A focus on professional development in palliative care

March 2018

Facilitator: Margaret Fitch

Plan for session

Highlight challenges in palliative care/end-of-life nursing

Discuss impact of these challenges on nurses

Describe possible approaches for managing the impact(s)

Defining palliative care

The World Health Organization defines palliative care as

“an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

Benefits of palliative care

Provides relief from pain and other distressing symptoms

Affirms life and regards dying as part of the normal process of living

Neither hastens nor prolongs death

Integrates the psychological and spiritual aspects of patient care

Offers a support system to help patients live as actively as possible until death

Offers a support system to help the family cope during the patient’s illness and throughout their own bereavement

Enhances quality of life, and may also positively influence the course of illness

Is offered early in the course of the illness, in conjunction with other therapies that are intended to prolong life, and includes investigations to better understand and manage distressing clinical complications.

Hospice palliative care (CHPCA)

Aims to relieve suffering and improve quality of living and dying

Strives to help individuals and families

Address physical psychological social spiritual and practical issues and their associated expectations needs hopes and fears

Prepare for and manage self-determined life closure and the dying process

Cope with loss and grief during the illness and bereavement experiences

Aims to treat all active issues and prevent new issues from occurring

Promotes opportunities for meaningful and valuable experiences, personal and spiritual growth, and self actualization

Benefits-hospice palliative care

Hospice palliative care engages individuals and their families in planning for the care they want at different stages in their illness based on their own goals and values and on a clear understanding of their prognosis and treatment options (advance care planning).

When people have access to palliative care services, they report fewer symptoms, better quality of life, and greater satisfaction with their care.

The health care system reports more appropriate referrals, better use of hospice care, fewer emergency room visits and hospitalizations, and less use of ineffective intensive interventions in the last days of life.

Nurse role in palliative care

Nurses advocate for and support persons in their experience of living-dying.

Nurses provide comprehensive, coordinated, compassionate and holistic care.

PC nursing practice attends to pain and symptom management and provides psychosocial, grief and bereavement support.

PC nursing includes all areas of practice: clinical, education, administration, research and advocacy.

Dimensions of Nursing in Palliative Care

Valuing – believing in the intrinsic value of others, the value of life and that death is a natural process.

Connecting – establishing a therapeutic connection (relationship) with the person and their family through making, sustaining and closing the

relationship.

Empowering – providing care in a manner that is empowering for the person and family.

Doing for – providing care based on best practice in pain and symptom management, coordination of care and advocacy.

Finding meaning – helping the person and family find meaning in their life and their experience of illness.

Hospice palliative care

General units…

Specialized units

Specialized (inter-professional) teams

Acute care settings

Home care and community setting

Long term care/nursing home settings

A couple of questions…

How many care for palliative care/end-of-life patients?

What do you find are the most challenging issues you have to face or manage?

Some challenges

Heavy workload

Not enough resources/equipment

Complex patient situations

Complex family situations

Tensions among staff

Other…

event individual response outcome

stimulus impact cognitive well-being

(changed emotional

state) behavioral

Event Individual

Environment

APPRAISAL

Psychological Stress

The relationship between the person and the environment that is appraised by the person as taxing or exceeding his/her resources and endangering well-being

The judgment that a particular person–environment relationship is stressful and hinges on cognitive appraisal

Distress

an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with situations

extends along a continuum from common, normal feelings of vulnerability, sadness, and fears, to problems that are disabling (e.g., true depression, anxiety, panic, feeling isolated, spiritual crisis) (Holland, 1999)

Conceptualizing Psychosocial Distress

Normal

Distress

Severe

Distress

• Fear

• Worries

• Sadness

• Depression

• Anxiety

• Family Dysfunction

• Spiritual Angst

Impact of distress

How do you know you are feeling distress?

Impact can be varied

Physical

Emotional

Psychological

Spiritual

Interferes with problem-solving…relationships…productivity

Compassion fatigue (CF) (to weep for a stranger)

fatigue, emotional distress, or apathy resulting from the constant demands of caring for others

symptoms are normal displays of stress resulting from the care giving work you perform on a regular basis

Symptoms of CF in self Excessive blaming

Bottled up emotions

Isolation from others

Receives unusual amount of complaints from others

Voices excessive complaints about administrative functions

Substance abuse used to mask feelings

Compulsive behaviors such as overspending, overeating, gambling, sexual addictions

Poor self-care (i.e., hygiene, appearance)

Legal problems, indebtedness

Reoccurrence of nightmares and flashbacks to traumatic event

Chronic physical ailments such as gastrointestinal problems and recurrent colds

Apathy, sad, no longer finds activities pleasurable

Difficulty concentrating

Mentally and physically tired

Preoccupied

In denial about problems

Organizational symptoms of CF

High absenteeism

Constant changes in co-workers relationships

Inability for teams to work well together

Desire among staff members to break company rules

Outbreaks of aggressive behaviors among staff

Inability of staff to complete assignments and tasks

Inability of staff to respect and meet deadlines

Lack of flexibility among staff members

Negativism towards management

Strong reluctance toward change

Inability of staff to believe improvement is possible

Lack of a vision for the future

Burnout

a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress

occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands.

as the stress continues, you begin to lose the interest and motivation that led you to take on a certain role in the first place.

reduces productivity and saps your energy, leaving you feeling increasingly helpless, hopeless, cynical, and resentful…eventually…you have nothing more to give.

Causes of burnout

Work-related causes of burnout Feeling like you have little or no control over your work

Lack of recognition or reward for good work

Unclear or overly demanding job expectations

Doing work that’s monotonous or unchallenging

Working in a chaotic or high-pressure environment

Lifestyle causes of burnout Working too much, without enough time for socializing or relaxing

Lack of close, supportive relationships

Taking on too many responsibilities, without enough help from others

Not getting enough sleep

Personality traits can contribute to burnout Perfectionistic tendencies; nothing is ever good enough

Pessimistic view of yourself and the world

The need to be in control; reluctance to delegate to others

High-achieving, Type A personality

Are you on the road to burnout?

You may be on the road to burnout if:

Every day is a bad day.

Caring about your work or home life seems like a total waste of energy.

You’re exhausted all the time.

The majority of your day is spent on tasks you find either mind-numbingly dull or overwhelming.

You feel like nothing you do makes a difference or is appreciated.

Comparing…

Stress

Characterized by over engagement

Emotions are overactive

Produces urgency and hyperactivity

Loss of energy

Leads to anxiety disorders

Primary damage is physical

May kill you prematurely

Burnout

Characterized by disengagement

Emotions are blunted

Produced helplessness and hopelessness

Loss of motivation, ideals and hope

Leads to detachment and depression

Primary damage is emotional

May make life seem not worth living

Coping

Constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person

(process oriented; requires mobilization; are efforts to manage – minimize, avoid, tolerate, accept)

Coping as a Process

Concerned with what a person actually does

Examined within a specific context/ particular situation

Change in thoughts/actions as events unfold

Coping Function (purpose)

Problem-focused managing or altering the

problem/environment causing distress

Emotion-focused regulating emotional response to the

problem

Major Categories of Resources

Health and energy

Positive beliefs (control, hope)

Problem-solving skills

Social skills

Social support

Material resources

Two major pathways…

Personal stress management

Personal professional development

Dealing with compassion fatigue

Be kind to yourself.

Enhance your awareness with education.

Accept where you are on your path at all times.

Understand that those close to you may not be there when you need them most.

Exchange information and feelings with people who can validate you.

Listen to others who are suffering.

Clarify your personal boundaries. What works for you; what doesn't.

Express your needs verbally.

Take positive action to change your environment.

Boost your ability to stay on task

Learn how to reduce stress in the moment.

Manage troublesome thoughts and feelings.

Motivate yourself to take the steps that can relieve stress and burnout.

Improve your relationships at work and home.

Rediscover joy and meaning that make work—and life—worthwhile.

Increase your overall health and happiness.

Coping with stress…burnout

Turn to other people…

Reframe how you look at work

Re-evaluate priorities

Make exercise a priority

Support mood and energy levels by eating a healthy diet

Turn to other people

Invest in your closest relationships

Try to be more social with your coworkers

Limit your contact with negative people

Connect with a cause or a community group that is meaningful to you

Power of giving…(new friendships)

Reframe how you look at work

Try to find some value in what you do

Find balance in your life

Make friends at work

Take time off

Re-evaluate priorities

Set boundaries

Take a daily break from technology

Nourish your creative side

Set aside relaxation time

Get plenty of sleep

Make exercise a priority

Aim to exercise for 30 minutes or more per day

Try rhythmic exercise

Mindfulness…awareness of body and surroundings (not intrusive thoughts about work)

Eat a healthy diet

Minimize sugar and refined carbs

Reduce intake of foods that can adversely influence your mood

Eat more Omega-3 fatty acids

Avoid nicotine

Drink alcohol in moderation

Professional development

How clear are you about the role/responsibilities assigned to you?

What competencies do you need in your practice role? To fulfil your responsibilities?

Do you feel you have the knowledge and skill necessary for your role?

How comfortable do you feel in the performance of the competencies?