Stress Management in the Healthcare Setting

Stress Management in the Caregiver Setting

An increasing body of evidence points to the intensity of the labor involved in caring, and the impact it has on the caregiver in a healthcare setting. Whether lay or professional, it seems that the potential for suffering among caregivers is enormous. When a person reaches a state of physical, emotional or mental exhaustion, burnout occurs, and it appears to affect both lay and professional caregivers alike. Almberg's study, for example, suggests that exhaustion and burnout from caring happen in many different cultures and that 'relatives who have been giving caregiver for many years may experience similar emotional exhaustion to that suffered by staff' (Almberg et al. 2007). Whether lay caregivers would express their state as burnout is questionable, since it tends to be a term mostly used in professional discussion, but there is evidence of high levels of stress and illness among informal or lay caregivers (Henwood 1998). Lay caregivers, in one study (Princess Royal Trust 2009), felt that it was not even of interest to professional caregivers whether they could cope or not. Over 70% of 1300 lay caregivers involved in this study reported that it was largely assumed that they would cope with looking after a person at home, and were not asked if they could do so. Are they not being asked because of ignorance, because of fears of what might turn up if they were asked, because of denial ... what is not known about does not hurt? Professional caregivers, however, are supposed to have special training which equips them to deal with the suffering of others dispassionately, maintaining a certain distance which 'protects' both them and their patients or clients.

Thesis: If work is our centre, but it fails us, for whatever reason, then we have literally lost our faith. The centre no longer holds and we may fall apart - showing all the signs and symptoms of stress and burnout, addiction and co-dependence.

Salvage (2005) writing from a nursing context and Dossey (1995) from a medical viewpoint both suggest that fostering the internalization of feelings, as part of the socialization of caregiver workers, has serious consequences for the caregiver. Doctors, nurses and others, including perhaps lay caregivers, are all given clear signals that we are supposed to act as if 'we can take it': don't complain, never ask for help, never call for more resources, no matter how difficult the situation becomes. If we break this unwritten rule, the response of the uncaring culture is often to blame the victim. The caregiver who complains may find themselves being asked 'What is wrong with you that makes you unable to cope?' instead of getting a response that recognizes that more help is needed. The impact of this attitude, this whole cultural approach to caring, is chilling. Evidence is accumulating about the price that is paid by caregivers, both lay and professional. The World Health Organization (WHO) (2004) saw burnout, the exhaustion and loss of function associated with stress at work, as a major problem for caregiver professionals. Factors such as inadequate resources, lack of involvement in decision-making at work, authoritarian leadership styles, excessive case loads and poor staff relationships are all cited as significant causes. Similar factors appear in a Health Education Authority report (1996), which noted the principal effects of stress as emotional symptoms (e.g. depression, hopelessness, despair, anger, frustration, reduced enjoyment at work and home, suicidal feelings), behavioral changes (e.g. poor concentration and decision-making, absenteeism, marital and work conflicts, increased use of tobacco and alcohol and physical effects (e.g. high levels of various illnesses such as infections, back pain and headaches. The report also highlighted a number of causes specific to the health services. Like the WHO report, it found the causes of stress to lie in heavy workloads and lack of support, but emphasized also ineffective communication and consultation systems, invasion of personal space and lack of respect for functional and professional boundaries and pressures leading to an inappropriate management style. Additionally things like loss of support in a work community through radical reorganization, financial considerations taking precedence over human resource considerations, and the problem of getting the right balance between the two, disputes between managers and medical consultants and between other groups of staff or lack of coordination between departments and between individuals were also included. One is also advised for that the patients and families not be more demanding following the Patient's Charter, threaten with physical and verbal abuse, not exclude from consultation on policy-making until after key decisions have been made, not to work to overload through lack of control of patient admissions and accelerated throughput from the reduction of waiting lists. Completely avoid as best practice, excessive paperwork - performance statistics that are quantitative and not qualitative, performance measures that distort decision-making, lack of trust between managers and staff and between disciplines. The WHO also advises that pressure on acute services, because of social services policies and practices, contracts negotiated without consultation with those who will be involved in fulfilling them or bringing together different organizational cultures as a consequence of change; are all detrimental.

There seems little doubt that many of the recommendation are colored by specific changes in the government sector over the past 20 years. During that time, enormous changes have taken place in workplace practices. Not coincidentally, large numbers of workers have left to take early retirement on sickness grounds or to start caregivers in independent practice. Many of the latter seem to have found their way as independent complementary therapy practitioners. Others have sought to learn such practices and integrate them into their work as a means of producing more holistic caring and better team relationships.

An organizational culture that does not nourish and caregiver for its staff often demonstrates the same symptoms of stress that appear in the staff themselves: an inability to function effectively, grasping at short-term or quick-fix solutions in an effort to resolve or hide the problem, blaming the victim rather than dealing with the cause. (Perhaps this also applies to societies in which individual members feel alienated or unsupported when caring for others at home.) In turn, if the organisation is sick, then the staff who identify with it may take on the same characteristics. 'We attach to the organisation (held in the mind) the same emotions so that, to a greater or lesser degree, the members of the organisation will experience the same feelings as a result of their interrelatedness with the holding environment' (Stapley 1996). In such settings, staff themselves will respond in a wide variety of ways.

Feeling helpless at work, we may resort to blaming everyone and everything around us for problems, perhaps internalizing this and blaming ourselves as well, especially when things go wrong and a patient or client suffers. Blaming is often a sign that we feel helpless in a situation (Stapley 1996), and it is closely related to another classic victim response - the whinge. Maya Angelou (2010) has a warning to offer us about this: 'So watch yourself about complaining, sister. If you can't change a thing, change the way you think about it. Whining is not only graceless, but dangerous. It can alert a brute that a victim is in the neighborhood.' Whining when we feel helpless is unlikely to produce a positive reaction from the manager, who is probably equally hard-pressed and caught up in the sickness of the organisation. Whingeing and whining are simply expressions of blaming the other for our problems. We try to justify our own status, self-esteem and effectiveness, to preserve some good feelings about ourselves in the face of a sick, often hostile, context. Nevertheless, whingeing is not the response of someone often labeled the 'negative personality' who always has something to complain about; it is a cry of pain in the face of helpless feelings and a hopeless organisation.

Whingeing and victim-blaming are serious problems for any individual or organisation, yet the difficulties go even deeper. Caregivers in organizations such as hospitals or community teams tend to blame the organization, while lay caregivers at home see the problem lying with the social services providers, or government, or society as a whole. In the face of helplessness, wherever we define the organisation to be, the sickness can be found 'out there'. It seems we find it very difficult to look clearly at what is going on around us, to look objectively and without attachment at the sources of our difficulties. After all, if a particular organisation is sick, and you're part of that organisation, and that organisation is part of society, then where does the 'blame' or the 'fault' originate? If only we had more money, staff, resources, nicer bosses, or whatever, then these would solve all our problems. With shoulders to the wheel and noses to the grindstone, we are in a very difficult position from which to look up and see how the world might be different. A cycle of victim behavior and blaming can come to characterize our every action, and for many, the personal consequences can be very serious indeed.

A study published by the Nuffield Trust (Williams et al. 1998) highlighted what had long been a subject of interest in the caregiver media: the levels of stress, sickness, absenteeism and burnout among professional caregivers. This report, from an authoritative and reputable organisation, brought together much of the prevailing evidence about the alarming state of the government funded workforce, which, despite a growing independent sector, is still responsible for giving over 90% of health caregiver. The report states that 'for the sake of good management and from simple compassion, both we and the Government should view these findings with due alarm, and accept shared responsibility for working quickly together to develop a program for action.

Studies highlighting stress and burnout in professional caregivers continue to mount. Kapur et al. (2009) demonstrated continuing high levels of stress among consultants and junior doctors, and a report by Sarah Boseley (2010) raised further alarms about stress among medical staff and the connection with high levels of drug and alcohol abuse. The Professions Allied to Medicine (1998), which includes radiographers, chiropodists, physiotherapists and dieticians, have also recently reported exceptional low morale and high stress levels among a survey of 1800 members. A further report (Borril et al. 1998) took account of the views of 11-000 government funded nursing staff. More than one-quarter were suffering from significant levels of stress, with nurses being 40% more likely to suffer stress than other groups of technical and professional workers with whom they were compared.

Stress Management for the Caregiver Givers

As awareness of the effects of stress upon caregivers has grown, an increasing number of steps have been taken to counter the problem. Lay caregivers may find that there is access to respite or counseling facilities to aid them in their work, and many voluntary associations offer help through mutual support groups. Organizations have tried to introduce measures which give more direct support to the staff and produce more staff-friendly managerial cultures. Other organizations and consulting agencies have been set up to research and advise on stress management. Books and papers on the subject fill the library shelves and occupy the attentions of countless program planners and educators. A scan through the literature suggests that a huge range of options have been attempted. These include devising policies to involve staff more in decisions at work, introducing staff counseling services, improving pay and conditions of service, monitoring workloads and reducing them where excessive, teaching stress management, assertiveness and even relaxation skills. Other options to have been implemented in the healthcare setting for stress management are introducing exercise and healthy eating programs, access to occupational health services, better training in interpersonal skills, developing and implementing anti-bullying and anti-discrimination policies at work, introducing personal development plans. Stress management has also been tackled through development of clinical supervision and debriefing groups among staff to provide professional support, introducing family-friendly policies (e.g. opportunities for caregivers breaks, job sharing, flexible hours, creche facilities), taking steps to reduce violence in the workplace, giving staff more control over their own work and developing stress management groups. Developing 'listening groups' (teams of staff who collect information about staff experiences to identify causes of stress and make recommendations) are often coupled with programs such as team building, opportunities for time out, access to continuing education and better job-related training, better caregivers counseling.

All of these and more have been implemented with varying degrees of success in a wide variety of organizations. Attempts to help staff feel valued and cared for are legion and each can contribute to making the caregiver's workplace or home a more supportive place. An incremental approach, where the more options that are in place, the better the possible outcomes, would seem to be logical. However, it is not our intention to discuss all these approaches in detail. Each has its part to play and we would not wish to question the usefulness of any of them.

The solutions often run the risk of 'fire fighting' -- dealing with the problem after it has arisen rather than preventing it in the first place. Doing the latter requires a wholesale commitment to examine and change the organizational culture, the way in which people work together, and the ways that individuals participate in that culture. While it is important to examine workplace conditions and organizational systems and cultures, and to effect changes that may help staff to cope with stress and make the workplace a better place to be, there are other issues operating. The evidence cited so far tends to skirt around these. What are these issues? We get some clues from the common concern of caregivers that relationships are not working - relationships with employers, with work colleagues, with patients - that something doesn't seem right. The 'something' appears to be not just decent rates of pay, stress reduction techniques or better working conditions - laudable as it is to address such matters. Even when these issues are rectified, the problems seem to persist. Something more is amiss, and it is the 'something more' that this paper will seek to explore.

Some hints as to the deeper nature of the problem can be found. Dossey (2005), for example, argues that 'At the core of the problem is the truth that we, as a civilization, have turned our communal back on healing ... ignoring the role of consciousness, soul, spirit, and meaning - stock items in the arsenal of authentic healers - we have birthed a malaise that permeates not just the healing profession, but our entire society'. Can it be that the alarming list of difficulties so far discussed that many caregivers face is only part of the story? Can it be that other factors are at work which seeks to undermine effective caring relationships? If the answer to both of these questions is 'yes', then we need to examine what is going on in the caring relationship in a little more detail. Workloads and working conditions undoubtedly have a part to play in causing stress in caring, yet there are other factors too. It is worth noting that problems with relationships are often mentioned as a stress factor, and attempts to deal with these include team-building work. Perhaps there are other areas where the quality of a relationship is having an impact upon a caregiver's performance. As we seek to change the system and its culture we have to remember that these are not disembodied entities with a life of their own 'out there': we are the culture, we are the system. Who we are, each and every one of us, counts - each of us brings our own particular building block to add to the whole.

Prevention and Treatment. Everyone is exposed to environmental and personal stressors. The question is, How does one reduce the long-term neuroendocrine disturbances induced by stress and emotional arousal? There are thought to be three modes: (1) conservation / withdrawal, (2) relatedness, and (3) relaxation. In the face of major stress an individual uses conservation/withdrawal mechanisms such as shock, projection, displacement, repression, rationalization, and depression. All these help allow time for the psyche to move toward a realistic appraisal of the situation and to move outward to connect with interpersonal supports. This outward movement of coping can then be followed by the relaxation so essential to maintenance of neuroendocrine regulatory mechanisms and protection from disease-producing disturbance. Forsythe and Compas (1987) believe efficacy in management of stressors immunizes the individual against emotional disruption. Individuals with more personal and environmental resources use more active coping strategies when encountering difficulties (Holahan and Moos, 2002). A core set of attitudes, including optimism, self-efficacy, a sense of control, connectedness and coherence, and life sources of happiness and pleasure, resulted in positive outcomes (Sobel, 2008).

The Harvard Community Health Plan found educational materials, relaxation-response training, and awareness training were all helpful in coping with stress (Sobel, 1995). Life experience in successful stress management may be the most important resource elders have. In the future, nursing research should address personality impact, control, social supports, life experience, types of stressors, and gender differences in stress management. All of these and other unidentified factors may be significant, and as yet we do not know what combination is most effective in mediating stress in the lives of elders. We do know that 80% of health and stress management is self-initiated, so it is important to provide elders with an array of self-caregiver tools. Teaching the elderly stress reduction often begins with progressive muscle relaxation (PMR). This has several benefits in addition to stress reduction because it facilitates awareness of muscle groups and those that are weak, tight, stressed, or inactive. Weinberger (1991) found, in reviewing the literature, that elders given PMR training had beneficial results in stress reduction and enhanced immune function and memory. The procedure for teaching progressive muscle relaxation and the sequential order of proceeding from one muscle group to another. There are numerous books on the market for professionals and for lay persons that provide various techniques for managing stress. Some provide detailed scripts to induce relaxation (Lusk, 1992).

Stress and Growth

Humans have two qualities that allow them to make the most or the least of stressful situations: awareness and choice. Stress mediators that are useful include religion, optimism, and hypnosis (Ishler et al., 2007). Stress filters are components in one's life that may be used to channel stress into growth (Schafer, 1978):

Health and fitness

A sense of control over events

Awareness of self and others

Patience and tolerance

Support groups

Personal stability zones or a strong sense of self

Beliefs and values

Selye (1974) notes that stress inventories need to be more cognizant of individual differences. Self-knowledge allows us to judge whether we are running above or below the stress level that suits us best. The elderly are more prone to the adverse effects of stress and anxiety on the heart. Increased heart rate, blood pressure, insomnia, and irritability are some of the signs we have exceeded our optimum stress level. In the frail old, confusion may be the signal of stress overload.

The term eustress is good stress engendered by challenging, demanding situations in which an individual still feels capable and in control (Selye, 2008). Attitudes may make an event a negative or a positive stress. Selye's recipe for good stress is (1) seek your own stress level, which fits you best; (2) choose your own goals, not ones imposed by others; and (3) altruistic egoism -- look out for the self by being necessary to others and earning goodwill. Competence and usefulness make this feasible. Selye's recommendations are important to nurses as well as their aged clients.

The term eustress is good stress engendered by challenging, demanding situations in which an individual still feels capable and in control (Selye, 2008). Attitudes may make an event a negative or a positive stress. Selye's recipe for good stress is (1) seek your own stress level, which fits you best; (2) choose your own goals, not ones imposed by others; and (3) altruistic egoism -- look out for the self by being necessary to others and earning goodwill. Competence and usefulness make this feasible. Selye's recommendations are important to nurses as well as their aged clients.

Coping. "Buffering" and "hardiness" are terms that have captured the imagination of researchers interested in determining the differences in coping capacity of ostensibly similar elders. Buffers against decompensation with stress come from social supports and are usually seen as the most important coping resource.

Hardiness, the combination of personality characteristics of commitment, control, and challenge, apparently buffers the illness-related effects of stress (Ganellen and Blaney, 2008). Life goals and a sense of purpose or meaning undergird hardiness. Funk and Houston (1987) analyzed the research that has been done around the concept of hardiness and found many inconsistencies, but in general there is considerable support for the belief that hardy persons manage stress in a positive, growth-promoting manner more often than they experience its negative effects.