Week 7: Scaffa Chapter 17: Health Professional Well-Being

Well-Being

• A state in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community

• Oftencited characteristics include building and maintaining positive and fulfilling relationships, receiving and providing emotional support, experiencing positive emotions, pursuing personal growth, engagement, and accomplishment, and participating in spiritual or other activities that provide meaning

Triple Aim

• Proposes that health-care systems pursue three aims:

  • Improving the health of populations

  • Enhancing the patient experience of care

  • Reducing the per capita cost of health care

• Possible fourth aim would be improving the work life and well-being of healthcare professionals and staff

Burnout

• A psychological syndrome that involves a prolonged response to chronic interpersonal stressors on the job that results in feelings of being overextended and depleted of one's emotional and physical resources

• Consists of emotional exhaustion, depersonalization, cynicism, and a reduced sense of personal accomplishment

• Produces significant personal suffering for health-care providers in the form of broken relationships, alcohol and substance abuse, depression, and suicide

Physical Symptoms of Burnout

• Chronic fatigue

• Headaches

• Muscle pain

• Insomnia

• Hypertension

• Gastrointestinal disorders

Psychological Manifestations of Burnout

• Feelings of helplessness, anxiety, and depression

• Difficulties with concentration, memory, and decision-making

Behavioral Manifestations of Burnout

• Absenteeism

• Poor work performance

• Aggression

• Defensiveness

• Social withdrawal

• Substance use

• Risk-taking behavior

Coping Strategies Used by OTs for Burnout

• Self-awareness and self-monitoring

• Spending time with family and friends

• Striving for a personal and work-life balance

• Maintaining a sense of humor

Burnout: Stage 1

A compulsion to prove oneself

Burnout: Stage 2

Working harder to meet ones' own high expectations

Burnout: Stage 3

Neglecting basic personal self-care needs

Burnout: Stage 4

Displacement and the inability to recognize and deal with the source of one's distress

Burnout: Stage 5

Revision of values and the dismissal of once-important relationships and activities

Burnout: Stage 6

Denial of emerging problems, intolerance, cynicism, and aggression

Burnout: Stage 7

Withdrawal, isolation, loss of hope or direction, escape through alcohol or drug use

Burnout: Stage 8

Behavioral changes obvious to family and friends and increasing feelings of worthlessness

Burnout: Stage 9

Depersonalization and a loss of emotional connectedness to self and others

Burnout: Stage 10

Pervasive feeling of inner emptiness that may lead to addictive behaviors, such as gambling, overeating, compulsive sexual behavior, and drug and alcohol abuse

Burnout: Stage 11

Depression, loss of meaning, apathy, and hopelessness

Burnout: Stage 12

Burnout, total mental and physical collapse, potential for suicide need for immediate medical and psychological attention

Emotional Exhaustion

• Characterized by feeling overextended and overwhelmed by job demands

• Results in higher health-care costs due to staff turnover and lower job productivity

• Known to be the primary product of compassion fatigue and can lead to difficulties with creating a genuine empathic relationship with clients, which in turn can negatively affect the delivery of services

Depersonalization

Is exemplified by detachment, indifference, and cynicism

Reduced Sense of Personal Accomplishment

Manifested by feelings of inadequacy, perceptions of failure, and decreased confidence

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Control of Hazards and Exposures

• Chemicals

• Physical agents

• Biological agents

• Psychosocial factors

• Human factors

• Risk assessment and risk management

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Organization of Work

• Fatigue and stress prevention

• Work intensification prevention

• Safe staffing

• Overtime management

• Healthier shift work

• Reduction of risks from long work hours

• Flexible work arrangements

• Adequate meal and rest breaks

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Built Environment Supports

• Healthy air quality

• Access to healthy, affordable food options

• Safe and clean restroom facilities

• Safe, clean and equipped eating facilities

• Safe access to the workplace

• Environments designed to accommodate worker diversity

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Leadership

• Shared commitment to safety, health, and well-being

• Supportive managers, supervisors, and executives

• Responsible business decision-making

• Meaningful work and engagement

• Worker recognition and respect

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Compensation and Benefits

• Adequate wages and prevention of wage theft

• Equitable performance appraisals and promotion

• Work-life programs

• Paid time off (sick, vacation, caregiving)

• Disability insurance (short- & long-term)

• Workers’ compensation benefits

• Affordable, comprehensive healthcare and life insurance

• Prevention of cost shifting between payers (workers’ compensation, health insurance)

• Retirement planning and benefits

• Chronic disease prevention and disease management

• Access to confidential, quality healthcare services

• Career and skills development

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Community Supports

• Healthy community design

• Safe, healthy and affordable housing options

• Safe and clean environment (air and water quality, nose levels, tobacco-free policies)

• Access to safe green spaces and non-motorized pathways

• Access to affordable, quality healthcare and well-being resources

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Changing Workforce Demographics

• Multigenerational and diverse workforce

• Aging workforce and older workers

• Vulnerable worker populations

• Workers with disabilities

• Occupational health disparities

• Increasing number of small employers

• Global and multinational workforce

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: Policy Issues

• Health information privacy

• Reasonable accommodations

• Return-to-work

• Equal employment opportunity

• Family and medical leave

• Elimination of bullying, violence, harassment, and discrimination

• Prevention of stressful job monitoring practices

• Worker-centered organizational policies

• Promoting productive aging

Issues Relevant to Advancing Worker Well-Being Through Total Worker Health: New Employment Patterns

• Contracting and subcontracting

• Precarious and contingent employment

• Multi-employer worksites

• Organizational restructuring, downsizing and mergers

• Financial and job security

Primary Work Setting for OT practitioners (25.8%)

Long-term care (LTC) or skilled nursing facilities (SNFs)

Next Two Most Common Employment Sites for OT Practitioners after LTCs and SNFs

1. Hospital settings (23.9%)

2. Schools (19%)

School Employees in California were Reported to be at Risk for injury from hazards such as:

• Chemical spills

• Ergonomics

• Infectious disease

• Poor indoor air quality

• Trips, slips, and falls

Risk Factor

• Any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury

  • Ex: underweight, unsafe sex, high blood pressure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene

Haddon’s Matrix

• Developed by William Haddon Jr.

• A matrix that conceptualizes injury as occurring in three phases in interaction with human factors, an agent or vehicle, and physical and sociocultural environment

  • Pre-injury event

  • Injury event

  • Post-injury event

Pre-Injury Event Phase

• Primary prevention efforts are appropriate

  • Ex: Speed limit enforcement to reduce motor vehicle crashes

Injury Event Phase

• Secondary prevention is the focus

  • Ex: Shortening emergency response times and improving the efficacy of rehabilitation

Haddon’s Matrix for Health-Care Workers

Hazard

• The potential to cause harm, or a condition or activity that if not controlled could result in illness or injury

• Typically fall into four broad categories

  • Physical

  • Chemical

  • Biological

  • Psychological

Physical Hazards

Include such things as radiation, noise, and poor working conditions

Chemical Hazards

May be naturally occurring or human-made, such as vapors and gases from industry and tobacco smoke

Biological Hazards

Take the form of allergens, blood, bacteria, viruses, and other microbiological organisms

Psychological Hazards

Are typically occurrences that induce unreasonably high levels of stress, such as exposure to violence

Haddon’s Categories of Injury Prevention Strategies (Haddon Ten)

• Preventing the initial creation of a hazard

• Reducing the amount of energy a hazard contains

• Preventing the release of existing hazards

• Modifying the rate or distribution of a hazard

• Separating the hazard, by time or space, from the person

• Using material barriers to prevent exposure to a hazard

• Modifying qualities of a hazard to reduce its impact

• Increasing the person’s resistance to damage from a hazard

• Countering the damage already done as quickly as possible

• Stabilizing, repairing, and rehabilitating the damage produced by a hazard

Injury Prevention and OT

• Occupational therapists are uniquely equipped to analyze daily activities in work, leisure, and self-care; to identify potential risk and protective factors; and to then design strategies to reduce the risk of injury

• Strategies OTs use may include modifying environmental, equipment, and activity variables to increase safety in the workplace, decreasing individual risk factors for injury, and increasing protective factors

Evidence-Based Workplace Interventions

• Ergonomic interventions (training, rest breaks, forearm supports, specially designed glasses, workstation redesign) increase work comfort

• Ergonomic workstation redesign and training reduce days lost, pain prevalence and intensity, and injury rate among health-care workers

• Changes in the workplace design, equipment, and organization reduce sickness absence in several occupational classifications

• Participatory ergonomics reduces pain among workers

• Web-based monitoring at work only may not be better than no intervention to reduce pain. Adding strengthening and relaxation exercises to a web-based monitoring program may have a positive effect on pain and on stress.

Infectious Agents Include

Bacteria, fungi, viruses, and parasites that have the ability to spread an infection or infectious disease

According to the NIOSH (2017a), health-care workers are at risk from the following infectious agents:

• Blood-borne pathogens (BBPs)

• Ebola

• Influenza

• Middle East respiratory syndrome (MERS)

• MRSA

• SARS

• TB

Sharps Injuries

• Include needlesticks

• Can transmit BBPs such as HIB, hepatitis B virus, and hepatitis C virus

How do sharps injuries impact a worker’s well-being?

• Stress of undergoing immediate and long-term testing

• Waiting for results

• Being treated if infected

What financial impact does the health-care system face from sharps injuries?

• Additional staffing to cover missed work

• Testing expenses

• Preventative or curative treatment regimens

• The time and cost of injury investigation and documentation

What is the primary prevention strategy regardless of the infectious agent?

• Education regarding specific risk-reduction techniques

• The appropriate use of safety supplies and equipment

• The consistent reporting and reviewing of data on infection rates at the institution or in the community, as well as at state, national, and global levels

Isolation Procedures

• Hand hygiene

• Eye protection

Hand Hygiene

A simple but very effective prevention strategy to decrease the transmission of infectious agents, but studies show that some healthcare providers practice hand hygiene les than half of the times they should

Workers have the right to:

• Working conditions that do not pose a risk of serious harm

• Receive information and training (in a language and vocabulary the worker understands) about workplace hazards, methods to prevent them, and the OHSA standards that apply to their workplace

• Review records of work-related injuries and illnesses

• File a complaint asking OSHA to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHAs' rules. OSHA will keep all identities confidential

• Exercise their rights under the law without retaliation, including reporting an injury or raising health and safety concerns with their employer or OSHA. If a worker has been retaliated against for using his or her rights, the worker must file a complaint with OSHA as soon as possible but no later than 30 days.

Stress

• The source of this can include exposure to infectious diseases, productivity demands, insufficient staffing, role ambiguity, complex authoritarian management systems, ethical dilemmas and moral distress that arise from being involved in decisions that have an impact on people’s health and well-being, and burnout

• Can lead workers to leave their respective professions

Adverse Effects of Occupational Stress

• Psychological

  • Ex: irritability

• Behavioral

  • Ex: difficulty sleeping, attendance issues

• Physical

  • Ex: headache

Moral Distress

Tension that arises when a moral agent (e.g., a practitioner) is unsure of the best course of action to take or encounters a barrier that prohibits doing what is known to be right

Expectations that were Linked to the Highest Level of Moral Distress Include:

• Being expected to obtain as many billable units as possible per client regardless of individual client needs

• Being unable to provide optimal therapy services because of limited insurance coverage or insurance cutoffs reported

• Being expected to treat and/or write documentation for more clients than time allows

Recommended Risk-Reduction Strategies for Health-Care Workers Include

• Organizational change interventions

• Stress management interventions

Organizational Change Interventions Recommended by the CDC

• Involvement of employees in all aspects of planning and evaluating the intervention with a focus on team processes

• Use of interdisciplinary health-care teams

• Multipronged interventions that include risk assessment

OSHA Suggestions for Organizational Change Interventions

• Address work-related stressors such as inadequate work space, unreasonable work load, lack of readily available resources, inadequate and unsafe equipment

• Recognize and take action on legitimate concerns regarding overbearing physicians and supervisors

• Establish employee assistance programs and organizational change programs

• Provide greater flexibility with job assignment, hours, and alternative job arrangements

Suggestions from OSHA for Stress Management Interventions

• Educate employees about job stress

• Establish and maintain stress-management programs

• Provide readily available counseling from a nonjudgmental source

• Provide group therapy for specific job-related stressors (e.g., death of patients)

• Use of relaxation exercises and biofeedback until stress source is identified

Impact of Burnout on Individual Health-Care Professionals Includes

• Increase in anxiety

• Increase in depression

• Increase in disrupted sleep

• Increase in substance abuse

• Increase in marital discord

• Increase in early retirement

• Increase in suicide rates

Stressors in the Health-Care Work Environment that Lead to Burnout Include

• New payment and health-care delivery approaches

• Electronic health records

• Publicly reported quality of care metrics

• Excessive workloads

• Inadequate staffing

• Decreased autonomy and lack of control over work processes

Specific Stressors Related to Occupation Therapy Include

• Staff shortages

• Work overload

• Role ambiguity

• Lack of recognition and support from colleagues

• Low visibility of the occupational therapy profession

Resilience

• Patterns of positive adaptation during or following significant adversity or risk

• Is protective against compassion fatigue and burnout

• A dynamic, adaptive process throughout the life span that can be learned

Internal Factors that Contribute to Resilience

• Personality traits such as optimism

• Beliefs such as self-efficacy

• Skills such as adaptive coping

External Factors that Contribute to Resilience

Refer to environmental resources (material and energy) and the access to and stability of those resources over time

Social Factors that Contribute to Resilience

• Include feelings of connectedness to the people around us

• For health-care workers, includes mutual trust and connectedness to colleagues

Resilient Health-Care Worker

One who has the ability to maintain personal and professional well-being in the face of ongoing work stress and adversity

Two Complementary Types of Behaviors that Resilience Consists of

• Preventive

• Corrective

Preventive Behaviors

Those activities someone engages in that protect from burnout and help the person resist adversity

Corrective Behaviors

Those activities a person engages in that help the individual cope effectively with stressful conditions

Compassion Satisfaction

• The joy and fulfillment a person derives from helping other people

• The more a person has, there is less risk of burnout

Compassion Fatigue

• An emotional state with negative psychological and physical consequences that emanate from acute or prolonged caregiving of people stricken by intense trauma, suffering, or misfortune

• A direct result of a caregiver ignoring the symptoms of personal stress combined with inattention to personal emotions over time

• If not addressed, can become burnout

Signs and Symptoms of Compassion Fatigue

• Trouble sleeping/exhaustion

• Increased emotional reactivity/hypersensitivity to emotional material

• Hypervigilance or heightened sensitivity to potential threats to self

• Diminished interest in regular activities

• Reduced ability to feel empathy

• Anger and irritability

• Absenteeism (work, family event, social events) or poor work skills

• Difficulty separating work life from personal life

Job Engagement

• The antithesis of burnout

• Is conceptualized as an energetic state of involvement with personally fulfilling activities that enhance one's sense of professional efficacy

Characteristics of Job Engagement

• Pleasurable engrossment with work tasks (similar to the concept of flow)

• Enthusiasm

• Persistence

• A sense of professional efficacy, satisfaction, and success with work

Action Collaborative on Clinician and Resilience

• Initiated by the National Academy of Medicine (NAM) in 2017

• Designed to address health-care provider well-being and prevent burnout

Goals for the Action Collaborative on Clinician Well-Being and Resilience

• Improve baseline understanding of challenges to clinician well-being

• Raise the visibility of clinician stress and burnout

• Elevate evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver

Clinician Well-Being Model

• Depicts the individual and organizational/environmental factors that affect clinician well-being and resilience

• A holistic model that captures the relationship between the patient and the clinician and the complex interaction of factors that affect professional well-being and thereby have an impact on patient care

• Purpose is to guide research on clinician well-being and the development of effective intervention strategies at individual, organizational, and systems levels

Clinician Well-Being Model: The Three Concentric Circles in the Center of the Diagram

• Form the nucleus

• Represent (from the inside outward) patient well-being, the clinician-patient relationship, and clinician well-being

Clinician Well-Being Model: Individual and External Factors that Affect Clinician Well-Being and Resilience

• Encircle the nucleus

• Individual factors:

  • Health-care role

  • Personal factors

  • Skills and abilities

• Environmental factors:

  • Sociocultural factors

  • Regulatory, business, and payer environment

  • Organizational factors

  • Learning/practice environment

Stanford (University) Physician Wellness Model

• Identifies personal resilience, efficiency for practice, and a culture of wellness as determinants of well-being, the interaction of which promotes professional fulfillment

• Similar to the NAM model in that it emphasizes the interaction of internal (personal resilience) and external factors (efficiency of practice and culture of wellness) that affect clinician well-being

Professional Fulfillment in Stanford (University) Physician Wellness Model

Happiness or meaningfulness, self-worth, self-efficacy, and satisfaction at work

Prevention and Intervention Programs to Reduce Burnout and Enhance Resilience

Can be directed at the individual, the worksite or organization, the community or system, or some combination of these

Four Levels of Salazar and Beaton’s (2000) Ecological Approach that Addresses the Context in Which Occupational Stress Occurs

• Microsystem

  • Consists of the individual and immediate work environment

• Organizational system

  • Includes the physical structures, organizational culture, and policies and procedures

• Periorganizational system

  • Societal influences on the worker and the organization

• Extraorganizational system

  • Includes customs, cultures, traditions, and government policies that affect the worker and the organization

Professional Self-Care

• Attending to one’s own health and wellness needs

• Engaging in behaviors and activities that increase energy, lower stress, and contribute to health and well-being

Basic Recommendations for Professional Self-Care

• Restful sleep

• Good nutrition

• Adequate physical activity

Coping

• Conscious, volitional efforts to regulate emotion, cognition, behavior, physiology, and the environment in response to stressful events or circumstances

• Strategies can be problem-focused or emotion-focused

Problem-Focused Coping

Involves planning and engaging in specific behaviors to overcome or solve the problem causing the distress

Emotion-Focused Coping

• Addresses the feelings associated with stressful situations and can be active or avoidant

• Ex (active):

  • Positive reappraisal

  • Relaxation techniques

  • Emotional support from others

  • Use of humor

  • Prayer or meditation

Avoidant Emotion-Focused Coping

Involves avoiding distress through denial, distraction, behavioral disengagement or escape (use of substances)

Mindfulness

• The awareness that emerges through paying attention, on purpose, and nonjudgmentally to the unfolding of experience moment by moment

• Practices include sitting and walking meditations, breath training, and body scans

Breath Training

Modifies shallow or quick breathing into deeper, diaphragmatic breathing, providing more oxygen to all tissues of the body, including the brain

Mindfulness-Based Stress Reduction (MBSR)

• Originally developed for persons with chronic medical conditions

• An 8-week evidence-based intervention that teaches mindfulness meditation, diaphragmatic breathing, and other relaxation techniques

• Consistently demonstrated improvements in depression, anxiety, quality of life, and overall well-being in a variety of populations

Yoga

• An ancient practice that originated in India

• Means unity and refers to the union of mind and body and the union of individual and universal consciousness

• Ultimate aim is self-awareness

Benefits of Yoga

• A more positive outlook on life

• Increased efficiency at work and job satisfaction

• Enhanced self-confidence, self-sufficiency, and sociability

• Healthier interpersonal relationships

• More effective responses to life challenges