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Clinician Stress and Burnout

Background

Those caring for seriously ill patients are known to experience stress from situations such as dealing with death and dying, team conflict, amount of direct patient care provided and time pressures which can lead to burnout. Levels of burnout have not been shown to be greatly elevated within specialist palliative care, [1-3] however, a recent study from the US suggest a much higher rate at around 62%. [4] Burnout levels of the oncology health professionals appear similar to the general population. [5]

What is known

The best established measure of stress and distress in health care workers is that of burnout. The assessment tool most frequently used for identifying burnout is the Maslach Burnout Inventory [6] which measures three domains - emotional exhaustion, depersonalisation, and lack of personal accomplishment. Personality and personal characteristics influence the burnout process [7] with correlations between attachment style and levels of burnout shown to exist, [8] as well as work factors. [2] Palliative care units seem to have protective factors that need to be explored further to prevent burnout. [9-10]

Some of the aspects of work practices that have been shown to affect clinician stress are: self confidence in own communication skills with patients and relatives [9] and multidisciplinary decision making. [11] The skills, attitudes and approach of individual clinicians when responding to difficult encounters may affect their risk of burnout. Clinicians who have received communication training have their self confidence increased in dealing with difficult situations, so are less likely to experience burnout. [9]

What it means in practice

  • Individuals should take responsibility for their own self care, which comprises of knowledge, skills and attitudes including self reflection and self awareness, identification and prevention of burnout, appropriate professional boundaries to maintain their personal well being [12] and their quality of patient care. This needs to be acknowledged and supported by employers and managers through the provision of education and training. [1] This consists of monitoring those who have a substantial amount of patient contact, neglect to take adequate leave or who have not attended communication skills training, [5] particularly focusing around end of life issues. Clinicians who possess a high level of emotional self-awareness are better able to manage and overcome the stresses that arise in clinical practice that benefit both themselves and their patients.
  • There remains limited evidence about self care programs and skill training for clinicians in palliative care. Though this is increasing and a structured Self-Care Module, based on an awareness-based model of self-care, [13] has been evaluated to show it is useful and operationally feasible as a method to provide this skill training, for medical learners going through a palliative care rotation. [14] Where organisations are developing programs, documenting these approaches, evaluating them using validated tools and reporting them back to the field could improve our understanding of this issue.
  • Health care organisations have a responsibility to ensure that their culture and structure provide education about potential effects and possible management strategies and opportunities to reflect about feelings related to interaction with patients and their families as required by the Standards for Providing Quality Palliative Care for all Australians [15] Organisational interventions can include structured debriefing, mentoring, and professional supervision which are well-known staff support mechanisms that have been reported as having a positive effect on staff. [1] Creating an environment that helps staff to reflect and develop coping mechanisms can be helpful in reducing stress. [2] Changing work schedules can also reduce stress, but other organisational interventions have no clear effects. [16]
  • The importance of self care is also supported by many of the palliative care related professional associations [17-19] and palliative care expert group. [20] They provide clear recommendations about managing stress through self-care and note the importance of preventive health care practices for both physical and mental health, strategies for maintaining work / life balance, and peer support arrangements. These activities should be encouraged and facilitated by health care organisations, and modelled and mentored by clinicians.
  1. Peters L, Cant R, Sellick K, O’Connor M, Lee S, Burney S, et al. Is work stress in palliative care nurses a cause for concern? A literature review. Int J Palliat Nurs. 2012 Nov;18(11):561-7.
  2. Koh MY, Chong PH, Neo PS, Ong YJ, Yong WC, Ong WY, et al. Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study. Palliat Med. 2015 Jul;29(7):633-42. Epub 2015 Mar 31.
  3. Dunwoodie DA, Auret K. Psychological morbidity and burnout in palliative care doctors in Western Australia. Intern Med J. 2007 Oct;37(10):693-8. Epub 2007 May 21.
  4. Kamal AH, Bull JH, Wolf SP, Swetz KM, Shanafelt TD, Ast K, et al. Prevalence and predictors of burnout among hospice and palliative care clinicians in the U.S. J Pain Symptom Manage. 2015 Nov 24. pii: S0885-3924(15)00614-4. [Epub ahead of print]
  5. Girgis A, Hansen V, Goldstein D. Are Australian oncology health professionals burning out? A view from the trenches.Eur J Cancer. 2009 Feb;45(3):393-9. Epub 2008 Nov 14.
  6. Maslach C, Jackson SE, Leiter MP. The Maslach Burnout Inventory. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
  7. Gama G, Barbosa F, Vieira M. Personal determinants of nurses' burnout in end of life care. Eur J Oncol Nurs. 2014 Oct;18(5):527-33. Epub 2014 Jun 2.
  8. West A. Associations among attachment style, burnout, and compassion fatigue in health and human service workers: A systematic review. J Human Behav Soc Env. 2015; 25(6):571-590. Epub 2015 Apr 14.
  9. Pereira SM, Fonseca AM, Carvalho AS. Burnout in palliative care: a systematic review. Nurs Ethics. 2011 May;18(3):317-26.
  10. Sinclair S. Impact of death and dying on the personal lives and practices of palliative and hospice care professionals. CMAJ. 2011 Feb 8;183(2):180-7. Epub 2010 Dec 6.
  11. Hernández-Marrero P, Pereira SM, Carvalho AS; DELiCaSP. Ethical decisions in palliative care: Interprofessional relations as a burnout protective factor? Results from a mixed-methods multicenter study in Portugal. Am J Hosp Palliat Care. 2015 Apr 28. pii: 1049909115583486. [Epub ahead of print]
  12. Sanchez-Reilly S, Morrison LJ, Carey E, Bernacki R, O'Neill L, Kapo J, et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. 2013 Jun;11(2):75-81.
  13. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA. 2009 Mar 18;301(11):1155-64, E1.
  14. Kim HC, Rapp E, Gill A, Myers J. An innovative self-care module for palliative care medical learners. J Palliat Med. 2013 Jun;16(6):603-8. Epub 2013 Apr 30.
  15. Palliative Care Australia. Standards for providing quality palliative care for all Australians. 4th edn. Canberra: Palliative Care Australia; 2005. (633kb pdf)
  16. Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015 Apr 7;4:CD002892.
  17. Canning D, Yates P, Rosenberg JP. Competency standards for specialist palliative care nursing practice. Brisbane: Queensland University of Technology; 2005. (193kb pdf)
  18. Australian Medical Association (AMA). Health and wellbeing of doctors and medical students - 2011 [Internet]. 2011 Apr 5 [cited 2016 Feb 10]. 
  19. Australian Association of Social Workers (AASW) SA. A practical guide for students and new practitioners. Hindmarsh (SA): AASA SA; 2014 Oct. (1.10MB pdf)
  20. Palliative Care Expert Group. Emotional care of the provider of palliative care. In: Therapeutic guidelines: palliative care. Version 3. Melbourne: Therapeutic Guidelines Limited; 2010.
Last updated 14 February 2017