 7.7% (14.0%)

– Surgery/OR: 16.2% (14.0%)

– Educ/Support: 11.5% (8.5%)

– Radiology: 4.6% (5.4%)

– OP Services: 8.5% (7.4%)

Linked Follow-up Surveys

37.0 37.7

22.3

20.3 16.7

14.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Average Score: Baseline (n=130) Average Score: Followup (n=130)

Me

an S

core

ProQOL scores from PreTest to PostTest: Linked Surveys

Compassion Satisfaction Burnout Secondary Trauma

ns

t(129)=4.53; p<.01

t(129)=5.37; p<.01

Course Evaluations

1 2 3 4 5 6

...in your daily work

...in your personal life

5.45

5.41

Unlikely (1) to Very Likely (6)

Likelihood Will Practice... (n=659)

1 2 3 4 5

Would recommend to a co-worker

4.69

Unlikely (1) to Very Likely (5)

Would Recommend to a Co-Worker

(n=653)

1 2 3 4 5 6

Average facilitator rating

Overall rating

Relevance to your daily …

5.74

5.65

5.60

Lowest (1) to Highest (6)

Compassion Fatigue Course Ratings

(n=660)

Is your job stressful?

• If so, what are some of the causes?

• What are some of the effects?

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CAUSE AND EFFECT

Past learning

Perceived threat

Sympathetic dominance

CAUSES of Stress

Insufficient staff

Angry collegue or patient

Poor access to supplies

Unreasonable time frame

Bad Coffee

EFFECTS of Stress

Frustration

Sense of failure

Cannot sleep

Angry

Sad

Very tired

Anxious

High Anxiety Increased basal ganglia activity

Normal Note the lessened activity

of the basal ganglia

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Physiological Brain Mechanics Other Effects

▲Heart Rate ▲ Basal Ganglia & Thalamic Fx ▲Obsession

▲ Breathing Rate ▼ Neo-cortical Fx ▲Compulsion

▼ Breathing Volume ▼Frontal Lobe activity

▼Executive Fx

▼Fine motor control

▼Emotional regulation

▼ Speed & Agility

Centralized Circulation

▲ Muscle Tension ▼Temporal Lobe Activity

▼Language (Werneke’s)

▼Speech (Broca’s)

▼ Strength

▲ Energy ▼ Anterior Cingulate Constricted thoughts & behaviors

▲ DIS-EASE Fatigue

FIGHT or FLIGHT 27

Avoidance symptoms • Loss of enjoyment in self-care activities

• Loss of energy

• Relational difficulties – turn patients off

• Loss of hope

• Self soothing behaviors

Arousal symptoms • Increased anxiety

• Sleeplessness

• Impulsivity

Intrusive symptoms • Work issues encroach on personal time

• Inability to “let go” of work related issues

• Thoughts and feelings of inadequacy as a

caregiver

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“Burnout is a psychological syndrome of

emotional exhaustion,

depersonalization and

reduced personal accomplishment”

(Maslach & Goldberg, 1998; 2003)

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In the work place: • fatigued

• often nervous

• has increased sick days

• is more cynical and pessimistic

• has a loss of self esteem

• directs anger towards coworkers

• dreads going to work

• often feels like quitting their job

At home: • sleeplessness

• loss of interest in sexual activities

or social events

• change in appetite

• weight loss/gain

• relational problems

• nightmares about work experiences

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Compassion Fatigue

The Problem

Disease is the absence of

Effective Antibodies not the presence of a

Toxic environment

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CDC definition

RESILIENCE Compassion Fatigue “Antibodies”

1. Self-regulation – ability to immediately shift from sympathetic to

parasympathetic dominance (especially when perceiving threat)

2. Perceptual Maturation– Detoxify Workplace & Personal

Optimization

3. Intentionality – Principle-based vs. demand driven; living

mission

4. Connection/Support – develop and utilize support network

5. Self-care/Revitalization – aerobic activity, healthy pursuits;

refueling

RESILIENCY SKILLS Antibody 1: Self Regulation

Chill

Developing “bodyfull-ness”

o Relaxing tension of pelvic floor muscles switches from sympathetic to parasympathetic dominance

o Psoas, Sphincter, and Kegels (anterior + posterior)

o Regaining of neocortical functioning in 20-30 seconds

o Relieves pressure on vagus nerve

o Impossible to experience stress – comfortable in one’s own skin

Self-Regulation

B. Scaer (2006) NIMH (2004)

D. Bercelli (2003) R. Sapulsky (1999)

Porges (1999)

1. While sitting, put your hands under your bottom.

Feel the two pointed bones (Ischial tuberosities upon which you are sitting.

2. Next, touch the two boney points on your hips (anterior iliac spine)

on your right and left side just below the waist.

3. Visualize the four point you’ve touched and connect the points to make a square

4. Close your eyes, breath deep and slowly, feel the area in the middle of the square

and allow the square to expand.

5. Release and relax all muscles in the area of the square.

Self-Regulation

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Antibody 1: Self-Regulation

No Clenching

Antibody 2: Perceptual Maturation

“Change the way you look at things and the things you look at change.”

Can You See The Arrow?

Where is the Horse?

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Perceptual Maturation

o Evolving perception of our workplace can significantly “detoxify” our work experience

o Environmental stimuli are less likely to be perceived as threats.

Perceptual Maturation

o Just as you can regulate your body, you can regulate your thinking

o Disciplined process of your thinking and attention

Antibody 3: Intentionality

• Requires self-regulation

• Mission driven

• Internal locus of control

• Principle-based

• Tolerance of pain for growth

• Maturation of spirituality

Do I go where I aim myself?

Antibody #3: Intentionality

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Writing your covenant

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Compassion Fatigue “Antibodies”

1. Self-regulation

2. Intentionality

3. Perceptual Maturation/Self-validation

4. Connection

develop and utilize support network

5. Self-care

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Qualitative Study: Nurse Residency

o “Hearing what your co-workers who you don’t get to work with, you guys have something in common. Kind of nice to be reassured that “Oh, that patient gave you a hard time?”

o These stories help, especially from our preceptor mentors. When they are like “I once had this and this is how I handled it: I file it kind of back there and I say the same words maybe the next time and it helps”.

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Compassion Fatigue “Antibodies”

1. Self-regulation

2. Intentionality

3. Perceptual Maturation/Self-validation

4. Connection

5. Self-care

aerobic activity (3x/week) primary

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• Aerobic activity (3x per week)

• Fuel for “enduring burning”

• Music/Art/Sport that combines

discipline and improvisation

• Active instead of passive

• Solitude/Spirituality/Nature

• Intentional Plan

Antibody #5: Self Care / Refueling

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1. Self-Regulate

scan your body for muscle tension and stop squeezing muscles (200 – 500x/day)

2. Mature Perceptions

attend to what you can control & accept the rest, be at choice, self-validated, not in danger

3. Be Intentional

follow your Mission/Code-of-Honor, bring into alignment transgressions (even small ones)

4. Connect with Peers

share difficulties, get support

5. Care for Yourself

Put on your running/walking shoes 3 x/week, evolve spirituality, be creative, get good sleep, eat well

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“Between stimulus and response there is

a space. In that space is our power to

choose our response. In our response

lies our growth and our freedom”. - Viktor Frankl

BJC Compassion Fatigue program & materials developed from the work of J. Eric Gentry, PhD., Compassion Unlimited, 2013

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