Staff Stress and Resilience - CE/NCPD

ALERT

If a health care team member’s resilience is tested by extremely stressful working conditions, a challenging patient, or a difficult situation, ensure that there is a reproducible process in place that evaluates the concern and identifies and implements solutions.

OVERVIEW

Caring for patients during a disaster or pandemic exposes health care team members to the entire spectrum of human emotion, sometimes during a single day. Caring for ill or injured patients can result in repetitive stress that can reach acute levels of stress.^{undefined#ref7">7} Maintaining equilibrium, professionally and personally, in the face of fear, the unknown, anger, grief, and perceived hopelessness, can be challenging. Frequent exposure to high levels of suffering and distress can lead to compassion fatigue.⁶

Compassion fatigue is the result of exposure to prolonged, multiple stressors while providing care that exceeds one’s ability to successfully cope with those stressors.¹⁵ Compassion fatigue leads to physical, emotional, and spiritual distress.¹⁵ Some of the symptoms of compassion fatigue include sleep disturbance, irritability, anxiety, and loss of hope.¹³ For many health care team members, the negative effects of providing care are offset by the reward of work that they find meaningful. However, for some, the fatigue can lead to burnout, which involves a diminished sense of professional satisfaction and accomplishment.⁵ The negative effects of compassion fatigue do not only impact the health care team member providing care; they can also have a negative effect on patient outcomes.¹⁵

Health care team members should take steps to maintain their emotional wellness, with continued support from the organization, which plays an essential role in the maintenance of individual and team wellness.

When balance is lost in the workplace, health care team members begin to suffer the consequences of burnout and move from personal fulfillment and job satisfaction to emotional exhaustion and stress.⁵ The stressors of compassion fatigue and the cumulative effects of burnout can cause team members to leave the health care profession. A healthy balance is achieved through a person’s resilience, or the ability to respond and adapt well to the stressors of the job. The ability to be resilient typically determines how an individual gauges personal success and how that individual determines positive approaches to the next task. Occupational stressors that overwhelm a team member’s resilience can lead to decreased quality of care, damaged team morale, and staff turnover.

Resilience can be learned, and it can be regained. It grows with experience and closely follows self-confidence. To cultivate and nurture resilience, individual, group, and organizational efforts should be made to protect health care team members from being overwhelmed. Confronting suffering, while also being open to and present in that suffering, should be the goal of these efforts.⁵ Self-care and stress management are vital in decreasing compassion fatigue and the risk for burnout.² Focused awareness of the challenges at work and of the team member’s own emotional responses to those challenges is integral to effective self-care.^2,11 Meditation practices, such as mindfulness, as well as individual rituals (e.g., memory sharing), can greatly enhance resilience and awareness.^4,11

Self-care on the individual level is the practice of taking actions to preserve one’s well-being, including a cultivation of self-awareness, resilience, and mindful vulnerability. Protective team factors provide democratic conflict management, a safe environment for candid discussion, and commitment of the group to work together on difficult cases. Organization practices should raise awareness about services, increase health care team members’ use of services available, and protect the autonomy of service.

ASSESSMENT AND PREPARATION

Assessment

1. Assess the health care team member for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.⁹
2. Identify the root of the health care team member’s concern. Is it clinical, social, emotional, or spiritual?
3. Help the health care team member reflect on the source of the team member’s negative emotional response.
4. Assess the health care team member’s situation.
   1. Does the team member require the assistance of another discipline or mentor?
   2. Does the team member have the appropriate skill set to care for an assigned patient, family, or situation effectively?
   3. Does the team member recognize a limitation that is hindering intervention?
5. Evaluate the urgency of the health care team member’s concern.
6. Determine which self-care tools have been used with success and which may be introduced or considered.
7. Help the health care team member reflect on the source of the team member’s negative emotional response.

Preparation

1. Consider the health care team member’s values and goals. These may differ depending on experience, education, practice setting, age, and other personal and professional factors.
2. Understand that health care team members are often exposed to acute suffering. Create a space that allows for candid discussion of difficult and challenging cases. Ideally, discussions should be interdisciplinary to take advantage of multiple perspectives.
3. Recognize that health care team member care should be a holistic interdisciplinary approach with consideration for the health care team and individual and is achieved through effective communication and teamwork.²
4. Define self-care as it applies to work and life outside work.
5. Create an environment of trust and safety.
6. Create an environment that advocates for health care team member needs.

STRATEGIES

Self-Care Practices

1. Implement informal practices to promote mindfulness and reflection.⁸
   1. Walking meditation
   2. Mindful pauses before patient interaction
   3. Focused breathing
   4. Therapeutic listening
   5. Mindful pauses after patient interaction
   6. Journaling, while maintaining patient privacy
2. Use debriefing as a method for sharing insight and receiving guidance.
3. Implement informal mindful practices outside of work (e.g., meditation, yoga, martial arts, reflective journaling, art, exercise).

   Rationale: Finding meaningful outlets for dealing with stress and negative energy assists health care team members with creating a healthy separation between work and private life.

4. Engage in rituals (e.g., grounding prayer, reading a meaningful poem, bereavement calls).³

   Rationale: Rituals are familiar, reproducible processes that can return the health care team member to focus or calm the mind amid sensory overload.

5. Engage in activities that promote the development of personal resilience such as exemplifying a positive attitude, practicing self-reflection, and seeking mentorship from others.¹²
6. Take actions that nurture the mind, body, and spirit and engage in self-care. Understand that at times, self-care may require that one needs to say no to a request.¹

Team Practices

1. Promote open and honest communication within the interdisciplinary team.
2. Encourage burden sharing among health care team members to identify unique differences and skill sets to meet the challenges of a difficult case.
3. Create some time and space for breaks to support health care team members where the focus is discussing the emotional impact of difficult patients or situations.
4. Encourage mentorship, if possible, to facilitate open communication.
5. Recognize successes and celebrate milestones.
6. Schedule debriefing sessions, as appropriate, to discuss difficult cases and situations. Discuss what may be needed and available for team member support.

Organization Practices

1. Maintain clear and consistent messages highlighting the importance of self-care.
   1. Posters encouraging resilience through mindful self-care
   2. Organization-wide programs that identify team members at risk (e.g., Schwartz Rounds^® [a regularly scheduled forum that brings team members together with the goal of processing difficult emotional and social issues faced in caring for patients and families]).¹⁰
2. Provide education about resources and specifically about updates on disasters or pandemics.
3. Provide information on the status of a crisis.

   Keeping the health care team informed and providing accurate information is essential to minimizing stress.

   Rationale: Unreliable or inaccurate information can increase stress.¹⁴

4. Assess the need for an employee assistance program (EAP) consult and seek a consult as appropriate.

REASSESSMENT

1. Continue to monitor health care team members for stress and burnout.
2. Monitor the effectiveness of support measures offered to health care team members.

EXPECTED OUTCOMES

• Improved staff resilience
• Use of resources for self-care
• Open discussion among health care team members about challenges
• Improved interaction among health care team members
• Improved interaction between health care team members, patients, families, and caregivers
• Reduced turnover

UNEXPECTED OUTCOMES

• Unmanaged stress
• Refusal to use self-care resources
• Ineffective discussion
• Increased turnover
• Loss of team morale
• Decrease of productivity
• Patient care negatively affected

DOCUMENTATION

• Usage of available resources
• Notes from debriefing or discussions
• Unexpected outcomes and related interventions

REFERENCES

1. American Psychiatric Nurses Association. (n.d.). Self care tip sheet for nurses. Retrieved December 4, 2023, from https://www.apna.org/files/public/APNASelfCareTipSheet.pdf
2. Baqeas, M.H., Davis, J., Copnell, B. (2021). Compassion fatigue and compassion satisfaction among palliative care health providers: A scoping review. BMC Palliative Care, 20(1), 88. doi:10.1186/s12904-021-00784-5 (Level I)
3. Buzzanell, P.M. (2018). Organizing resilience as adaptive-transformational tensions. Journal of Applied Communication Research, 46(1), 14-18. doi:10.1080/00909882.2018.1426711
4. Conversano, C. and others. (2020). Mindfulness, compassion, and self-compassion among health care professionals: What’s new? A systematic review. Frontiers in Psychology, 11, 1683. doi:10.3389/fpsyg.2020.01683 (Level I)
5. Cross, L.A. (2019). Compassion fatigue in palliative care nursing: A concept analysis. Journal of Hospice & Palliative Nursing, 21(1), 21-28. doi:10.1097/NJH.0000000000000477 (Level VI)
6. de Oliveira, S.M. and others. (2019). Prevention actions of burnout syndrome in nurses: An integrating literature review. Clinical Practice and Epidemiology in Mental Health, 15, 64-73. doi:10.2174/1745017901915010064 (Level I)
7. Frey, R. and others. (2018). Burnout, compassion fatigue and psychological capital: Findings from a survey of nurses delivering palliative care. Applied Nursing Research, 43, 1-9. doi:10.1016/j.apnr.2018.06.003 (Level VI)
8. Green, A.A., Kinchen, E.V. (2021). The effects of mindfulness meditation on stress and burnout in nurses. Journal of Holistic Nursing, 39(4), 356-368. doi:10.1177/08980101211015818 (Level I)
9. Joint Commission, The. (2023). National Patient Safety Goals for the behavioral health care and human services program. Retrieved December 4, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_bhc_jan2023.pdf (Level VII)
10. Maben, J. and others. (2021). Realist evaluation of Schwartz Rounds^® for enhancing the delivery of compassionate healthcare: Understanding how they work, for whom, and in what contexts. BMC Health Services Research, 21(1), 709. doi:10.1186/s12913-021-06483-4 (Level VI)
11. Orellana-Rios, C.L. and others. (2017). Mindfulness and compassion-oriented practices at work reduce distress and enhance self-care of palliative care teams: A mixed-method evaluation of an “on the job” program. BMC Palliative Care, 17(1), 3. doi:10.1186/s12904-017-0219-7
12. Prosser, S.J., Metzger, M., Gulbransen, K. (2017). Don’t just survive, thrive: Understanding how acute psychiatric nurses develop resilience. Archives of Psychiatric Nursing, 31(2), 171-176. doi:10.1016/j.apnu.2016.09.010 (Level VI)
13. Xie, W. and others. (2021). The prevalence of compassion satisfaction and compassion fatigue among nurses: A systematic review and meta-analysis. International Journal of Nursing Studies, 120, 103973. doi:10.1016/j.ijnurstu.2021.103973 (Level I)
14. Yumiya, Y. and others. (2019). Unreliable information as a risk factor for worse mental fatigue among residents in Fukushima after the nuclear power station accident. Tohoku Journal of Experimental Medicine, 248(4), 261-272. doi:10.1620/tjem.248.261 (Level VI)
15. Zhang, Y.Y. and others. (2018). Determinants of compassion satisfaction, compassion fatigue and burn out in nursing: A correlative meta-analysis. Medicine, 97(26), e11086. doi:10.1097/MD.0000000000011086 (Level I)

ADDITIONAL READINGS

Ruiz-Fernández, M.D., Pérez-García, E., Ortega-Galán, Á.M. (2020). Quality of life in nursing professionals: Burnout, fatigue, and compassion satisfaction. International Journal of Environmental Research and Public Health, 17(4), 1253. doi:10.3390/ijerph17041253

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Loraine Fleming, DNP, APRN, PMHNP-BC, PMHCNS-BC

Published: January 2024