Stress can burn out even the most dedicated children's hospital employees. Here's how to recognize the signs and help staff members reignite their passion for providing the best care to kids.
By Amanda Bertholf
Advances in medical technology and medication allow more care to take place in the outpatient setting, leaving staff in the hospital to care for a larger number of patients who may be facing serious medical issues. Because staff members on the front lines in children’s hospitals interact with these critically ill or terminally ill children every day, they are particularly vulnerable to stress, burnout and compassion fatigue. They also witness day in and day out many distressing situations in which children are vulnerable—family difficulties, car accidents, child abuse and even animal attacks. “Things like death, illness and physical and emotional pain are intensified when we see them in children,” Schwanzl says. “We understand adults are going to experience illness and death, but it’s harder when you’re working with kids.”
For the teams who work with patients, there’s a cumulative effect if they don’t deal with the issues they’re seeing every day. Employees are regularly exposed to stressors, sometimes on an hourly basis. If they don’t learn how to effectively cope, they could put aside or partition off their emotions—this can lead to burnout. More than just having a bad day or week, burnout is a cumulative process typically marked by emotional exhaustion and withdrawal associated with increased workload and stress on the job. Several factors can cause burnout, including a lack of social support, an inability to control one’s work schedule or assignments, a chaotic or monotonous job, work-life imbalance or working on an understaffed team.
Similar to burnout, compassion fatigue is also prevalent among staff members in children’s hospitals. Compassion fatigue is the emotional strain of dealing with traumatic and difficult situations on a daily basis. Sufferers exhibit symptoms that include hopelessness, a decrease in finding pleasure in experiences, constant stress and anxiety, sleeplessness or nightmares and a pervasive negative attitude. This can have detrimental effects on employees, both professionally and personally, including a decrease in productivity, the inability to focus, and the development of feelings of incompetency and self-doubt. And, when compassion fatigue hits critical mass in the workplace, the organization itself suffers. Chronic absenteeism, high turnover rates, friction between employees, and friction between staff and management are among organizational symptoms that surface, creating additional stress.
The two issues of burnout and compassion fatigue are closely intertwined. Left unchecked, burnout can lead to compassion fatigue, and this can result in experienced and valuable staff members leaving the profession altogether. According to Joyce Hood, director of occupational health services at Cook Children’s Medical Center in Fort Worth, Texas, registered nurses deal with burnout the most. The American Sociological Association estimates 49 percent of nurses under the age of 30 and 40 percent of nurses over age 30 experience high levels of burnout. “They tend to have a high level of responsibility every minute of every day they’re at work,” Hood says.
Nurses provide direct, 24/7 care to patients and see firsthand the limits of what medicine can do. And on top of those emotions are the mental and physical demands of the job. It’s tough, stressful and physically and emotionally exhausting. The shifts are long, often 12 hours for multiple days. And doctors also suffer emotionally, too. A 2012 Medscape survey found nearly half of all physicians have experienced burnout.
One way hospitals can keep burnout at bay is to make sure employee assistance programs are in place. At Helen DeVos Children’s Hospital, leaders create an environment that helps team members feel comfortable reaching out for help. “It’s not normal to watch child after child deal with a difficult medical situation—most adults never see that happen in their whole lives,” Schwanzl says. “We have staff members who see that every day.” To help employees after traumatic experiences within the first 24 to 48 hours, teams hold an emotional debriefing session. Unlike a clinical debrief, this exercise allows the clinical team to talk about the emotions of an experience. Schwanzl says if this kind of conversation doesn’t happen regularly, employees begin to feel the cumulative effect, and they can burn out.
At the Cleveland Clinic in Ohio, doctors and nurses can call in a code lavender to help fight stress and burnout. A holistic care rapid response team serves medical units in need of emotional or spiritual support after troubling or exhausting times, often after they experience the death of one or several patients. Within 30 minutes of a call, the team of holistic nurses arrives at the unit and provides a massage, healthy snacks, water and lavender colored arm bands to remind the nurse or physician to take it easy for the rest of the day.
At Cook Children’s, Hood chairs the Hardiness Workgroup, which offers programming and educational sessions centered on wellness for employees. “We recognize a need to do what we can to help our employees be more resilient,” she says. The hospital offers several classes including a critical incident stress management class and a compassion fatigue class, which Hood says is always at capacity. The class helps employees recognize that stress is common in everyone. Attendees also learn how stress prevents them from being as compassionate with the patients as they could be. “We get dull and work like a robot after a period of time,” Hood says. “And that’s not good for our patients, and it’s not good for us.” The hospital also has a waiting list of staff members who want to take the Vitamin BE class, which is about mindfulness and relaxation and the Vitamin Z class, which is about sleep hygiene. Hood says inadequate sleep and shift work are risk factors for fatigue and burnout.
In an effort to provide complete care and aid the wellbeing of staff members, Cook Children’s also offers yoga, the services of a massage therapist, and a concierge who will process staff members’ laundry or order meals. “These are things that, combined, help employees feel like they are cared for,” Hood says. “A wellness program should include every domain of a human being, not just physical domain, but psychological as well.”
At the team level, Cameo Gore has implemented morale boosters like birthday celebrations, including cake and lunch once a month. “Up until about six months ago, that was something we never did,” says the director of perioperative services at UCSF Benioff Children’s Hospital Oakland. With some nurses who have been on staff 20, 25 even 30 years, Gore says it’s important for someone who’s been with an organization that long to feel appreciated and have fun. “Employees have an intense need to feel that management appreciates what they’re doing,” she says. Gore has found that simple gestures go a long way, like rewarding people in real-time for a job well done with cafeteria passes for a free coffee or lunch.
She also insists on being present to personally thank staff members for a job well done. “It’s easy to get into a rut and start thinking because we’re so busy that we have to keep our heads down,” Gore says. “But we have to create time and space outside of that to have appreciation and gratitude and create a positive experience.”
Leaders lead by example
Stress management comes from the top down. Leaders must first manage their own feelings of stress to set an example—if you’re burned out those feelings are going to trickle down to your team. “All leaders are put in stressful situations at one time or another,” says Robert Connors, M.D., president of Helen DeVos Children’s Hospital, “but they must maintain perspective for effective leadership. Staff appreciates it when leaders take a more calm approach to stressful situations, and I encourage everyone on my team to take on issues this way.”
One of the best ways to maintain an even keel is to create work-life balance. “Set expectations and boundaries that are realistic for someone in a management position,” Gore says. “Being a manager is stressful and comes with a lot of duties and requirements, but you still have to balance that with being able to have time to decompress, relax and pursue interests that fulfill you when you leave work.” Gore, who likes to relax with a yoga regime, also enjoys hiking and connecting with nature. She says spending time in natural environments is one of the most important things you can do to reset your energy and stress levels. While it’s hard for some people to work that relaxation time into a busy schedule and make it the heart of a daily or weekly routine, once they start to feel the stress release from a regular practice, it can be transformative.
At Helen DeVos Children’s Hospital, managers stay connected with the teams in their units, and they interact with each other on a regular basis. Schwanzl says because of the size of the hospital (about 1,200 to 1,500 employees), she is able to get to know a number of staff members. That small size helps create a communal and team-oriented environment where team members know and care about each other. “It’s easy for managers and supervisors to be in tune with their staff members and know if somebody’s off,” she says. “Because of those relationships, we can pull someone in and say, ‘You don’t seem like yourself. How can I help? What’s going on?’”
Schwanzl says sometimes the challenge for managers is to not get involved at too deep of a level because they aren’t therapists, after all. Of course, managers can be caring and compassionate, but setting boundaries is key. Managers should recognize there might be a problem, and then provide the right resources for staff members and encourage them to take the time to do whatever it is they need.
Sometimes burnout can cross over to a performance issue that managers will need to address. If a team member is suddenly making multiple errors and that’s not the norm, discuss it. “Be candid in conversations and encourage people to get support,” Schwanzl says. “And if somebody’s at the point where we feel like it affects the care they provide, then it’s our responsibility to say, ‘You need help, things have to turn around.’”
Helping employees deal with stress is not a one-time deal. It’s something that must be ongoing. “The complexity of nursing and health care has blossomed over the last 10 years, and that’s not going to change,” Hood says. “We must care for employees emotionally and mentally—they are a finite resource and not replaceable.”
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