Beyond Burnout and Bullies: Addressing Healthcare Occupational Stress

Monday, 23 July 2018: 8:30 AM

Richard J. Westphal, PhD
Family, Community, and Mental Health Service Department Chair, University of Virginia, School of Nursing, Zion Crossroads, VA, USA

The purpose of this presentation is to introduce an evidenced-based model to recognize and respond to burnout and bullying. Traditional models of burnout and bullying focus on individual risks and behaviors and rarely address the impact of personal and occupational stress injuries in the context of the environment of care. The Caregiver Occupational Stress Control (CgOSC) model is an evidenced-based peer support intervention that provides a framework to recognize the continuum of stress, potential for stress injury, stress first-aid measures, and tools for assessing the environment of care impact on individuals, teams, and patient care. This model is used to develop team-based peer support strategies that empowers healthcare personnel to help each other and change the work culture.

Burnout and bullying have long been recognized as sources of occupational risk in the nursing profession that are associated negative physical and psychological health (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Sauer & McCoy, 2017), patient safety (Teng, Shyu, Chiou, Fan, & Lam, 2010), and intent to leave the profession (Bobbio & Manganelli, 2015). Traditional models for understanding burnout and bullying behavior focus on individual characteristics and behaviors. Interventions for addressing burnout predominately focus on self-care strategies related to reducing autonomic arousal, mindfulness, and making healthy choices (Henry, 2014). Anti-bullying interventions focus on building individual skills; assertiveness skills for victims, and emotional intelligence skills for bullies (Etienne, 2014). Thematically, burnout and bullying are often presented as failures in self-care and coping that result adverse behaviors. Environment of care factors related to workload, shift rotations, and work culture are often presented as a context for individuals to build resilience in order to tolerate or adapt to the work environment. There is a fundamental limitation to all individual and self-care based models. Nurses are other-focused not self-focused. Nurses choose nursing to make a difference in the lives of others, the opportunity to provide care, and a sense of connection to a greater community (Eley, Eley, & Rogers-Clark, 2010). This dedication to others and to quality care is a strength and a vulnerability for nurses.

The Caregiver Occupational Stress Control (CgOSC) model was initially developed in 2007 for U.S. Navy Medicine to address occupational stress related to providing complex poly-trauma care with a medical work-force that experienced direct and secondary trauma (U.S. Marine Corps & U.S. Navy, 2010). The CgOSC model has been adapted for use in non-military academic healthcare settings; home health care teams; and with Fire, EMS, and Law enforcement personnel. The CgOSC model is a framework that has three conceptual elements that guide assessment, peer support, and organizational action.

The first CgOSC element is a stress continuum heuristic image that provides a four-color schema to enhance early recognition and dialog about behavior change as a stress injury indicator. This element reduces stigma about offering and accepting help. The stress continuum approach also shifts the discourse from a failure of coping (burnout) or communication (bullying) to signs of stress injury (needing help). Framing changes in work behavior as a potential occupational stress injury facilitates peers, managers, and organizations to use empathic approaches versus shaming approaches.

The second CgOSC element is the Stress First Aid (SFA) intervention (Watson, et al., 2013). The SFA element identifies that there are four sources of stress injury – trauma, loss, fatigue, moral distress – that can cause a resource-demand imbalance that may result in altered role performance. A stress injury has the potential to impact five essential human needs; safety, calming, social support, coping competence, and hope for the future (Hobfoll, et al., 2007). The SFA element is used by peers and managers to recognize when a peer has a stress injury, engage that peer in a supportive dialog, and help connect the stress injured person to additional resources. The stress injury and SFA response skills have been useful for both staff members who are showing signs of withdrawal, often associated with burnout, and aggressive staff behaviors, often associated with bullying.

The third CgOSC element includes evidenced-base assessment tools for individual and unit assessment and leader strategies for mitigating stress injuries and shaping a healthy unit culture. One of the unit assessment tools is the ProQOL Version 5 (Stamm, 2010) where the results can be used to discuss the relationship between secondary traumatic stress, burnout, and compassion satisfaction in relation to stress injury behaviors. Leaders and managers are better able to understand the impact of unit culture, the environment of care, and work-flow turbulence through the use of individual and unit assessment tools and work with the team to identify and implement collaborative solutions. Examples of individual, unit, and organization level assessments will be presented.

Models for assessment and intervention of burnout and bullying need to move past an individual focused paradigm to a model that accounts for the core values and beliefs of nursing practice with in the context of occupational health and safety. The CgOSC model is one of the first models that integrates individual and unit assessment with peer support and actions that can be used to shape the health care culture and policies to improve both work-life and patient experiences.