managing stress boundaries burnout copy managing stres… · hospice education network 2007 ....

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Copyright © 2007

Managing Stress,Boundaries & Burnout

Hospice Education NetworkRita Wells, RN, MSN

Copyright © 2007

DOWNLOAD HANDOUTS

• Remember to download the handouts• Click the LINKS button• Handouts are in PDF Format• You can print them out for use during

the program

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Purpose

• Promote reflection andawareness regarding stress,boundaries and burnout.

• Encourage self-care, assuringprofessional integrity as well ashealth patient/familyrelationships

Owner

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This PDF includes slides and other program collateral

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Learning Objectives

• Identify two consequences to violatingprofessional boundaries.

• List three ‘red flags’ that one might recognizein themselves or others if they were havingboundary issues.

• Name a risk and a benefit to working inhospice, with dying patients.

• List three symptoms or consequences thatone might recognize in themselves or othersif they were experiencing increased stress.

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PART I:Professional Boundaries

• The “zone of helpfulness” vs. violationof boundaries

• Compassion vs. emotional involvement• Sympathy vs. empathy

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PROFESSIONAL BOUNDARIES

• Under-involvement– Can violate discipline specific practice

standards• Over-involvement

– Can hinder the therapeutic relationship• A different kind of challenges in

homecare and hospice settings

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Professional Boundaries

• The beginning and end of the nurse-patientrelationship is determined by the patient’shealth care needs

• All people seek benefits of attachment,closeness, and security; especially duringtimes of stress

• Boundary setting requires constant vigilanceand means understanding personal andprofessional boundaries

Source: Durkin, 2000; Wright, 2006

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Consequences of ViolatingProfessional Boundaries

• Prevents patient from achievinghealthcare goals

• Does not allow patient/family to movebeyond

• Contributes to stress and burnout• Ethical and legal dilemmas

– Can threaten job; risk of losing license;disciplinary action

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Other Considerations:Why is it Harmful?

• Inequity of power– Power & influence inherent in the role of

the health professional– Professional has access to private

information– Intimacy of providing care– Patient is vulnerable, often powerless

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Recognize Red Flags!• Personal disclosure• Keeping secrets (including letters, gifts)• Patient possessiveness (‘super-nurse’

syndrome)• Spending more time with ‘favorite’ patient• Off-duty visits (pseudo-family)• Exchanging personal telephone numbers• Patient pays special attention to you• Flirting• Failure to recognize or admit an attraction

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Exceptions

Intentional boundary violation• Sharing of stories for therapeutic

reasons• Entering personal or professional

relationship with former patients– Seek counsel– Time considerations

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The Do’s:Maintaining Good Boundaries

• Adhere to employer policies & procedures• Practice in accordance with state licensure & regs• Understand your scope and standards of practice• Know your disciplines Code of Ethics• Seek advice from supervisor• Exercise good judgment; stay focused on POC• Maintain professional integrity• Protect your license• Reassure patient/family

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The Don'ts:Maintaining Good Boundaries

• Get involved in personal affairs• Share personal problems• Assume dual relationship (outside

context of your role as healthcareprovider)

• Keep it to yourself

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Summary and Conclusion: Part I

• Gain perspective of professionalboundaries

• Show good judgment for reasonable andappropriate boundaries

• Recognize emotional involvement inothers

• We all have/had patients who tempt usto cross the line– Share with others– Collaborate and help one another

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Part II: Stress and Burnout

• Caring for patients/families with terminal andprogressive illness– Risks vs. Benefits– Research regarding stress

• Causes & Considerations of Stress & Burnout– Burnout Syndrome– Variables– Secondary Traumatic Stress

• Symptoms and Consequences of Stress• Alleviating and Preventing Stress / Burnout

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Hospice Care:The Risks & Benefits

• Risks– Increases vulnerabilities– Heightens own fears of illness or death– Raises anxiety– Contributes to stress and burnout

• Benefits: The counterbalance– Being part of a peaceful death experience– Job satisfaction; personal rewards– Sense of completion, helping, and

community

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Hospice Care:The Risks & Benefits

• Stress scores directly related to working with dyingpatients– Nearly 50% higher than widowed woman– Higher than woman newly diagnosed with breast cancer

• Stressors specific to Hospice– Work overload– Emotional demands, feelings of helplessness– Accumulated loss– Management of intractable symptoms– Relationships; Family Dynamics; Communication issues– Dichotomy between ideal vs. reality of dying experienceSource: Kulbe, 2001

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Causes and Considerations ofStress & Burnout

Stress• When demands exceeds the ability to

cope with or control the situation(stressors)

Source: Sherman 2004

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Burnout Syndrome• Social and psychological dysfunction of

clinical staff who are repeatedlyexposed to suffering, death, and thedemand for compassion andunderstanding

Source: Yancik, 1984

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• Burnout vs. Stress:work situation vs. life

• Stressors lead tostress

• Stress leads to burnout• Burnout leads to poor

patient care• Poor quality of care

leads to patient distrust

BURNOUT

POOR QUALITY CARE

STRESS

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• Personal Variables– Perfectionism– Over-involvement (boundary issues, esp.

among younger, less experienced staff)• Interpersonal Variables

– Rate of patient decline– Over-identification with patient/family– Relationships with other staff

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• Interpersonal Variables– Inadequate support (from family & colleagues)– Inability to grieve appropriate (no time)– Lack of debriefing– Patient/Family variables (extreme denial,

anger, abuse, difficult cases– Unmanageable work loads– Interpersonal conflict caused by demands of

IDT (i.e. roles overlap, goals of care differ)

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• Healthcare Variables– Short staffing– Increased patient case load– Lack of organizational resources– Scheduling conflicts– Mandatory overtime (pressure to work

extra)– Compromise: personal life vs. work

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• Professional Variables– Moral & ethical dilemmas (patient goals

oppose one’s own values)– Medication and treatment errors– Professional liability– Regulatory Issues: Paperwork and

information overload– Hospice Trends (short LOS, different type

of pt)– Nurse-Physician Issues (pain

management, communication, orders)

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Symptoms and Consequences• Physical Symptoms

– Change in appetite– Gastro-intestinal complaints– Somatic complaints– Physical exhaustion

• Emotional– Ambivalence– Loss of interest/concern (personal &

professional)– Loss/change in relationships– Avoidance– Distress

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Symptoms and Consequences• Psychological Symptoms

– Memory loss– Shortened attention span– Anger & frustration– Self-doubt– Decrease in self-esteem– Isolation– Impaired judgment– Constant fatigue– Disengagement– Poor judgment– Risk of transference

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Symptoms and Consequences

• For Health Professional– Illness– Substance abuse– Family conflict– Job dissatisfaction– Effects on physical,

emotional,psychological, andspiritual well-being

• For Organization– High staff turnover– Decrease productivity– Increase sick calls– Patient dissatisfaction– Increase costs

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• Serious Concerns– Depression– ETOH abuse– Drug use– Suicidal ideation

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Care of patient becomes compromisedwhen health professionals fail

to care for themselves

Source: Sherman 2004

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• Secondary Traumatic Stress– Refers to the knowledge of another’s

suffering/trauma and the unmet desire toalleviate it

– Similar to Post-traumatic Stress Syndrome– Pre-disposes to burnout

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Alleviating and Preventing Stress & Burnout

• Self-care Activities: A Priority– Promote good health and general sense of well-

being– Pay attention to inner self: mind, body, spiritual

connection– Trust instincts and intuition (listen to body)– Appreciate personal strengths and limitations– Forgiveness of self and others– Nature as a way of healing: a walk on the beach,

trail hikes, mountains, bird-watching, etc.

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• Self-care Activities: A Priority– Reflections and journal keeping (why Hospice

- fond memories serve to reinforcecommitment)

– Maintain personal & professional relationships– Assure good physical health (diet, exercise,

rest, relaxation activities– Emotional health: Calming and peaceful

thoughts and activities (meditation, music,sharing with others)

– Spiritual and religious practices

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• Personal/Professional Activities– The 3 R’s: Recreation, Rest, Reflection– Saying no, setting limits, take time off– Be open to sharing feelings with colleagues– Setting priorities and reasonable expectations– Expose self to new ideas; professional growth– Advocacy activities: patient, staffing, resources– Consider personal beliefs regarding end of life– Humor

Source: Durkin, 2000; Kulbe, 2001; Wright, 2006

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• Organizational-care Activities– A clear philosophy (include skilled team building)– Memorial services– Collaboration and collegial atmosphere: Promoting

high morale and team support– In-services and continuing education– Institutional ethics committee (difficult

cases/decisions)– Debriefing teams; staff support groups– Professional involvement = sense of well-being

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Summary & Conclusions:Part II

Personal and professional success willinvolve good health, fulfilling professionaland personal relationships, creativefreedom, empowerment, and peace ofmind

Source: Durkin, 2000; Kulbe, 2001; Sherman, 2004;Wolfelt, 1989

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Thank You

Hospice Education Network

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Hospice Education Network 2007 www.hospiceonline.com

Managing Stress, Boundaries, and Burnout by Rita Wells

Boundary Issues Case Studies

Case Studies: Case studies can be used as an interactive tool with other staff members, or for self-reflection. It is encouraged to discuss each case, or role play. They are true stories. Based on the readings, and power point lecture, determine what issues are apparent and how the situations should/could have been handled differently. Case A It’s a harsh winter day. Kelly, a hospice nurse, is battling with snow, wind, and ice to get to her last patient of the day. It’s been an absolutely horrible day. Kelly would describe it as “a day from H-E-L-L”!! She is very stressed, and running VERY LATE! To top things off, she has to be at her 8 year old daughter’s school that evening for a meeting with the teacher that she really doesn’t want to go to; but, she has already cancelled twice because of work. The teacher is insistent upon meeting and has indicated that there’s a problem. Kelly finally arrives at the home of her patient, Gladys, with whom she has become quite fond. Gladys has been clinically stable and still able to live on her own, so they are alone. Gladys has also become quite fond of Kelly, and looks forward to her visits. When Kelly arrives, Gladys is immediately aware of her stress level, so she asks her about it. Kelly conveys her frustrating day, how short staffed her agency always is, and tells her about her growing patient caseload that she can barely manage. She also tells her about her obligations at the school that evening, and goes on and on. Gladys, of course, is very sympathetic, and asks Kelly numerous questions pertaining to her work and private life. Kelly begins to de-stress after telling Gladys everything, and answering Gladys’ questions. Gladys offers Kelly tea, advise, and a listening ear; doing her best to take care of Kelly: She wants to give something back to her favorite nurse. After chatting for an hour and a half, Kelly feels so much better! She takes Gladys’ blood pressure and tells her she’ll see her next week.

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Case B Holly is a 36 year old young mother who is dying of ovarian cancer. She experienced a difficult life, doing her best to raise a daughter by herself; taking what jobs she could, without any formal education, to make ends meet. Just prior to her diagnosis, she met Jim; a quiet, kind man, with little financial means; but, one who seems devoted to Holly. He has been devastated by her illness. Jim, nor Holly, has any other family. They were so glad to have found one another. Holly had felt so alone, especially after having her daughter, who was now 5 years old. She had never been willing to share any information regarding her daughter’s biological father; he had never been told of Holly’s pregnancy. Holly was in the final stages (weeks) of life when she was referred to Hospice. Joan became involved as the Hospice Social Worker. Joan immediately took to Holly and Jim, and the little girl. She couldn’t sleep at night worrying about their situation. She gave Jim her home telephone number, cell phone, and pager. He would call frequently during the night. Joan encouraged Jim during these calls to express his feelings, cry if he needed to. She would talk with Holly several times a night, as well. Nighttime seemed particularly difficult. Joan visited every day, sometimes more than once. She talked to Holly about her daughter, and Holly made her promise to take care of Jim and her daughter; make sure they were okay after she died. Holly felt that Joan was “like the sister she never had”. Joan was only 6 years old when her own mother died, also of ovarian cancer; so, she felt she could relate to their situation particularly well. She had been orphaned by age 8, her father dying just 2 years later. Joan felt that no one could understand this patient’s/family’s plight quite like she could. Joan was so grateful that she was on the case and made sure she was present in the final hours. They all became so close. Before she died, Holly revealed her wishes of a beautiful ‘send-off’ in the way of a funeral, and Jim ‘humbly and shamefully’ talked with Joan about how he could not even give Holly the proper burial. He verbalized his anguish that he didn’t even have the money to bury Holly, who had become the love of his life. Joan took care of everything. She arrived one day, just 4 days before Holly’s death, to show her the beautiful dress she bought for Joan to wear for her burial. Holly loved it! Joan made all the funeral arrangements, paying for everything. Her only request in return was that Holly and Jim never tell anyone at her agency that she was doing this. She really cared for them, and wanted to do everything she could to help. They were so grateful.

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Managing Stress, Boundaries, and Burnout by Rita Wells Keeping a Journal

Reference: College of Dupage (1999) with excerpts from The Five Year Journal, by

Doreene Clement. http://www.cod.edu/news

Why Journal

Expressing our thoughts and feelings through the written word can heal us. It can

focus, support, and enhance our lives and well-being. Keeping a journal can help us to

understand more about ourselves, and one another; whether we laugh or cry, whether

through sorrow or joy. Some benefits of keeping a journal might be:

• Reduces Stress

• Helps to set goals

• Organizes time and energy

• Channels the focus

• Can improve well-being

• Allows personal time

• Creates a personal reminder and memories

• Becomes a treasured keepsake

How to Journal

On a piece of paper, in a notebook, or in some type of journal book begin by

answering the question, "Which 3 words best describe how I am feeling right now?"

Writing about whatever is important to you right then and there is journaling. Tracking

what you have planted in your garden is journaling. Writing about family holidays, or

coffee with a friend is journaling. There is no set amount of words or pages that

constitutes a journal. There can be a set theme, or topic, in your journal; but, there does

not have to be. You can write about yourself, others, your friends, your dreams for the

future. It is personal choice. It is similar to a diary - a place where you choose to store

what is important to you.

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When to start

Any day of any year is a good time to start your journal. The day you feel you

want to start recording your experiences and thoughts is the perfect day to start - Whether

on January 1, June 10, or today. There is no set time of year to begin a journal, or to pick

up where you left off. Some people like the idea of starting their journal on January 1st.

They write their goals and ideas starting at the beginning of the year. Others like the idea

of starting the very day it occurs to them that they want to write about their lives in a

journal. Whatever you choose, it is the right way for you, and that is all that matters.

What to journal in

There are a lot of choices of where to record all those thoughts, feelings, ideas,

dreams, and desires. What you will write in and what you will write with, again, is up to

you. Try several choices, several types of books, and several types of pens or pencils.

Find the tools that fit you. You can also record your journal on tape, video, or the

computer. Writing a letter can be another form of journaling your experiences: Letters to

yourself.

What to write about

In her book, Clement speaks of a woman who wanted to be a comedian. In her

journal, she wrote a joke a day. Another person had been stuck for several years writing

her novel. She started to journal about writing her novel, and gained the focus she

needed. She finished her novel within a few months after she began her journal. Another

person might track money they spend. For healthcare providers, writing about your

experiences may prove to be helpful. Write about your thoughts, feelings, the challenges

you face; include the areas of stress that you want to change. Write about your career

choice; it may help to remind you of the all the benefits and joy you receive in your

chosen profession. The beauty of keeping a journal is that it is your book. You get to

choose not only when to write, but what to write. You can write as much or as little as

you want - a word, a thought or two, pages, you choose.

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Remembering to journal

Place your journal where you will see it every day. Like taking vitamins, if you

don’t see them, you may forget to take them. So, place your journal on your bedside

table, or where you have coffee in the morning. Also, you don’t have to write every day.

Write when you want to express something, but try to get in the habit of writing at least

weekly.

Keeping your journal safe

You may want to have a special place for your journal, so no one else can read it.

You can keep it in a locked box, or tuck it away. You can also ask the people around you

not to read your journal, to respect your privacy. As you journal about specific events, or

people, you can also use code words for those experiences. It is important that you feel

safe when writing about your thoughts, so think about how you can create that for

yourself in your own environment.

With the passage of time, we gain a different perspective. Time is a healer. What was

once hard, or unbearable, can now make more sense, giving us a clearer picture.

Recording and tracking our lives, by keeping a journal, can actually bring relief, clarity,

joy, and laughter.

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MANAGING STRESS, BOUNDARIES AND BURNOUT by Rita Wells

SELF-CARE ACTIVITY The things I love to do

In the first column, list things that you love to do, either when ‘you have the time’ or that you know would help when feeling overworked or stressed. In the next column, describe how frequently you do each activity (i.e. daily, weekly, monthly, hardly ever, etc.). In the following column, indicate if you enjoy the activity alone (A), or with other people (P) – reflect on whether you enjoy the activity because you are alone or with others. In the last column, indicate if the activity costs more than $5 by using a dollar sign ($), any more than $20, use 3 dollar signs ($$$).

Activities I love Frequency A/P $

1.

2.

3.

4.

5.

6.

7.

8.

Reflect on what you have learned by doing this activity. Answer (use back of paper):

1. What I learned_______________________________________________

2. I was pleased to learn__________________________________________

3. I was displeased with__________________________________________

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