Compassion Fatigue and Secondary Traumatic Stress Identification for Healthcare Providers

to “Compassion Fatigue and Secondary
Traumatic Stress Identification for Healthcare Providers.” This webinar is part of a
series of modules sponsored by the U.S. Department of
Health and Human Services, Office of the
Assistant Secretary for Preparedness and Response or ASPR’s Technical
Resources, Assistance Center, and Information
Exchange, or TRACIE. ASPR TRACIE works closely
with healthcare facilities, coalitions, ASPR Recovery staff, and HPP partners
across the country and has repeatedly heard from
disaster affected communities that disaster
behavioral health recovery has been challenging for
the healthcare providers involved in recent natural
disasters and no-notice events. Each of the modules
we’ve developed includes a micro-learning
module and a longer webinar. The three topics are: 1. Addressing Compassion Fatigue
and Behavioral Health Needs for Healthcare Providers 2. Organizational
Behavioral Health and Wellness for Executive Level
Healthcare facility staff, and 3. Healthcare Provider
Cognitive Strengthening Preparedness Program ASPR TRACIE launched
on September 30th, 2015. The development and
functionality of ASPR TRACIE are collaborative, involving multiple
HHS Operating Divisions and other federal government
departments and agencies; local, state, and
regional government agencies; national associations;
nonprofit organizations; and private sector partners. TRACIE is
comprised of three domains: Technical Resources, which
houses our Resource Library and subject
matter expert-reviewed Topic Collections,
the Assistance Center, where users can
receive personalized support and responses to
requests for information and technical assistance, and the Information Exchange, an area for
password-protected discussion among vetted users
in near real-time. ASPR TRACIE has also developed
several resources specific to disaster behavioral health; these are housed on our Select Disaster Behavioral
Health Resources page. Now, I’ll turn it over
to Dr. April Naturale, who developed and will
lead all of these modules. APRIL: Hello and thank
you for joining us today. My name is Dr. April Naturale and I am a
traumatic stress specialist who provides disaster
and emergency preparedness and response
consultation to responders and community members. At the
conclusion of this webinar, you will be able
to define, identify, and apply
personal and professional self-care strategies
to prevent and address the behavioral health
effects associated with: compassion fatigue,
secondary traumatic stress, vicarious trauma, and burnout. This webinar was
developed specifically for healthcare professionals. A reference to professionals who work in health
care, mental health and behavioral health settings who are called upon to respond
to emergencies and disasters. We know that those who
work with the suffering suffer themselves
because of the work. Our colleague in the
field and in research, Dr. Charles Figley developed the
concept of Compassion Fatigue and has written
extensively on this topic. His work is a great
resource for understanding and addressing this concern
for healthcare providers and others who work with traumatized
patients and clients. The word trauma is derived from
the Greek word for “wound,” so it makes sense for you and
your colleagues in healthcare to refer to it in
the physical sense. In this webinar series, however, we will be referring to
trauma and traumatic stress primarily in the emotional
or behavioral health sense. The Substance Abuse and Mental
Health Services Administration notes that more than
half of men and women report exposure to at
least one traumatic event in their life time
and 90 percent of clients in public
behavioral healthcare settings have experienced trauma. As we talk about the identified
concerns, keep in mind that we are focusing here
on healthcare professionals and some of the signs more commonly seen
in this profession, but much of the
general information applies to many different disciplines, so I am sure you will be
able to relate this information to family and
friends who may be doing other trauma
exposure related work. We start here with
Compassion Fatigue, or “CF” which is usually identified by the distress
signs noted here, not always all of them, but enough of them
with a level of intensity that causes them to
really ‘bother’ the person who experiences them. The most common of
these signs is a sense of work-related
exhaustion upon accompanied by some
depressive-like symptoms – like sadness,
crying, and loss of energy. The effects tend to
overwhelm the person with the sense that they cannot
really make a difference, or improve the situation. These individuals may
become cynical as a result and additionally, tend
to disconnect from others, they report a lack of feeling and often indifference as
to the feelings of others. And as in many other disciplines that lead and
support disaster response, we see the
increased use of alcohol and other mind
altering substances both in the workplace and
at home as a means of coping. This often goes
beyond social use and can have negative effects
both at work and at home. Secondary Traumatic Stress is the experience of trauma
symptoms in healthcare providers as a result of, and in relationship
to their exposure to, that is seeing and listening
to the trauma material and experiences of
their patients and clients. STS distress
symptoms usually mirror those of the people
they are working with. Vicarious
Traumatization is similar to CF and often includes some signs
of secondary traumatic stress, but additionally
vicarious trauma can negatively change
one’s view of the world and belief systems. It often decreases the
sense of personal safety – that is, one feel’s less safe. So for example, if you
are caring for a child who has been abused, you might have the
experience of feeling very sad, even depressed, unsafe, and unable to sleep at night without visions of the abuse
flashing before your mind’s eye. And Vicarious Traumatization
usually occurs over time similar to CF
while STS can occur with only one exposure to
disturbing trauma material. Burnout is a bit different
than the other two effects and is most often
expressed in ways that are almost
opposite the others. Instead of an intense feeling
of not being able to help or sadness at not
being able to do so, burnout is beyond feeling, it’s usually a lack of feeling
empathy towards the patients, clients and their
families, an indifference, or a disinterest in
the work altogether. The causes of Burnout are
less connected to the work of actually caring
for patients and clients and attending to their families. It is more connected to
administrative problems like not having
helpful supervision, or not agreeing with some
of the organization’s policies or not getting
along with your peers. And in the
healthcare profession, we see the common
problems of long shifts, high volumes of acute patients, insufficient
staffing, demanding patients, and an administrative emphasis
on performance measures, or numbers, and
patient evaluations. This difference in
causation is important because it means that mitigation
and intervention strategies are also different. What we have
seen, is that often, if not successful in
addressing serious burnout, staff may need
to leave the agency or they may decide to leave
the profession altogether. Many of the terms just described
have been used interchangeably along with
indirect traumatization, cumulative stress, and traumatic
countertransference, but there is little
research behind them. Here we will mostly
refer to compassion fatigue and secondary
traumatic stress together as they are most similar and they have the
best research base, thus are most used
in the field today. Burnout will also be referenced
as a standalone disorder. As a healthcare
provider in general, and especially one
who provides emergency and disaster response services, it is likely that
you have been exposed to many traumatic situations. These might include treating
or working with victims and survivors of violent
crimes, survivors of a fire, or a car crash with serious, life threatening injuries. And as you are likely aware, biohazards are one of the most
significant threats globally. Viruses, bacteria and parasites as well as human caused
threats stemming from terrorism or accidents – anthrax,
ricin, chemical spills, all create
stressors to protect oneself as well as save others, a unique workplace hazard
for staff in healthcare and behavioral
healthcare settings. You may have to cope
with a larger scale incident like a hurricane, flood or mass shooting incident
where multiple victims require lifesaving
efforts at the same time, causing intense
pressure to perform quickly and continuously for
long periods of time. What I really want
to focus on here is the fact that most
healthcare providers, and I am going to speak
here with the assumption that you in the audience
are professionals working in a general health,
medical, mental health or substance
abuse settings and that you are group who do not see
yourselves as individuals who would develop
compassion fatigue or secondary traumatic stress. That is primarily
because you are professionals who tend to be a
highly self-reliant group – that is, you see
yourselves as the helpers, and not as the people who would
need assistance from others, either in assessing your needs or in delivering
support services. And the stigma around
behavioral health concerns is as active in
health related disciplines as it is in the general public. Most people don’t see themselves in need of
mental health supports even when working in the
intensely stressful environment of trauma services. Also, either because
of staffing patterns or the desire to help others
on a very human caring basis which brought you to
the profession to begin with, most of you in the
healthcare professions, see yourselves as having
to ‘work ’till it hurts,’ often putting in long hours, covering staff
shortages, skipping breaks, working through lunch, and routinely sacrificing
your own comfort and self-care to ensure the care of others. You are a group that is
very hard on yourselves, as if nothing is ever enough. If you are a
healthcare professional who has learned well and does a good job
taking care of yourself, I congratulate you. But you are the not the norm. healthcare
professionals are also a group that is skilled in
providing specific services for which you are trained
to deliver as an individual, but also while functioning
within the team setting. Thus, your performance
is usually quite visible to your coworkers and thus, you tend to work a bit harder
at controlling and concealing any distress symptoms for
fear of being seen as weak or providing any basis
for being judged negatively or stigmatized by your peers. In addition to
experiencing traumatic stress in the workplace, there are several professional
and personal factors that can create a higher level
of risk for experiencing STS. Providers who see a
high number of trauma cases as opposed to having a mix
of other patients or clients, that is some with
physical ailments or illnesses not related to a
traumatic event, are at a higher risk of STS. Also, another work
related risk that is of concern is the perception of
healthcare providers that they did not
have adequate training to provide the
level of care needed to effectively
assist patients or clients. On the personal side, providers who have a history of
trauma experiences themselves, such as child abuse or neglect, interpersonal violence
such as domestic abuse, rape or a physical
attack may experience STS at a higher rate than those who
do not have such experiences in their personal history. And those without
good social support, who isolate themselves, don’t have good coping skills, or use negative
coping such as alcohol and other mind
altering substances are also at higher
risk of suffering with STS or compassion fatigue. Additionally, we know
that our blood pressure is often twice as
high during the work day compared to when
at home or time off. The worst work-related
stress is caused by jobs where people have little control
over the activities they do and the rate at which
they have to deal with them. Race is also a factor; genetics, family illnesses. A high fat, high
salt diet contributes, via blood pressure increase. And professional woman
or men who are caregivers with children
suffer more, for example, your blood pressure doesn’t
go down when you go home. Here is a good snapshot of some
of the various signs of STS. I will go into more
detail in the next few slides. As mentioned earlier, these signs parallel those
of your patients or clients and can include
a rapid heartbeat, stomachaches and headaches that
have no physiological basis, sleep problems and a
lowered immune system which makes you more susceptible
to colds and sore throats. Anxiety symptoms
are common in addition to signs of depression
like sadness and crying. On a personal level you may
find yourself much more cynical and negative in general, with mood swings, often isolating and
even seeking out alcohol and other substances
to change your mood. In the workplace, we see healthcare workers with increasing incidents of
being late, calling in sick, a lack of initiative or
motivation in their work. Overall, we see lower staff
morale and higher turnover rates and higher error rates. In the spiritual domain
we see people questioning their sense of meaning in both their personal
and work life choices. Some even
question their beliefs; and others who
suffer with depression and are isolated may also
develop a sense of hopelessness, which puts them
at risk for suicide. Here we have a
more comprehensive list of some of the
physical impacts of STS. This list includes
changes in weight, breathing difficulties,
overall aches and pains, and worsening of
chronic medical conditions including high blood pressure. I also want to point out that
sleep problems and insomnia in particular are the most
common physical complaints in disaster and
emergency workers. Any emotional
effects should be addressed. Whether they look like
mild depression or anxiety, or a sense of helplessness
and lack of confidence. We don’t want to see any effects
worsen or become chronic, and are concerned about
those who start to detach, and decrease their ability to
empathize with their patients or clients and
their family members. We need to be aware of PTSD
symptoms such as flashbacks, nightmares,
hyper-vigilance and avoidance. All of these effects
are distress symptoms that we should pay attention to. The effects of STS on an
individual’s spirituality is not addressed
enough in the literature, but anecdotally, we hear
many healthcare providers talk about how witnessing trauma makes them think
about their lives in terms of meaning
making and purpose. Some question why they
are in the profession, others search for meaning
in their lives in general and take a closer look
at their relationships. Some people will
even question their faith and become angry thinking
that God or a higher power allows these traumatic
events to hurt people. We should all be listening
for signs of hopelessness as it is one of the red flags
for increased suicide risk, especially in
people who are isolated. An extension of
spiritual effects can include moral injury, which is a construct
that describes extreme and
unprecedented life experience including the harmful aftermath
of exposure to such events. Events are considered
morally injurious if they “transgress deeply held moral
beliefs and expectations.” Thus, the key
precondition for moral injury is an act of transgression, which shatters moral
and ethical expectations that are rooted in
religious or spiritual beliefs, or culture-based,
organizational, and group-based
rules about fairness, the value of life,
and other such things. These can occur in
mass casualty incidents or public health emergencies and can create extremely
challenging conditions and make for
difficult decisions. For example, how do you
handle giving one child a vent and explaining why you’re
choosing one child over another to the parents. Or if you’re triaging
mass violence patients, how do you know when
to administer pain meds to someone you
think is expiring? Though in a normal situation, you’d take more
measures to save them, versus knowing
when to treat someone in a very chaotic
non-traditional environment. This creates for contradictory
priorities that cause harm, unintentional errors, acts that are committed
by yourself or others, and, again, creates
difficult decisions. Moral injuries can result in: Shame – feeling
unworthy, and Guilt – a feeling of responsibility
or remorse for some behavior which are generally combined and form some of the most common
responses to traumatic stress. Moral injury can
also cause Isolation – as workers feel they are
alone in their transgressions and that no one
will understand them. These can lead to long
lasting emotional distress – that is, chronic
problems that build and can often lead
to additional concerns like substance misuse
and relationship problems. Also, it is not
unusual for Moral Injury to come at a much later
date after the incident, causing delayed
emotional distress that the healthcare staff
then have difficulty connecting to a particular event and don’t know how to
resolve their feelings. The impact of STS on your
work is of great importance because as you know, it affects
patient and client care. healthcare professionals
are under more stress than any other profession
to get everything right. To make the 99.9
percent accuracy target, basically, to not make mistakes. So, monitor for signs of STS – a feeling of exhaustion not
related to a lack of sleep, and not being productive,
communicating poorly or incorrectly in
your notes, your orders, and with other staff. You may notice
being more impatient and having increased
conflicts with coworkers. One of the signs we
see in healthcare workers and emergency responders that we
don’t see in other professions is the inability
to stop working, almost being obsessed and overworking to the point of risking your own health
and personal relationships. Some staff lose
confidence in themselves and begin second
guessing everything. Traumatic stress also negatively
affects our cognition. Poor judgment and
poor decision making are not unusual as the response
and recovery phases continue. And again, as mentioned before, one of the more serious
signs is detaching yourself, isolating from others,
numbing your feelings so you avoid feeling
any distress at all. STS and exposure to trauma can have a negative
interpersonal impact as well. We become so isolated
and withdrawn from others, we’re lonely and may
even begin to mistrust others, a bit of a paranoia, actually. Anger can become
our default emotion because it hides distress and doesn’t make us
feel as vulnerable, and it is acceptable
culturally, especially for men, to express anger rather
than sadness or distress. We often take out our
anger on those we work with and our loved ones,
children especially, and others around us. Other than
posttraumatic stress disorder, some of the more
serious problems that are common in healthcare
and other helping professionals include self
medicating with alcohol and other mind
altering substances like opioids or
anti-anxiety meds. Some may
self-sooth by overeating or excessive drinking. Relationships
follow poor coping – from extramarital affairs
and even suicidal thinking and gestures when one sees no way out
of their deep pain. These effects aren’t pretty and the real problem is
that we as a profession tend to hide them by continuing
– or thinking we are able – to continue functioning at work. Thus, many might not
know we have a problem, and we are
pretty good at denial, until it becomes
so serious or chronic and has already
destroyed our relationships, our work, and even
our sense of self. There is, however, good news. There is ample satisfaction
and meaning in the work that we do that
is very powerful. We need to
recognize that the reason we came into the
helping profession is because we want to feel
good about the work we do. We don’t
necessarily have to experience only negative
stress in this work. We can gain very positive energy or what we call
compassion satisfaction, the sense of doing
something meaningful, being happy about that, and feeling useful
and connected to others and the community around us. We know too, that many people
in the healthcare professions report what we
call traumatic growth – that is, we can learn and grow from witnessing and
experiencing trauma. Some people learn to appreciate
their relationships more, others learn good coping skills and others report
feeling more grateful for many aspects of their lives. Providing the type
of care that you do, listening and
supporting your patients, clients and their families, can lead to a sense of strength, self-knowledge, confidence,
meaning, spiritual connection, and respect for human
resilience over time. Thus, we can nurture
these protective factors by looking for and recognizing
them in our experiences and even seeking opportunities
to practice good coping like supporting each other and having
gratitude for all the small, positive things
that happen every day. Now that you know what
CF, STS, vicarious trauma, burnout, and compassion
satisfaction look like, think about how your work – both during disaster
and non-disaster times – may be
contributing to your experience of these signs and symptoms. What can you do to address them? Start with a real honest look
at how you feel you’re doing. How are you coping really? What are your areas of concern? And where are your strengths? Most importantly, what are you willing to do
to improve your situation? Nothing will change if
everything remains the same. Consider what you are
doing on a routine basis that may either contribute to or help decrease any
uncomfortable stress symptoms. Are you over
committed personally? If so, this will spill
over into your work situation and likely increase the stress
you experience in the workplace. Have you taken on
too much at work? Are you
participating in activities that you feel are
beyond your skill set, that might even
possibly cause harm to your patients or clients? Also consider if you are
particularly vulnerable. Do you have a history
of trauma in your past that still has strong
negative effects on your life? Have you had someone close
to you die in the past year? Or have you experienced a
medical illness yourself? Or been in a life
threatening situation such as a car accident? These things can
temporarily increase your risk. In order to make determinations
about all of these situations, you need to have some
sense of self awareness. Are you someone who
avoids looking at these issues? Do you just say, ‘I’m fine’ and not give any real
considerations to the concerns? Self awareness means
that you can look critically at how you have to
perform in each of these areas, take in feedback
from those around you and use tools that can
help create an objective look, one that is not based
only on your own perspective. We’ll talk about that
process in the next few slides. A good way to
increase your awareness of the impact of stress and to prepare
yourself for coping with stress is to create a stress profile. This means, to know ahead
of time what stresses you out and what helps
decrease your stress. Don’t wait to do this
until you are so stressed that you won’t want to bother,
or you think it’s too late. Create a path to self care. Let’s take a few minutes to engage in a
stress profile exercise. Pause the webinar and take a look at the
four sections of the profile. Ask yourself, what are the things
that stress me out at work? These will likely be
different for everyone. Is it the unit
secretary who makes you file all your own charts and
that really bothers you? For someone else, it’s having to see the
children’s oncology unit every time they
go to their office. Think about it, do the exercise, write down 2 or 3 things that
really stress you out at work. For health and mental
health professionals, those stressors could
include a lack of support or access to support staff, challenging or overburdened
supervisors and managers, challenging clients, and a lack of resources to
better assist the clients with their variety of needs. Then write down
your warning signs. Do you start yelling orders
at staff across the desk? Do you become
impatient and tell everyone you don’t really have
time to talk to them, so they better make it fast? Do you get a headache? Pain in your shoulders? Write that down. These should
become red flags for you, things that warn you that
your stress is getting intense. Then identify what things you do
to cope that really don’t help – now be honest here. Does having alcohol
every evening really relax you or do you find it
makes you wake up with a rapid heartbeat at 3 am and unable to get back to sleep? Does yelling at the
kids to leave you alone because you are tired from work really make you feel
better or just guilty? Write it down. Look at what works to truly
make you feel less stressed. Is it a walk? 10 minutes of sitting with
your loved one and catching up? Taking a few
minutes to gather yourself before you sit
down with the family? These things don’t
have to be complicated or take hours to accomplish. They can actually be
simple and fairly quick. I live with an introvert
who needs to be left alone when first
coming home from work, without a lot of questions
as soon as the door opens. So I learn to wait a
bit before engaging, saves a lot of
arguing in my house. Again, you are the only one who
can recognize these concerns and determine
what works for you. Here are some of the things that
you might find yourself doing if you don’t care for yourself: Abusing alcohol
or other substances. Shutting out
friends and family. Refusing to eat. Blaming yourself or
others for what happened or how you are responding. Engaging in risky behavior. Expressing excessive
anger towards other people, or snapping. And that brings us to
the concept of self care. For those of you who
don’t know what self care is, and I know there are
a lot of you out there, self care is your
ability to do things that protect and maintain your physical self –
that is, your whole body. Your emotional-mental
health – that is your attitude, clarity of thought, good
coping and good decision making. Your relational health –
having close relationships, making time to be
with people you love, and those who love
and understand you. And your spiritual health – here, referring to
your sense of meaning, your place in the world
and your sense of safety. When you are
creating a self care plan, look at each of these aspects and write down at least
one or two activities that address your
needs in each of those areas. Are you walking every day? Do you do things
that bring you joy? Do you connect with those
you care about in some way, calling, texting, writing? And what fulfills
your spiritual needs? Doing something
in the community? Collecting for the food bank? Driving someone in need
to a doctor’s appointment? Coaching the kid’s
after school activities? As healthcare professionals
engaged in emergency response, have you and your family
planned and prepared for how to manage when
you are pulled into long, intense days of work? Do you have a go pack
with a change of clothes, medications,
pictures of the family and other things
that bring you comfort? Do you have a schedule of when to communicate
with your loved ones? Have you arranged for
someone to care for your pets? All of those things
that we tell the public to do to prepare
for an emergency should be things that we
have in practice for ourselves. Being prepared can reduce
anxiety. This is self care. That brings us to the
concept of a self care plan. One of the problems we
hear from our colleagues is that many of you
know what stress management and coping skills
are that can be helpful, but you don’t have
time to implement them. When psychologists
look at this issue, we find that people are
more likely to follow a plan when it is written out, when it is very specific, and when it is tied to
a way of keeping track, such as a calendar
or a daily planner. For example, if you commit to
exercising three days a week, you are much more
likely to carry out that plan if you write it down, identify the actual day and time that you will
engage in the activity. It’s important to create
and practice a self care plan as a regular part
of your profession. When working during a disaster, it is even more important that
all healthcare professionals pro-actively
practice their self care plan to mitigate the
even higher probability of experiencing
workplace stress and burnout. Here are the basics – that is the minimal
aspects of self care – that are
referenced as the Core Four. They include: Regulated sleep. Know
how much sleep you need. Are you a 7 or 8 hour person? Work backwards and determine
what time you need to go to bed in order to get your designated
number of hours of sleeps. Physical movement is essential to getting stress
hormones out of your body. Walking is a great exercise. Walking in nature every
day will change your life. 10 minutes, 20 or 30
minutes, it’s doable, but you have to
choose to make the time. Active mental relaxation
includes mindfulness – or focusing on something simple
like breathing or walking, staying quiet;
meditation, guided imagery, calming music that
is timed to the breath. Make yourself a
playlist of music that is timed to a slow
breath so that you can listen whenever you anticipate needing
it or after a difficult day. These are a few
examples that can help you. There are a couple of apps
that might be helpful as well: Calm, Insight Timer, Headspace
are a couple examples of those that you can check out
to help you get started in the practice of
breathing and mindfulness. Research shows that social
supports and close relationships are good for our
physical and mental health. Make time to visit
those you support you – who understand and
accept how you feel – not people who
invalidate your concerns. And check in with family
members and other loved ones, even a text or a
brief call or a postcard can make us feel more connected. How do you connect with those that you care about
on a regular basis? Determine what change
you want to focus on. Ask yourself: What’s one thing I
would like to work on to reduce stress and burnout? Do I need anyone to help me? What cues or reminders
can help me to take action? When in my day will I most
likely be able to do this? What resources do I need? And how can I use
my self care plan to remain resilient
during disaster work? It’s recommended that
each person write out their own action plan and start fairly small
with easily achievable goals, then grow into a
more comprehensive plan once the early
planning goals are met. Remember, it’s
important to include the written self care
plan as part of your “go kit” to access and use while
working during a disaster. Let’s do a short
exercise together. All you need is a
piece of paper and a pen or an electronic device. Note three leisure activities
that allow you to destress – make it simple, routine things
that you know help to relax you. Then put a date next to each
activity within the coming week when you expect to be able
to engage in that activity and then put the exact time that
you can engage in that activity next to the event. It doesn’t matter if
you carry out the activity at the exact time that
you have written down there. You can easily
change it if you need, but the act of
creating these details are what will help
you act upon the plan. If things don’t
work out one day, just do it again
and keep trying. Don’t give up. As mentioned earlier,
monitoring your stress levels, your compassion fatigue, secondary
traumatic stress and burnout can be a helpful
and objective way to monitor how you are doing. You can do this by using
a tool called the ProQOL 5. The ProQOL self assessment tool is the only scientifically
valid and reliable tool designed for those in the helping
professions specifically. You are the only person who
can control your stress levels, so if you have a
reasonably accurate idea of how you are doing, you are more likely to be able
to address it realistically. This is a tool that
is accessible online and free to use. The author, Dr. Beth Stamm just
asks that you do not change it and provide proper citation
if you refer to it or copy it. There are only 30
questions in total and you can score it yourself. Be honest and open
with your responses. The scale is broken
down into three subscales. Compassion fatigue and
secondary traumatic stress is the first subscale, the second is
compassion satisfaction, which is known to counter
some of the negative effects of compassion fatigue, and the third
subscale is burnout, which is a measure
that looks at how much the administrative
issues may be interfering with the satisfaction that
you get from the work itself. The link to the
ProQOL is and it is recommended
that staff use this tool every few months or so to help
monitor how they are doing. Also, use the ProQOL during or
following a disaster assignment. The interesting
thing I have observed about people
engaging in this assessment is that they are
often very pleased to find that they are managing better
than they thought they were and this seems to
spur them on to commit to their stress management plan. This scale can help you
get an outside perspective of where you are and learn
something about yourself from it that can lead you
towards the right direction in terms of
professional development, making you a more competent
and confident counselor and healthcare professional. Now that you have
an understanding of and know how to
monitor compassion fatigue and secondary traumatic stress and how to engage
in self care planning, let’s look at some
skills you can develop both personally
and professionally that will help get you to
carrying out your action plans. Start by interrupting the
physical stress response. Specifically, plan and
maintain a balanced lifestyle as an active part of
your professional commitment. Know how to
control your breathing in a way that destresses you – and I will walk you through a couple of examples
of this in a minute. Engage in body movement – stretching and walking
are two of the simplest ways you can interrupt the
automatic stress response. Integrate some low
impact brief exercises that may get you on your way to regularly practicing
how to manage your work stress so it doesn’t interfere with
your relationships at home, with your spouse, your partner,
your kids, parents, friends. So that it doesn’t
build to the point of causing you to lose
your job or your health in terms of a
stroke, a heart attack or secondary problems like
diabetes from a poor diet, or emphysema from smoking or liver disease
from excessive drinking – some of the most common health
problems that many adults in the U.S. suffer from and which are
directly connected to stress. Then as mentioned
in the Core Four, evaluate the meals
you eat at the workplace and away from work. What we eat is one
of the ways that many of us control our stress levels. Can we plan better
so we’re less stressed when deciding what to eat? Also, sleep is a
very significant player in stress and
performance levels. Know how much sleep
you need to function well. What helps you go to
sleep and stay asleep? Is it soft music, or
a white noise machine? Is it making sure
the television is off and that you
haven’t had any sugar in the two hours prior to sleep? You probably already know
these things about yourself. Are you acting on them? And again, the
research is very clear that social
supports are critical for good physical
and mental health. These are basics that
we need to include here and they are a
personal responsibility. Then we move to
changing our cognition because stress is
all about perception. One person can see a
situation as stressful and the other does not. Our thinking
controls our actions, thus we can actually control how
our body responds to stress. Cognitive behavioral therapy is
one of the most effective ways to change how we
perceive things, therefore
changing our cognition. We will be looking at ways
to change and to strengthen our cognition in
another webinar in the series so we can focus on those skills. Some simple ways to
teach your mind to focus is with the use of
mindfulness, meditation, affirmations and guided imagery. These tools are great because
you don’t have to do anything, you can turn them on. You don’t even have
to consciously listen as your mind will
take in the messages, but they are even more powerful
when you do focus on them. Listen to different
voices and messages to see which ones you like. And as mentioned earlier, there are different apps that
are online and several are free. Try them out for yourself. So when you look back
at your self care plan and see what you identified as
helping decrease your stress, decide what action
you are going to take. That is, what
behavior will you engage in to decrease your stress? It can be as simple as saying
no to going out on a night when you’re most exhausted, and your defenses are down, so that you don’t drink too much and just ruin all your self
care plans for the weekend. Whatever behavior change
you make, start somewhere. Remember none of these skills – personal or professional will
work if you don’t use them. Self care planning is
particularly important to practice during and following
a disaster assignment. I promised to show you a couple
of simple breathing techniques. One of the most important
stress management skills is breathing in a way that
helps get rid of toxic stress. Are you a shallow breather? That is someone who normally
doesn’t take in full breaths, thus, not really ever getting a good amount of
oxygen in the body. This is so important
because full and deep breaths help us to get toxic stress
hormones out of our body. You should know how to
breathe fully and deeply, and practice this. It’s especially
helpful when under the stress because it controls
the nervous system, it keeps the rapid
heartbeat under control, which is so
uncomfortable when it happens and usually makes us think
we are having a heart attack. You cannot have an
anxiety driven rapid heartbeat and breathe
deeply at the same time. It’s physically impossible. So learn some
breathing exercises. On the screen is a
simple one that tells you to take in a normal
breath through your nose with your mouth closed and then to exhale very
slowly through your mouth, concentrating on a calming
word like ‘calm’ or ‘relax’; and then count to 4 before
taking the next breath. Do this about 10 times, and it will reduce
the rapid heartbeat from anxiety and stress
and slow your breathing. Alternately, you
can do another one that’s very simple to remember, it’s called the box breathing
because it is 4x4x4x4. Start by counting to 4
slowly while breathing in, hold it for 4 seconds, release the breath
to the count of 4 and then count slowly to
4 before beginning again. Doing this several
times a few times a day will help keep stress down and get oxygen
flowing through your body, pushing toxic stress out. Working on a disaster can
be an extraordinarily busy and stressful assignment
for healthcare professionals. You may not have time for much, however taking a
few moments to focus on simple breathing techniques is
doable in a disaster setting. Another way to address
stress is to figure out when you need to take a break. If you remember
this Acrostic HALT, it spells out the
need to recognize when you are Hungry,
Angry, Lonely or Tired. Each of these means
it’s time to stop, breathe, take a break and
implement self care. If you recognize you’re hungry, take a short
break to eat something. If you’re angry, do some breathing exercises
or counting to calm yourself. If you’re lonely, seek out your
buddy or make a quick call home. And if you are tired, figure out when the earliest
time is that you can get rest. Can you take a break right away or do you need to
cancel your evening plans and get some much needed sleep? What is it that you need to do? Research tells us that
we can decrease stress and build our own
personal resilience with this list of attributes. While we might not
all be able to develop all of these characteristics, we can focus on increasing
several of these abilities to strengthen our
capacity to deal with and even decrease
stress both in the workplace and in our personal lives. Create a positive attitude: Give yourself
positive messaging. For example, remind
yourself that you’re strong and you can grow
stronger and more wise as you handle life’s challenges. We tend to believe
what we tell ourselves. Develop self-awareness: Understand what
you’re feeling and why. The self care planning
process can help increase your self awareness
around stress management. Develop internal control: Know that while you can’t
control all the circumstances that occur around you, you can control how you
respond to those circumstances, and that makes
all the difference. Internal control helps
create a better attitude and the course
that our lives take. Developing optimism can
help you become more resilient by giving you a
sense of competence, confidence and control
in how you view the world. Social Support: Those with strong
networks of social support tend to stay healthier
and happier throughout life, and they tend to
cope well with stress. And those with a
sense of humor about life tend to experience
life as less stressful, are able to bond with others
during difficult times, too. If you can take a step
back from a difficult situation long enough to
maintain your sense of humor, you will be more resilient, too. Exercise has been correlated with stronger
levels of resilience. This may be
due to the effects the endorphins
have on one’s mood, or the physical health benefits
to those who exercise, or both. Studies have shown that
those who are more spiritual tend to be more resilient. Perseverance: Don’t give up on your situation; don’t stop working
towards getting through it. Trust the process. Patience is a perception and thus can be
controlled by how we think. For many healthcare providers, we can much more easily
be patient with others. The gift here, is to be
patient with yourself – just do your best and
know that’s ok, you’re human. So, to summarize what
you can do personally, start by taking the time to
create a written self care plan and schedule the
activities within each of the different areas that
you would like to address. Use the plan as a regular part
of your professional practice and step it up
even more proactively during and after a
disaster assignment. Make time for
personal social support. Family support has been related
to less emotional exhaustion at work, and social support is
related to a sense of efficacy. Talk about your self care plan with someone in your
personal support circle and check your plan routinely. Are you engaging in
the self care activities you identified as helpful? How often are you doing so? Is the plan realistic or do you
need to make some adjustments so that you can
actually meet your goals? Seek your own therapy
if you’re distressed. Cognitive-behavioral therapy has
resulted in positive effects on traumatic stress, burnout, and produced greater effects than other types of
workplace interventions. This type of
treatment is usually very focused and short term. Take the time. And monitor your self: your levels of stress,
your attention to self care. We will talk about another
tool to do so in just a minute. Let’s look at ways to increase your professional
stress management skills. One of the top suggestions is
to utilize collegial support. Peer support is emerging as
one of the most helpful ways that providers support
each other in the workplace. Mental health
professionals report that valuable support comes
from peers or colleagues who understand and
accept how you feel. This can be done by
identifying a buddy. It’s always helpful to
have a work buddy – someone who understands
you and the work situation – not someone who
invalidates your worries. Peer support can be individual, but also very helpful when
conducted in group settings, like group supervision,
case conferencing, workgroups. The important part of peer
support is to be authentic in sharing your concerns. You can still
keep confidentiality by not mentioning
patient or client names, brainstorm and problem
solve with your peers. Hear their suggestions. Peers should come from a place
of mutual respect and equality – rather than a hierarchy – so there are no titles
used in peer settings. Managers, supervisors
and line staff can all learn from each other. Peers also check in with each
other – especially buddies – providing follow up
contact and supportive words or recommendations routinely and most
especially after an emergency or difficult incident
with a patient or a client. Often we hear staff
say they are happy to forgo supervision meetings. This is not really
to your advantage. Effective
supervision has been found to be associated
with lower levels of CF and STS and burnout, and higher levels of personal
growth and satisfaction, for both new and
experienced providers, especially those working with
trauma patients and clients. You are entitled to
and deserve to have access to supervision routinely. Take advantage of
it and use it well. Bring your agenda
items in and prepare to share your concerns in
an honest and productive way. Expect feedback
and recommendations for follow up actions. Ask for them.
What is your advice? How do I best handle this
patient or that situation? Patient and clients caseloads should be varied
wherever possible. Certain staff
members should not be taking all the most difficult cases. No one needs to be a hero. healthcare providers use some of the most
integrated team approaches and that’s a great strength. Individuals and
supervisors should work to vary every staff member’s caseload, so each person can learn
and improve their skills and build more capacity to manage difficult and
stressful traumatic situations. Individuals
should make every effort to avoid working too long alone without checking in or
working long hours routinely. Practice only within
your role and your abilities. If you suddenly find
yourself trying to do something you have not done before or don’t really have
the skills to do, it may be a sign you
are in a stressful situation that is
distorting your judgment. Also, stick to the
rules of your profession. Remember it’s a rare occasion
when the rule don’t apply. Again, if you’re
finding yourself thinking, ‘well, this is different,’ it may be a sign of poor
decision making due to stress. Make sure students,
interns and all staff working with trauma patients
and clients are aware of CF and STS and its
potential development. Everyone needs to
be on the same page in order to support each other through these
stressful work environments. Each should have the training, the psycho-education about
how to identify the symptoms from each of the contexts, as well as what helps
to decrease symptoms. Everyone should be encouraged
to seek peer and other supports as they need it. Common attitudinal
obstacles to self-care for healthcare
providers include thinking, “It would be
selfish to take a break;” “Others are working
hard, so should I.” “The needs of
those I’m supporting are more important
than my own needs;” “I can contribute the
most by working all the time;” and then the famous,
“Only I can do x, y, or z.” Make sure staff understand
and identify personal ways they may protect themselves
from patients and clients projections of
their pain, anger, fear, frustration and trauma. Mastering this,
controlled empathy, is a necessary skill
for healthcare providers. Role play boundary setting
as a way of helping staff understand the importance of
doing this and how to do it. Whether that means
saying no, or delegating, or asking for help,
or removing themselves from a heated or
conflicting situation. Find out what issues
they struggle with most and practice how to handle them. We as a society do
not learn how to manage very distressing
emotion in others, even in our
patients and clients. Emotions like fear, grief,
conflict, disappointment. In the healthcare setting, staff have to deal
with these all the time and when asked,
most staff tell us they have never
learned techniques to help with these everyday
occurrences in their workplace. These would be useful trainings for improving
staff’s professional skills in working with patients,
clients and their families and would also
decrease their stress due to not knowing how to help. So, if we look at what you
can do on a professional level, we see there is a lot
that can help you avoid and address
CF/STS and even burnout. Use peer supports and
professional supervision. This is critical. Use your breaks and lunch
time for stress management, not to catch up on work. Take a ten minute walk
in nature on your break, or do some mindfulness
exercise, call home, stretch, sing, dance. Use your benefit time routinely. Schedule time
off across the year, those times when you can take
your vacation or personal time. Research is very
clear we need to be living a balanced life of work
time and leisure time. We are more
focused and productive when we have
sufficient time off, are rested and
are less stressed. Even more so when we engage in
body movement and mindfulness. It is possible you can do work
better or even get more done when you are refreshed
and able to think clearly as a result of using
time off to recharge. Take the time to
monitor yourself. Use your self care plan
and use the ProQOL and feedback from trusted
colleagues and loved ones to help you get an accurate
sense of how you are managing. In summary, all health
care providers can benefit from learning what to do on both a professional
and personal level. How to identify your stressors, create a self care plan for use as a regular part
of your professional practice and certainly during and
following a disaster assignment. Personal and
professional supports will help us mitigate the
negative effects of CF and STS, so we need to allow ourselves
to seek the type of support we want and then to monitor
our self care activities on a regular basis. There is nothing
on any of these lists that is beyond your ability. It’s a matter of education,
willingness and practice. You may be
saving your profession and very likely, your health. Also, know that
you are not alone. There are many others
struggling with these issues and we can be a
help to each other. In addition to using supervision
and working with your buddy, access the
resources that are out there to increase your understanding
of how to tackle these concerns. There are many
resources that can inform you further about acute stress, posttraumatic stress and
secondary traumatic stress and compassion fatigue. ASPR TRACIE and SAMHSA DTAC
have Educational Fact Sheets, webinars and podcasts that
are free and accessible online. Some are for survivors,
other are for helpers, some are for parents
and other caregivers. Check them out. And for those of you who
are interested in the research, the National Center for Posttraumatic
Stress Disorder’s website will bring you to
the Pilots database, which is the most comprehensive
collection of literature on these subjects. These articles are also free and
downloadable once you register. Thank you for attending
this webinar sponsored by ASPR TRACIE. We hope it was an
informative one and useful and that you can
use this material to help improve your
sense of well being, in addition to improving
your confidence in your ability to continue the work that you do in this most
important profession. Our wish for you is to
remember your own good will and your heart so
that you can continue to take care of your
patients, your clients, and yourself in the
best ways possible. And we encourage you to
access the rest of the videos in this series. Produced
using taxpayer funding by the U.S. Department of
Health and Human Services.

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