www.nccosc.navy.mil

Bart Jarvis, PhDHeidi Kraft, PhD

Monique Beauchamp, MFT

Caregiver Occupational Stress Control

(CgOSC) Training <DRAFT>

Introduction

HM3(FMF) Smith's infantry unit is deployed to Afghanistan. They

have lost many comrades to injury and death over the

deployment. Recently, HM3 has battled insomnia and night

sweats. He is increasingly edgy and easily irritated with people.

Despite this, he prides himself on his ability to handle many of his

Marines' medical concerns on deployment, including helping two

of them through significant home-front stressors.

After a grueling string of days for his platoon, HM3 suddenly

notices his friend, CPL Jones, acting differently. The corporal is

not sleeping, and his speech is racing and difficult to understand.

The Marine often paces, seems agitated, and talks of emailing the

Commandant to share thoughts on platoon leadership.

Why CgOSC?

• Increasing demands – Caregivers are facing

• Knowledge and tools

• Mediate risk-of negative outcomes

• Burnout-prevent or address

• Compassion Fatigue-Prevent or address

• Support resilient caregivers

Course Objectives

• Provider Ethics and Risk Management- in relation to CgOSC Principles

• Combat & Operational Stress Continuum Model

• Combat and Operational Stress First Aid (COSFA) Model

• 5 Core Leader Functions

• Resilience, Compassion Satisfaction and Caregiver Growth

• Duties of CgOSC Teams

Ethics of Caregiver Self-Care

• Self-care and buddy-care are foundations of caregiver ethics

• Deep connections-Caregivers have with their patients

• Increasing demand-to provide specialized care

• Poor judgment-Result from Burnout, Secondary Traumatic Stress (STS), Compassion Fatigue

• Risk-lapses in judgment, negligence, malpractice

Fallacy of Caregiver Self-Care

• High value for Self-Sacrifice

• Focus on others

• Tendency to ignore own issues

• Elevated substance abuse rates

• Elevated suicide rates

• Intrinsic Rewards-For caregiving, not self-care

• Extrinsic Rewards-Not persuasive for self-care

Initial Stress Symptoms

DiminishedSelf

Awareness

PoorConcentration

SocialWithdrawal

IrritabilityIncreased

SelfSoothing

Potential Caregiver Difficulties Burnout- Cumulative, predictablesubtle, mental fatigue, low energy, exhaustion, de-personalization

Compassion Fatigue (CF) or STS Anxiety, re-experiencing trauma, avoidance/numbing of reminders of trauma, sudden onset, unmet desire to help

Shared Trauma Caregiver and patient have gone through same or similar experience

Risk Factors: STS/CF and Burnout

HIGHER RISK LOWER RISK

High Caseload Reasonable Caseload, Ask for Help

High Exposure to ST Material Use of Active Coping, Humor, Active Optimism, Mindfulness

More than 40 Hours Work Per Week Reasonable Work Hours, Regular Down Time, Ask for Help

Personal Trauma History Positively Address, Cope with Trauma History

Isolation and Withdrawal, Poor Social Network

Utilize Positive Social Network

Minimal or Negative Supervision Positive Supervision

Substance Use/Abuse Awareness, Positively Address

Low Resilience Learn, Utilize Positive Resilience Factors

Caregiver Burnout Scenario HMC Brady is an IDC assigned to a busy clinic at a large MTF.

Due to high-op tempo and recently deployed staff in the clinic,

his patient load increased significantly, leading to long hours, no

breaks and minimal supervision. His wife has regularly said that

he needs to get help because he has been withdrawing from her

and their 12-year-old daughter. In addition, a staff member

recently approached HMC and told him he is becoming

distracted and appears indifferent to his patients.

Negative Ethical OutcomesSTS/CF Burnout

Practice Beyond Competency

Boundary Violations

Poor Risk Management

Lapses in Judgment

Negligence or Malpractice

Stress Continuum• Green – “Ready” Zone – Optimal functioning despite stressors;

leadership responsibility

• Yellow – “Reacting” Zone – Mild temporary symptoms; leadership and individual responsibility

• Orange – “Injured” Zone – Severe and lasting distress, decrease in productivity. See “Four Sources Of Stress Injury”; individual and leadership responsibility

•  Red – “Ill” Zone – Danger! Severe symptoms that do not improve without intervention; need professional intervention

ReactingReady Injured Ill

Adaptive coping

Optimal functioning

Wellness

FeaturesWell trained and prepared

Fit and focused

In control

Optimally effective

Behaving ethically

Mild and transient distress or loss of optimal

functioning

Temporary & reversible

Low risk for illness

FeaturesIrritable, angry

Anxious or depressed

Physically too pumped up or tired

Reduced self-control

Poor focus

Poor sleep

Persistent and disabling distress or loss of function

Unhealed stress injuries

Mental disorder

TypesPTSD

Major Depression

Anxiety

Substance abuse

FeaturesSymptoms and disability persist over many weeks

Symptoms and disability get worse over time

More severe and persistent distress or loss

Higher risk for illness

CausesLife threat, Loss,

Inner conflict, Wear and tear

FeaturesPanic or rage

Loss of control of body/ mind

Can’t sleepRecurrent nightmares/ bad

memoriesPersistent shame, guilt

or blameLoss of moral values

and beliefs

STRESS

Unit Leader Responsibility

Caregiver Responsibility

Individual, Shipmate, Family Responsibility

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Life Threat

A trauma injury

Due to events provoking terror,

helplessness, horror, shock

Loss Wear and Tear

A fatigue injury

Due to the accumulation of stress over time

Inner Conflict

A beliefs injury

Due to conflict between

moral/ethical beliefs and

current experiences

A grief injury

Due to loss of people who are

cared about

Four Sources of Stress Injury

Combat & Operational Stress First Aid (COSFA)

• Flexible, multi-step psychological first aid process

• Used for assessment and pre-clinical care

• Designed to help self and others

COSFAGOALS

PreserveLife

Prevent FurtherHarm

Promote Recovery

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Seven Cs of Stress First AidContinuous Aid 1. Check Assess, Observe and Listen 2. Coordinate Get Help, Refer as Needed

Primary Aid 3. Cover Get to Safety ASAP 4. Calm Relax, Slow Down, Refocus

Secondary Aid 5. Connect Get Support from Others 6. Competence Restore Effectiveness 7. Confidence Restore Self-Esteem and Hope

Combat and Operational Stress First AidCOSFA

Actions of COSFA

Reduce Anxiety, Distress, Arousal

Assess Current Status

Ensure Safety

Correct Negative Self-Talk, Normalize Reactions

Facilitate Social Connectedness

Foster Short & Long Term Resilience

Provide Resources, Refer as Needed

Augment & Promote Repair of Support Structures

Reacting Injured

Where COSFA Falls on the Stress Continuum

Promotes a Sense of Safety Promotes Calming Promotes Connectedness

COSFA VIDEO

COSFA Scenario

HM3 Banks is asked to escort the body of one of the Marines to Mortuary Affairs. He is

overcome with grief at the loss of his friend. He doesn’t know that this Mortuary Affairs unit

has been processing remains for several months without a break, during a time of very heavy

casualties. The Marine that Banks escorts MA is sent there prematurely. Banks and the

Marines of MA learn this when the medical officer who comes to officially pronounce the

Marine deceased informs them that his heart is still beating. The group – now including the

young corpsman – rallies around the seriously injured Marine, desperately hoping that he will

survive, despite the medical officer’s assessment that he will not. When the Marine’s heart

finally stops beating, the group is devastated. HM3 Banks is particularly affected, which

becomes obvious when he returns to his company. He is angry, irritable and experiences

frequent belligerent outbursts around his comrades and leadership. When confronted by

superiors, he becomes sullen and withdrawn, talking to almost no one for weeks.

Why the Five Core Leader Functions?

*The Five Core OSC Leader Functions were developed to reinforce a leader’s commitment to Sailors, families and overall command health

TWO C/OSCOBJECTIVES

MAINTAIN INDIVIDUAL

HEALTH & WELL-BEING

PRESERVEFORCE

READINESS

Five Core Leader FunctionsStrengthen• Leadership that is Firm, Fair, a Source of

Courage, Communicates Plans and Listens

• Expose to Tough, Realistic Training

• Foster Unit Cohesion

• Hardiness

• Remove Unnecessary Stressors

• Ensure Adequate Sleep and Rest

• Conduct After-Action Review (AAR) in Small Groups

Identify• Know Crew Stress Load

• Recognize Reactions, Injuries and Illness

Treat• Self

• Buddy Aid (Peers)

• Chain of Command

• Chaplain

• Medical

Reintegrate• Keep with Unit if at all Possible

• Expect Return to Full Duty

• Don’t Allow Retribution or Harassment

• Communicate with Treating Professionals (Both Ways)

Mitigate

Five Core Leader Scenario

HN Robertson recently returned from deployment with a Marine unit and was

assigned to an inpatient nursing unit at a large MTF. ENS Graves, his charge nurse,

began to assign HN Robertson patient care tasks, such as emptying bed pans,

changing beds and helping pass out patient food trays. HN thought these tasks were

menial and he began to get agitated and angry. He was adversarial in his interactions

with not only his charge nurse, but all his co-workers. He started telling everyone that

his life was over, he didn’t trust anyone, he should have died instead of several of his

Marines and that his girlfriend broke up with him. He also said he bought a car even

though he cannot afford the upkeep. He began to withdraw from his co-workers.

Resilient Caregivers• Resilience: The ability to overcome, adapt, grow and function

competently in the face of adversity and stressful situations

• Promote self- and buddy-care

• Associate with maintaining a balanced and healthy lifestyle

• Not a fixed state, can be strengthened and taught

• Less likely to experience burnout

• Less likely to experience compassion fatigue

• Maintain high-quality ethical practice

Values

• Foundation of individual and organizational resilience

• Foundation of individual and organizational guiding principles

• Life compass to help one navigate the storms and stay on course

Low Resilience High

Stress

High

Low

Leader effort

Individual effort

Optimal functioningMild distr

essModerate distr

essSevere distr

ess

Resilience Continuum

Sailor 1

Sailor 2

Factors That Contribute To Resilience

Behavior Control

Control and Confidence

Optimism

Positive Coping

Flexible Thinking

Values

Resilience

Awareness

Thoughts

Behavior Feelings

Awareness

 

• Interrelationship-among thoughts, feelings and behavior •   Interact-feedback loop which can go

in both directions  • Awareness-Key element, thoughts, feelings and behaviors

A-B-C Model

A = “Activating Event” is a life experience that has the potential to affect one in a particular manner

B = “Belief” is the interpretation or appraisal that one makes in response to

“A”

C = “Consequence” is the feelings and behaviors as a result of “B”

A B C

Flexible Thinking

• Ability to consider other alternatives

• Essential component of resilience

• Refrain from rigid beliefs

• Three flexible thinking skills:

– Positive reframing

– Disputing unhelpful thought patterns

– Meaning-making

Optimism

• Positive-thoughts, beliefs, attitudes, emotions and expectations

regarding life and being flexible about change

• Hope and positive expectations-when under periods of stress

• Sense of humor-and recognizing that difficult situations are temporary

• Identifying-“silver” lining of unfortunate or stressful situations

 

Resilience

--Henry Ward Beecher

‘‘’’

A person without a sense of humor

is like a wagon without springs.

It’s jolted by every pebble on the road.

Increasing Provider Resilience• Leaders – Teach, inspire, focus, instill confidence, exhibit

model ethical and moral behavior, communicate effectively, provide regular supervision

• Unit Cohesion – Mutual and supportive trust, important protective factor

• Caregiver Buddy-care– Encourage, support, watch for changes, ask hard questions

• Caregivers Self-care – Know self, know environment, monitor stress, know protective factors, monitor behavior, monitor physical, know resources

Compassion Satisfaction & Growth

• Chosen field can be very rewarding and self-fulfilling

• Scope of practice can be stretched

• Increased autonomy and responsibility

• Treatment allows for growth after trauma

CgOSC TEAM RESPONSIBILITIES• Teams: Master trained leader & co-leader, trained team

members. Adequate size to meet training & support needs

• Conduct CgOSC trainings & awareness briefs

• Provide referral information for healthcare professionals

• Execute ongoing caregiver stress related command assessments

• Provide command consultation, evaluation & staff support following stress-related work center event

• Align with SPRINT Team, establish referral procedures

QUESTIONS?

Bart Jarvis, PhDHeidi Kraft, PhD

Monique Beauchamp, MFT