Stress and the Health Care Worker:
Psychosocial Perspectives
Elizabeth A. Pector, M.D.
Naperville, Illinois
synspectrum.com
steps to master stress
1. Claim it: everyone has stress.
2. Name it: everyone’s stressors are
different. (ABCs of needs,TWERPS)
3. Reframe it: Look at your stress &
stressors in a different way. Hardiness,
coping.
4. Tame it: prepare, self-care, share, dare,
be aware
December 2, 2007
©Elizabeth A. Pector, M.D.
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1. Claim it: Stress 101
“Stake your claim in
the gold mine of stress”
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Stress: present in all organisms
– Nonspecific response to any demand placed on the organism
– Impulse pushes us out of balance or equilibrium
Stressors: factors that provoke stress response
Stress responses
– Acute Fight-or-Flight  Chronic stress.
Healthy stress (Eustress)- adaptive
– Motivates growth & learning.
Unhealthy stress (Distress):- maladaptive
– Can result from “impossible” demands. Biopsychosocial effects
Job stress:
– “Harmful … responses that occur when requirements of the job do not
match the capabilities, resources or needs of the worker.’’
NIOSH
– 10% of total occupational disease claims are due to stress. Marine et al
2007
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Mental
Health
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2. Name it:
ABCs of basic human needs
Accomplishment—reach worthwhile goals
Belonging—relationships help define us
Comfort—feeling secure
Dependability—predictable aspects of life
Esteem—feeling good about yourself
Finances—enough funds for a fulfilling life
– Maddi & Khoshaba, 2005.
December 2, 2007
©Elizabeth A. Pector, M.D.
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Stressful
Twerp
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2. Name it:
Your stressors: “TWERPS”
Tasks, Time
Worries
Environment, Expectations, Events
Roles, Responsibilities
People (yourself, others, communication)
Situations: all of the above put together
– How much is in your control?
– How much is from outside circumstances?
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Stress occurs at
interface between work & worker
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•
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Work factors
Personal (worker) factors
Do they fit well together?
If they don’t fit,
can work or worker
change to lower
stress levels?
– Limited evidence shows worker- and work-directed
interventions lowers stress in health care workers. –
Marine et al. 2007
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Job stress & health
Job stressors
Job Demands
Workload
Shift work
Limited worker control
Technology
Client demographics
(age, culture)
Organizational Factors
Role demands
Management style
Career security
Interpersonal relations
Change
Physical
Environment
Space, noise, heat,
cold, lighting, etc.
December 2, 2007
Individual
factors
Acute
stress
Personality traits
Motivation
Talent
Training
Chronic
stress
Reactions:
Physical
Stressrelated
Illness:
Psychological
Behavioral
Finances
Family
Hx trauma
Non-work
stressors
Social support
Coping skills
Hardiness
Buffer
factors
©Elizabeth A. Pector, M.D.
Heart disease
Depression
Infections
OR
Healthy
worker
Adapted from NIOSH Publ. 87-111;
7
Vachon & Pakes; Maddi& Khoshaba
Name it: Burnout
• Burnout is “the index of dislocation between
what people are and what they have to do.”
(Maslach & Leiter, 1997)
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High Depersonalization (“hardened, withdrawn”)
High Emotional Exhaustion (“drained”)
Low Personal Accomplishment. (“ineffective”)
Major contributor: Unsupportive work environment.
(Siebert critique: worker factors underrepresented in
Maslach Burnout Inventory.)
– Gradual, predictable. “Progressive loss of idealism,
energy & purpose…as a result of work conditions.”
(Edelwich & Brodsky, 1980)
– Relief occurs with vacation or job change.
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Burnout
• 6 main components of burnout (Maslach &
Leiter, 1997)
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Overload
Lack of control
Too little reward
Unfairness
Value conflict
Lost sense of community at work
• Management can work with employees to:
– Increase engagement, involvement, effectiveness &
hardiness (Maslach & Leiter, Judkins & Furlow).
December 2, 2007
©Elizabeth A. Pector, M.D.
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Name it: Compassion Fatigue
• Compassion fatigue is “the cost of caring”
(Figley) also called: Secondary traumatic stress,
vicarious traumatization (Boscarino et al., 2004)
– Less able to show empathy or bear clients’ suffering.
(Boscarino 2004)
– Exposure to & preoccupation with clients’ trauma.
– Symptoms like Post-Traumatic Stress Disorder:
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Re-experiencing (flashback, memories, dreams)
Avoidance (people, situations, feelings). Withdrawn, numb.
Hyperarousal (startle, anger, vigilance, insomnia)
See Figley 1995/1997 in handout, p. 2
• Compassion fatigue is related to clients’
experiences. Example: 9/11 social workers.
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Compassion fatigue model
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Maladaptive stress response
(Vachon & Pakes, 1984)
• Physical: fatigue, headache, insomnia, abdominal pain, diffuse
aches, frequent viral illness, increased sick days, weight and
appetite change, lack of exercise.
• Psychological: depression, frustration, denial, anxiety, conflictladen dreams, over-identification with patients, anger, projecting
blame onto others, awareness of own vulnerability, substance abuse,
feeling robotic (unable to feel anything), unresolved grief for patients
• Social: Bringing job stress home, changed libido, fear of pregnancy,
fear for family member’s health, no time for friends or no friends
outside work, conflict between job and personal life.
• Occupational: Unrealistic expectations (science can cure
everything, humans can be perfect), more & more time at work,
feeling overwhelmed by job, inability to detach from job,
overinvolvement with clients outside work, cynicism (insults, morbid
jokes, dehumanizing attitude), role ambiguity (trouble defining one's
duties and area of responsibility), decreased job satisfaction, role
reversal with clients (they become your therapist).
December 2, 2007
©Elizabeth A. Pector, M.D.
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Danger!
Compassion Crisis
• It is a crisis when you experience or practice:
•
•
•
•
– Repeated errors and omissions
– Drug or alcohol abuse
– Numb, robotic functioning
– Feeling suicidal, useless
– Abusing patients
– Blaming & criticizing other team members
– High absenteeism
– Tardiness
Compassion Fatigue/Burnout are contagious to coworkers, family.
It is not a sign of failure to realize you need a break, or a change!
Consider transition to less stressful situation that uses your talents
Treatment
– CBT more effective than relaxation or multimodal intervention in stress reduction
for all occupations (including non-health care) -van der Klink et al, 2001
– CF/PTSD: trauma-focused cognitive behavioral therapy (CBT), exposure-memory/site, stress management, EMDR. Debriefing controversial, may harm.
December 2, 2007
©Elizabeth A. Pector, M.D.
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Name it: healthcare workplace stress
Job Demands (General)
Workload
Shift work
Limited worker control
Technology
Client demographics
(age, culture)
Organizational Factors
Role demands
Management style
Career security
Interpersonal relations
Change
Physical
Environment
Space, noise, heat, cold, lighting
December 2, 2007
Health care (Specific)
Work overload, paperwork
Shortage of staff
Shifts/schedule issues, overtime
Lack of control
Patients older, sicker, and heavier
Management style, culture
Lack of supervisor & peer support
Work not valued, low salary
Lack of advancement options
Fear of errors
Conflict with coworkers, pts., staff
Moral dilemmas, death, dying
Risk of violence at work
Work environment in disaster
response
“Fishbowl” in ICU
Isolation (lab, dietician, SW, rural)
©Elizabeth A. Pector, M.D.
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Work factors by occupation
• Physicians: (Spickard et al., 2002)
– Work overload
• Drop in payment, insurer business practices, regulations.
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Family/personal life suffer: medicine is put first, family “later.”
Isolation: i.e. rural solo physicians.
Worries: Money, Medicare/Medicaid audit, Malpractice, errors.
More control  less burnout risk.
Management, leadership style, organization culture
Male doctors: Poor childhood or poor father relationship more
burnout risk.
– Female doctors: more likely than males to burn out.
• Greater risk with more hours worked; risk of sexual harassment
– Personality: compulsive, doubt, guilt, sense of responsibility
December 2, 2007
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Work factors by occupation
• Pharmacist 67% satisfied with job; 68% have stress.
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Stress greater in chain, mass merchandise, hospital (Mott et al 2004)
More demand: increased workload (pts older, on more drugs)
Interruptions
Unqualified/inadequate staff, especially chain & hospital
Undesirable schedules
Less satisfied if too little time spent in pt consults/managing drug use.
Work not valued; management/leadership style
Fear of committing error
Conflict with other professionals or non-clinical individuals
Women more satisfied than men.
Unmarried, female, nonwhite more likely to leave current setting
• Gaither et al. J. Am Pharm Ass 2007;47(2):165-173.
– Unmarried, low salary, no children, more time in filling rxs, more than 5
years experience: More likely for burnout in HMO setting
• Gireesh et al, J Managed Care Pharm 1998:495-503
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©Elizabeth A. Pector, M.D.
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Work factors by occupation
• Pharmacy tech: Less stress than pharmacists
– Excessive workload
– Interruptions
– Inadequate staffing
– Work/life conflict, schedules.
– Work not valued
– Lack of advancement options
– Support by supervisor is important
• Instead of education on error avoidance, most pharmacists
just pointed out error and asked tech to correct. Desselle Am
J Health Syst Pharm 2005.
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©Elizabeth A. Pector, M.D.
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Work factors by occupation
• Respiratory therapists/technicians
– Work environment: stress in critical care, hospital floor,
emergency settings.
– Downsizing, roles assigned to others (e.g. nursing)
– (Source: U.S. Dept. of Labor; AARC)
• Registered dieticians: increased need expected
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Most in hospital, nursing facilities & office
Pay rate, overtime
Inpatient consults, dying patients
Monotony in patient types
Noncompliance in patients (obesity, diabetes, others)
Lack of respect, lack of contact with MDs.
(Source: Dept. of Labor, posts on dieticiancentral.com)
December 2, 2007
©Elizabeth A. Pector, M.D.
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Work factors by occupation
• Lab technologists
– In 2000, 7-20% shortage in positions (ASCP survey)
– Work overload due to shortage, downsizing.
– Excessive hours, paperwork
– Lower sense of purpose with automation or changes in
procedures
– Monotony, boredom with repetitive tasks
– Lack of management explanations for changes
– Lack of control or input re: changes and work flow.
– Fear of making mistake (e.g. blood bank)
– Isolation from other health professionals
• Martin B. Burnout in the lab: symptoms, stages, strategies, Medical
Lab Observer 1986.
• Maher Medical Lab Observer 1996
• Dowie et al. 2006
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©Elizabeth A. Pector, M.D.
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Work factors by occupation
• Radiology tech
– Serious imbalance in supply/demand of techs
– Better productivity with filmless systems…but
there are limits.
– Staffing shortage worst in rural/academic:
especially general techs
– Dropping morale
– Inadequate compensation
– Limited advancement options
• Reiner et al, J Digital Imaging, 2004.
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©Elizabeth A. Pector, M.D.
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Work factors by occupation
•
Nursing:
– 17% fewer RNs in acute care hospitals in 2005 than 2000 (Reineck &
Furino)
– Workload: pts. old, ill, obese. Paperwork, language. (Reineck & Furino)
– Each added pt/nurse  23% higher risk of burnout & 7% higher pt.
mortality. (Aiken 2002)
– Inadequate/inexperienced staff & inadequate staff budget, agency RNs
– Shift work (nights), overtime, & pressure to reduce “time on clock”
– 12-hour vs. 8- or 10-hour shifts. Float/prn responsibilities
– Fast pace  not meeting pt needs or own expectations, fear of errors
– Leadership/management style.
– Professional/mgt/pt/family conflict
– Lack of input in care, including moral distress/conflict
– “Fishbowl” environment in ICU settings
– Proximity to death and dying pts
– Threatening/difficult/demanding pts (especially psych)
– Lack of advancement options
December 2, 2007
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Work factors by occupation
• EMT/paramedic
Risk of PTSD, physical & burnout symptoms
– More job dissatisfaction & negativity toward pts, less physical distress,
lower coping than nurses/doctors. High cortisol/catechol.
– Physical symptoms, stress, +negativity higher with worker substance
use.
– PTSD increased with critical incidents: disaster, child, suicidal.
• Risk of burnout increases with:
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Experience & age (greater experience/age  more stress)
Commercial service
Work in poor areas high in violent trauma
Low sense of coherence (confidence in predictability, manageability &
meaningfulness of challenges).
– Conflicts with ER personnel or poor communications w/ mgt.
– Worry about work conditions, safety/health threats (crime, O/D)
– Less support from supervisor & colleagues
– Boudreaux & Mandy; Jonsson et al., vanderPloeg et al.
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Work factors by occupation
• Social work: 39% current burnout in N. Carolina
– Work hours correlate with burnout
• Staff cutbacks result in higher caseloads & work overload
– Bureaucracy, funding limits, limited autonomy
– Stressful clients, i.e. “underprivileged, socially maladjusted.”
– Stressful environment
• Hospital, child welfare workers have more stress-related symptoms
• Proximity, identification, transference issues in disaster care
• Discharge planning is hurried, too little time for counsel
– Feeling responsible for clients
• Unreasonable self-expectations to “do it all”
– Personal history of troubled parent or childhood emotional abuse
– Job isolation, lack of support.
– Support from supervisors lessens stress
socialworker.org, Lahad, Siebert, Felton.
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Work factors by occupation
• Clergy: 40% depressed or worn out; obesity, heart dz (Pector, 2005)
– Emotional demands of role (baptism to funeral)
• Compassion fatigue risk, “need to be needed”
• Sometimes need professional help to learn to accept help
– Pastor’s own communication difficulties
– Client (congregational) conflicts or unrealistic expectations
• If clients don’t have mental health insurance, they turn to clergy for help.
– Workload: Less help than in past years from family, congregation
– Lack of career control
• Frequent relocation, occasional forced resignations
– Isolation from peers
• Denominations with strong, supportive tradition, e.g. Roman
Catholic, fare better
– Bureaucracy, budget, low salary
– Lack of mentors, clinical pastoral education, counseling coursework
– Lack of support for stressed pastors or their families
December 2, 2007
©Elizabeth A. Pector, M.D.
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Name it: Worker factors in HCW stress
•
Personal traits
– Age, partner/family status, race/ethnic, economic
– Personality
– Motivation
• Gain knowledge, use technical skills, help or work with people
• “Need to be needed” to boost self-esteem is a risk for work overload and CF
•
Talents & training
– Innate abilities that are advantageous in job
– Occupational training
– Experience
•
Non-work stressors
– Current personal stressors
– Previous personal or job trauma or crisis
•
Buffer factors
– Hardiness
– Coping style
– Social support
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©Elizabeth A. Pector, M.D.
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3. Reframe it: Hardiness
A “personal protective factor”
• Commitment: strive to stay involved
– Engagement with job, effort to stay involved, even when times
are rough
– Worker believes work deserves full attention & effort.
• Control: strive to influence outcomes
– Worker perceives high degree of control in work role
– Exerts influence thru imagination, knowledge, skill, choice.
– We can’t control what happens; we can control how we respond.
• Challenge: view as opportunity, not obstacle
– Change is the rule, not the exception
– React with openness, flexibility, innovation
• Transform and grow in response to change
• Don’t seek to preserve & protect the status quo
December 2, 2007
©Elizabeth A. Pector, M.D.
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Reframe it: Hardiness
A “personal protective factor”
• Transformational coping:
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Put changes in perspective
Realize you’re not facing change alone
Learn what change means for you: worst/best case
How can I take advantage of change?
• Learn from past success & failure
• Plan how to make best-case scenario happen
• Social support—Maddi & Khoshaba
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Work with others, don’t alienate them
Work toward constructive win-win solutions
Believe that problems can strengthen relationships
No matter what happens, don’t burn bridges.
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Reframe it:
Effective Coping Strategies
•
December 2, 2007
Brief COPE
– Active coping
– Planning
– Positive reframing
– Acceptance
– Religion
– Using emotional support
– Using instrumental support
– Self-distraction
– Denial
– Venting
– Behavioral Disengagement
– Self-blame
– Humor (avoid ridicule, self-defeating)
Blue: positive, Yellow negative
Tan neutral
©Elizabeth A. Pector, M.D.
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Think
Reframe it: a new view
•
•
Adopt a Hardy perspective
– Commonplace: Others have experienced same stressors.
– Manageability: The present is between the worst & best that
could happen
– Improvability: Think how YOU can improve situation.
– Time: Estimate when stress will ease (e.g. short-term deadline
stress)
– Unpredictability: Do what you can, the rest is out of your
hands.
Attitude: Turn lemons into lemonade; “Attitude of Gratitude”
– Cognitive behavioral therapy works to change thoughts, which
in turn changes feelings & behaviors. Accentuate positive,
reduce negative.
– Live in the present moment (Mindfulness)
– Adjust expectations.
– Serenity prayer: change what you can, accept what you can’t.
– Humor: shifts perspective to less threatening. ? Mixed effects
in coping with health care stress.
December 2, 2007
©Elizabeth A. Pector, M.D.
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4. Tame it:
TWERPs revisited
• Tasks: Do, Delegate, or Drop.
• Time: Manage it & schedules.
– Budget sleep and personal time!
• Worries: Change what you can, Accept what you
can’t, Know the difference.
• Environment: Advocate positive change.
• Events: Discuss critical incidents; Counseling.
• Expectations: Change unrealistic to realistic.
• Roles: Control responsibilities, Delegate tasks.
• People: Assertiveness, Communication (with
management & colleagues)
December 2, 2007
©Elizabeth A. Pector, M.D.
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Tame it:
Prepare, Self-care
• Prepare for the expected and the unexpected.
• Self-care: “Balance PIES”
– Balance: Clear line between work and “life.” Set limits!
• Work:
– Improve protocols, build teams & communicate.
– Maintain & upgrade skills.
– Network with others, followup with clients at home.
• Life:
– Make time (prioritize) for friends, family, hobbies.
– Relax, see nature, vacations, mental health days.
– Limit off-work time with clients.
– Physical: Diet, exercise, sleep, preventive care
– Intellectual: Advanced education, change or add roles
– Emotional: Self-acceptance. Counseling, meds as needed
(anxiety/depression). Positive outlook, ? humor.
– Spiritual: Morals, ethics, values, beliefs/religion, relax, meditate.
December 2, 2007
©Elizabeth A. Pector, M.D.
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Tame it:
Dare, Share, Be Aware
• Dare to Dream, Decide, & Act
– Meet with colleagues, research options
– Approach management with suggestions
• Share burdens with others
– Social support, support groups F2F & online,
professional help
• Be aware
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Journaling helpful in coping with stress
Ask others for feedback
Monitor progress in personal wellness
Stages of change model
December 2, 2007
©Elizabeth A. Pector, M.D.
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Tame it: Dare
Stages of Change for new/old habits
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Tame it: Self-care
Alternative individual strategies
& effectiveness
• Music (A)—patient’s preference
• Aromatherapy (lavender) (B)
– Essential oils in massage or in oil burner (check natural
health/New Age shops)
• Yoga in healthy people (B)
• Relaxation techniques (B to C) many types
– Autogenic training, breath therapy, guided relaxation, muscle
relaxation techniques, Qi gong, self-hypnosis, visualization,
biofeedback.
• Massage, meditation, acupuncture, acupressure, guided
imagery, therapeutic touch, other methods (C)
A= strong, B= good, C= unclear evidence
December 2, 2007
©Elizabeth A. Pector, M.D.
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Tame it: Relaxation
(Natural Standard, 2007)
• Goal: non-directed relaxation. 1) repetitive focus (on word,
sound, prayer phrase, sensation, or muscular activity), 2) passive
attitude towards intruding thoughts, and 3) return to the focus.
• Deep methods: autogenic, progressive muscle relaxation (PMR),
meditation ("thoughtless awareness," differs from relaxation).
– Progressive relaxation: client taught how to relax by comparing
relaxation with muscle tension. After months of practice, may
evoke relaxation response within seconds.
• Brief methods: self-control relaxation, paced respiration, and deep
breathing. Require less time, often a short form of a deep method.
• Applied relaxation: imagining relaxing situations, to induce
muscular and mental relaxation.
• Other techniques: guided imagery, deep breathing/breathing
control, passive muscle relaxation, refocusing.
• Instruction in hospitals, communities, books, audio/video, online
December 2, 2007
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Tame it:
Relaxation, Meditation
Online training
• allaboutdepression.com/relax/index.html (free, choice of techniques,
no music)
• healingchronicpain.org/content/relax/default.asp From Beth Israel.
Guided Imagery. Choose type of imagery, male, female.
• relax-online.com/imageryonline.htm (music, imagery, mind-body
(progressive muscle) relaxation, breathing)
• e-help.com/free_e-z_load_big_screen_relaxation_videos_online.htm
• learningmeditation.com
– http://www.learningmeditation.com/reduc1.htm
• Healthjourneys.com: Free 15-min. guided imagery audio
• Wilddivine.com Healing Rhythms: biofeedback hardware & sensors,
$299.00. Andrew Weil demo
wilddivine.com/content/HR_Demo1B_WD_QT384K.mov
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Tame it: Biofeedback
• Biofeedback amplifies small physiological
signals (i.e. muscle tension, brain waves)
and displays them to client in real time.
• Client uses this information to learn to
consciously change “subconscious”
physiological functions (heartbeat, muscle
tension, brain wave activity). (aapb.org)
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Tame it: Types of biofeedback
• EMG (forehead, upper back, other): For muscle
tension backache or headache, neck pain,
bruxism (grinding teeth).
• Temperature (sensor on finger): For Raynaud’s,
migraine.
• Galvanic skin response (sweat): stress.
• EEG (brainwave or neurofeedback). Attention
deficit, anxiety.
• Heart rate variability: the more variability, the
better. IBS, asthma, non-cardiac chest pain.
December 2, 2007
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Tame it: Biofeedback in action
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Tame it: Biofeedback efficacy in
stress-related disorders
•
Efficacious (Fourth level evidence):
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–
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–
–
•
•
•
Anxiety
Attention Deficit Disorder
Headache- Adult
Hypertension
Temporomandibular Disorders
Probably efficacious (Third level evidence):
– Alcoholism/Substance Abuse
– Arthritis
– Chronic Pain
– Insomnia
Source: aapb.org quotation from Yucha C. & Gilbert C. (2004).
Evidence-Based Practice in Biofeedback and Neurofeedback.
More info: aapb.org, bcia.org.
December 2, 2007
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Tame it: Share
Therapy, e-therapy
• Traditional counseling
– Cognitive behavioral therapy
– CBT/exposure/EMDR for traumatic stress
• “Coaching” -- personal or professional
• E-therapy Barak et al.:
– Online therapy, via email, website programs etc. can
be as effective as traditional therapy for anxiety &
stress. No studies cited specific to work stress.
– http://www.metanoia.org/imhs/ How to find a therapist
online, cautions etc. Older info.
– Ismho.org, onlineclinics.com
December 2, 2007
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Tame it: Share
Face-to-Face (F2F) & Online Groups
Present in F2F & online:
Unique online:
•
•
•
•
•
•
•
• Anonymity:
Sense of community
Empathy
Information & advice exchange
Self-disclosure
Shared experiences
Catharsis
Learning from peers and
mentors
• Helper role
• Advocacy
December 2, 2007
– Filters nonverbal cues
– Hides disturbing
personal characteristics
– Encourages prompt
intimacy/deception
• Writing is therapeutic
• Lurkers: 75-95% of
members lurk, yet
learn & identify with
group
• Response is delayed
(except in chats)
©Elizabeth A. Pector, M.D.
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Tame it: Share
Benefits & Risks of Online Groups
• Convenient access
• Decreased isolation
• Increased perceived social
support
• Easier discussion of sensitive
& controversial topics
(sexuality, ethics, atypical
lifestyle, suicide, end of life)
• Practical help received
• Ability to help others
December 2, 2007
•
•
•
•
•
•
•
•
Misinformation
Delayed treatment
Alternative medicine focus
“Meeting” severely affected peers
Strong emotions, arguments
Privacy/Identity Concerns
Stalking
Deception
©Elizabeth A. Pector, M.D.
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Healthy systems
Team problems,
Team solutions
“ …similar to shipmates preparing for a storm. Just as
shipmates understand that the ship must be made
with solid materials and fortified with necessary
provisions, so does the NICU crew rely on structure,
interdependent relationships, harmony and
leadership in their preparation.”
Reddick, Catlin & Jellinek, Crisis within Crisis: Recommendations for
Defining, Preventing, and Coping with Stressors in the NICU, J. Clinical
Ethics, Fall 2001.
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What do healthy systems look like?
• Structure: High level of function and effectiveness.
– Multidisciplinary team
• Mutual respect, cross-training, awareness of others’ roles.
– Flexible schedules, with staff input.
– Adequate staffing with independent, empowered staff.
– Education, training & development: for tasks, leadership, & coping with
stress
• Relationships: Communication
– All team members feel valued: Everyone’s opinions count.
– Communication flows both ways: workers to administration.
– Discussions after deaths, adverse outcomes, difficult clients
• Critical incident debriefing controversial for emergency workers
– Outside the hospital
• Reunions, classes, support groups
• Contact with community resources (visiting nurse,
home health, hospice, community pharmacists)
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What do healthy systems look like?
• Harmony:
– Workers have input into decisions, workload, work flow.
– Error response seeks system improvement, not scapegoat
• Leadership:
– Management listens and responds to employees,
– Management encourages risk-taking, trying new processes.
– Policies don’t “handcuff” employees to protocols, & allow
independent, innovative action.
– Mentoring
– Employee assistance programs (not enough by itself)
– Consultants, organizational changes
– Psychological training on attitude, communication & job stress
relieve stress. (Marine et al. 2007)
– Support and advice given by nurse managers or quality care
coordinators decrease Depersonalization on Burnout Inventory.
(Marine et al. 2007)
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Healthy systems:
Harmony in tough times
• Discussions for deaths, errors, stressful
cases, moral dilemmas
– Team case review (doctors & others)
• Focus on learning and improvement
• Kudos for good care
– Informal and formal discussions with peers
– Sharing memories & feelings with families
• Verbal and written: discharge, death, later
• Tears & appropriate touch can be professional
– Attend funerals for client death
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Healthy systems:
Forgiveness
“ Perhaps the single most useful piece of knowledge
…is…that more is unknown than can ever be known.
...A part of wisdom … is…that ignorance should be
accepted and forgiven…The forgiveness of families,
colleagues, and--most of all--ourselves becomes the
cushion against crises and the guiding spirit to coping
in a sea of chaos.” Reddick, Catlin & Jellinek, Crisis within
Crisis: Recommendations for Defining, Preventing, and Coping
with Stressors in the NICU, J. Clinical Ethics, Fall 2001.
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