ASPR TRACIE: Module 1B - Compassion Fatigue and Secondary Traumatic Stress Identification for Healthcare Providers

April: What I really want to focus on here is the fact that most healthcare providers, and I am going to speak here with the assumption that you in the audience are professionals working in a general health, medical, mental health or substance abuse settings and that you are group who do not see yourselves as individuals who would develop compassion fatigue or secondary traumatic stress. 

That is primarily because you are professionals who tend to be a highly self-reliant group-that is, you see yourselves as the helpers, and not as the people who would need assistance from others-either in assessing your needs or in delivering support services.

And the stigma around behavioral health concerns is as active in health related disciplines as it is in the general public. Most people don’t see themselves in need of mental health supports even when working in the intensely stressful environment of trauma services.

Also, either because of staffing patterns or the desire to help others on a very human caring basis which brought you to the profession to begin with, most of you in the healthcare professions, see yourselves as having to ‘work ‘till it hurts,’ often putting in long hours, covering staff shortages, skipping breaks, working through lunch, and routinely sacrificing your own comfort and self-care to ensure the care of others. 
You are a group that is very hard on yourselves, as if nothing is ever enough.  If you are a healthcare professional who has learned well and does a good job taking care of yourself, I congratulate you. But you are the not the norm.

Healthcare professionals are also a group that is skilled in providing specific services for which you are trained to deliver as an individual, but also while functioning within the team setting. Thus, your performance is usually quite visible to your coworkers and thus, you tend to work a bit harder at controlling and concealing any distress symptoms for fear of being seen as weak or providing any basis for being judged negatively or stigmatized by your peers. 

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April: In addition to experiencing traumatic stress in the workplace, there are several professional and personal factors that can create a higher level of risk for experiencing STS. Providers who see a high number of trauma cases as opposed to having a mix of other patients or clients-that is some with physical ailments or illnesses not related to a traumatic event, are at a higher risk of STS. Also, another work related risk that is of concern is the perception of healthcare providers that they did not have adequate training to provide the level of care needed to effectively assist patients or clients.

On the personal side, providers who have a history of trauma experiences themselves, such as child abuse or neglect, interpersonal violence such as domestic abuse, rape or a physical attack may experience STS at a higher rate than those who do not have such experiences in their personal history.

 And those without good social support, who isolate themselves, don’t have good coping skills, or use negative coping such as alcohol and other mind altering substances are also at higher risk of suffering with STS or compassion fatigue.

Additionally, we know that our blood pressure is often twice as high during the work day compared to when at home or time off.

The worst work-related stress is caused by jobs where people have little control over the activities they do and the rate at which they have to deal with them.

Race is also a factor; genetics- family illnesses.
A high fat, high salt diet contributes, via blood pressure increase.
And professional woman or men who are caregivers with children suffer more, for example, your blood pressure doesn’t go down when you go home.

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April: Here is a good snapshot of some of the various signs of STS. I will go into more detail in the next few slides.

As mentioned earlier, these signs parallel those of your patients or clients and can include a rapid heartbeat, stomachaches and headaches that have no physiological basis, sleep problems and a lowered immune system which makes you more susceptible to colds and sore throats. Anxiety symptoms are common in addition to signs of depression like sadness and crying.

On a personal level you may find yourself much more cynical and negative in general, with mood swings, often isolating and even seeking out alcohol and other substances to change your mood.

In the workplace, we see healthcare workers with increasing incidents of being late, calling in sick, a lack of initiative or motivation in their work. Overall, we see lower staff morale and higher turnover rates and higher error rates.

In the spiritual domain we see people questioning their sense of meaning in both their personal and work life choices. Some even question their beliefs; and others who suffer with depression and are isolated may also develop a sense of hopelessness, which puts them at risk for suicide.

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April:  Here we have a more comprehensive list of some of the physical impacts of STS. This list includes changes in weight, breathing difficulties, overall aches and pains, and worsening of chronic medical conditions including high blood pressure.  I also want to point out that sleep problems and insomnia in particular are the most common physical complaints in disaster and emergency workers.

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April: Any emotional effects should be addressed. Whether they look like mild depression or anxiety, or a sense of helplessness and lack of confidence. We don’t want to see any effects worsen or become chronic, and are concerned about those who start to detach, and decrease their ability to empathize with their patients or clients and their family members. We need to be aware of PTSD symptoms such as flashbacks, nightmares, hyper-vigilance and avoidance.  All of these effects are distress symptoms that we should pay attention to. 

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April: The effects of STS on an individual’s spirituality is not addressed enough in the literature, but anecdotally, we hear many healthcare providers talk about how witnessing trauma makes them think about their lives in terms of meaning making and purpose.  Some question why they are in the profession, others search for meaning in their lives in general and take a closer look at their relationships. Some people will even question their faith and become angry thinking that God or a higher power allows these traumatic events to hurt people.  We should all be listening for signs of hopelessness as it is one of the red flags for increased suicide risk, especially in people who are isolated.

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April: An extension of spiritual effects can include moral injury, which is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they "transgress deeply held moral beliefs and expectations".

Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and other such things.

These can occur in mass casualty incidents or public health emergencies and can create extremely challenging conditions and make for difficult decisions.

For example, how do you handle giving one child a vent and explaining why you’re choosing one child over another to the parents. Or if you’re triaging mass violence patients, how do you know when to administer pain meds to someone you think is expiring? Though in a normal situation, you’d take more measures to save them, versus knowing when to treat someone in a very chaotic non-traditional environment.

This creates for contradictory priorities that cause harm, unintentional errors, acts that are committed by yourself or others, and, again, creates difficult decisions.

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April: Moral injuries can result in:

• Shame – feeling unworthy and
• Guilt - a feeling of responsibility or remorse for some behavior which are generally combined and form some of the most common responses to traumatic stress.

Moral injury can also cause Isolation-as workers feel they are alone in their transgressions and that no one will understand them. These can lead to long lasting emotional distress – that is, chronic problems that build and can often lead to additional concerns like substance misuse and relationship problems.

Also, it is not unusual for Moral Injury to come at a much later date after the incident, causing delayed emotional distress that the healthcare staff then have difficulty connecting to a particular event and don’t know how to resolve their feelings.

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April: The impact of STS on your work is of great importance because as you know, it affects patient and client care. Healthcare professionals are under more stress than any other profession to get everything right. To make the 99.9 percent accuracy target, basically, to not make mistakes.  So, monitor for signs of STS –a feeling of exhaustion not related to a lack of sleep, and not being productive, communicating poorly or incorrectly in your notes, your orders, and with other staff.  You may notice being more impatient and having increased conflicts with coworkers. 

One of the signs we see in healthcare workers and emergency responders that we don’t see in other professions is the inability to stop working, almost being obsessed and overworking to the point of risking your own health and personal relationships.  Some staff lose confidence in themselves and begin second guessing everything. Traumatic stress also negatively affects our cognition. Poor judgment and poor decision making are not unusual as the response and recovery phases continue.

And again, as mentioned before, one of the more serious signs is detaching yourself, isolating from others, numbing your feelings so you avoid feeling any distress at all.

SLIDE 20

April: STS and exposure to trauma can have a negative interpersonal impact as well. We become so isolated and withdrawn from others, we’re lonely and may even begin to mistrust others-a bit of a paranoia, actually.  Anger can become our default emotion because it hides distress and doesn’t make us feel as vulnerable, and it is acceptable culturally, especially for men, to express anger rather than sadness or distress. We often take out our anger on those we work with and our loved ones, children especially, and others around us.

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April: Other than posttraumatic stress disorder, some of the more serious problems that are common in healthcare and other helping professionals include self medicating with alcohol and other mind altering substances like opioids or anti-anxiety meds. Some may self-sooth by overeating or excessive drinking.  Relationships follow poor coping – from extramarital affairs and even suicidal thinking and gestures when one sees no way out of their deep pain.

These effects aren’t pretty and the real problem is that we as a profession tend to hide them by continuing—or thinking we are able —to continue functioning at work. Thus, many might not know we have a problem, and we are pretty good at denial, until it becomes so serious or chronic and has already destroyed our relationships, our work, and even our sense of self.

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April: There is, however, good news. There is ample satisfaction and meaning in the work that we do that is very powerful.

We need to recognize that the reason we came into the helping profession is because we want to feel good about the work we do. We don’t necessarily have to experience only negative stress in this work. We can gain very positive energy or what we call compassion satisfaction—the sense of doing something meaningful, being happy about that, and feeling useful and connected to others and the community around us.  We know too, that many people in the healthcare professions report what we call traumatic growth-that is, we can learn and grow from witnessing and experiencing trauma. Some people learn to appreciate their relationships more, others learn good coping skills and others report feeling more grateful for many aspects of their lives.

Providing the type of care that you do, listening and supporting your patients, clients and their families, can lead to a sense of strength, self-knowledge, confidence, meaning, spiritual connection, and respect for human resilience over time. 

Thus, we can nurture these protective factors by looking for and recognizing them in our experiences and even seeking opportunities to practice good coping like supporting each other and having gratitude for all the small, positive things that happen every day.

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April: Now that you know what CF, STS, vicarious trauma, burnout, and compassion satisfaction look like, think about how your work— both during disaster and non-disaster times—may be contributing to your experience of these signs and symptoms.

What can you do to address them?

Start with a real honest look at how you feel you’re doing. How are you coping really? What are your areas of concern? And where are your strengths? Most importantly, what are you willing to do to improve your situation? Nothing will change if everything remains the same.

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April: Consider what you are doing on a routine basis that may either contribute to or help decrease any uncomfortable stress symptoms.

• Are you over committed personally? If so, this will spill over into your work situation and likely increase the stress you experience in the workplace.
• Have you taken on too much at work?
• Are you participating in activities that you feel are beyond your skill set-that might even possibly cause harm to your patients or clients?
  

Also consider if you are particularly vulnerable...

• Do you have a history of trauma in your past that still has strong negative effects on your life?
• Have you had someone close to you die in the past year?
• Or have you experienced a medical illness yourself?
• Or been in a life threatening situation such as a car accident?

These things can temporarily increase your risk. 

In order to make determinations about all of these situations, you need to have some sense of self awareness.

• Are you someone who avoids looking at these issues?
• Do you just say, ‘I’m fine’ and not give any real considerations to the concerns? 

Self awareness means that you can look critically at how you have to perform in each of these areas, take in feedback from those around you and use tools that can help create an objective look, one that is not based only on your own perspective. We’ll talk about that process in the next few slides.

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April: A good way to increase your awareness of the impact of stress and to prepare yourself for coping with stress is to create a stress profile. This means, to know ahead of time what stresses you out and what helps decrease your stress. Don’t wait to do this until you are so stressed that you won’t want to bother, or you think it’s too late.

Create a path to self care. Let’s take a few minutes to engage in a stress profile exercise.  Pause the webinar and take a look at the four sections of the profile.

Ask yourself, what are the things that stress me out at work? These will likely be different for everyone. Is it the unit secretary who makes you file all your own charts and that really bothers you? For someone else, it’s having to see the children’s oncology unit every time they go to their office.  Think about it, do the exercise, write down 2 or 3 things that really stress you out at work.

For health and mental health professionals, those stressors could include a lack of support or access to support staff, challenging or overburdened supervisors and managers, challenging clients, and a lack of resources to better assist the clients with their variety of needs.

Then write down your warning signs. Do you start yelling orders at staff across the desk? Do you become impatient and tell everyone you don’t really have time to talk to them, so they better make it fast? Do you get a headache? Pain in your shoulders? Write that down. These should become red flags for you, things that warn you that your stress is getting intense.

Then identify what things you do to cope that really don’t help – now be honest here. Does having alcohol every evening really relax you or do you find it makes you wake up with a rapid heartbeat at 3 am and unable to get back to sleep?

Does yelling at the kids to leave you alone because you are tired from work really make you feel better or just guilty? Write it down.

Look at what works to truly make you feel less stressed. Is it a walk? 10 minutes of sitting with your loved one and catching up? Taking a few minutes to gather yourself before you sit down with the family?  These things don’t have to be complicated or take hours to accomplish. They can actually be simple and fairly quick.

I live with an introvert who needs to be left alone when first coming home from work, without a lot of questions as soon as the door opens. So I learn to wait a bit before engaging, saves a lot of arguing in my house.

Again, you are the only one who can recognize these concerns and determine what works for you.

SLIDE 26

April: Here are some of the things that you might find yourself doing if you don’t care for yourself:

• Abusing alcohol or other substances
• Shutting out friends and family
• Refusing to eat
• Blaming yourself or others for what happened or how you are responding
• Engaging in risky behavior
• Expressing excessive anger towards other people, or snapping.

SLIDE 27

April: And that brings us to the concept of self care. For those of you who don’t know what self care is, and I know there are a lot of you out there, self care is your ability to do things that protect and maintain:

• Your physical self - that is, your whole body.
• Your emotional-mental health- that is your attitude, clarity of thought, good coping and good decision making.
• Your relational health- having close relationships, making time to be with people you love, and those who love and understand you.
• And your spiritual health - here, referring to your sense of meaning, your place in the world and your sense of safety.

When you are creating a self care plan, look at each of these aspects and write down at least one or two activities that address your needs in each of those areas.

• Are you walking every day?
• Do you do things that bring you joy?
• Do you connect with those you care about in some way, calling, texting, writing?
• And what fulfills your spiritual needs?
  • Doing something in the community?
  • Collecting for the food bank?
  • Driving someone in need to a doctor’s appointment?
  • Coaching the kid’s after school activities?

As healthcare professionals engaged in emergency response, have you and your family planned and prepared for how to manage when you are pulled into long, intense days of work? Do you have a go pack with a change of clothes, medications, pictures of the family and other things that bring you comfort? Do you have a schedule of when to communicate with your loved ones? Have you arranged for someone to care for your pets?  All of those things that we tell the public to do to prepare for an emergency should be things that we have in practice for ourselves. Being prepared can reduce anxiety. This is self care.

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April: That brings us to the concept of a self care plan. One of the problems we hear from our colleagues is that many of you know what stress management and coping skills are that can be helpful, but you don’t have time to implement them.  When psychologists look at this issue, we find that people are more likely to follow a plan when it is written out, when it is very specific, and when it is tied to a way of keeping track, such as a calendar or a daily planner.  For example, if you commit to exercising three days a week, you are much more likely to carry out that plan if you write it down, identify the actual day and time that you will engage in the activity.

It’s important to create and practice a self care plan as a regular part of your profession.  When working during a disaster, it is even more important that all healthcare professionals pro-actively practice their self care plan to mitigate the even higher probability of experiencing workplace stress and burnout.

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April: Here are the basics - that is the minimal aspects of self care – that are referenced as the Core Four. They include:

Regulated sleep. Know how much sleep you need. Are you a 7 or 8 hour person? Work backwards and determine what time you need to go to bed in order to get your designated number of hours of sleeps.

Physical movement is essential to getting stress hormones out of your body. Walking is a great exercise. Walking in nature every day will change your life. 10 minutes, 20 or 30 minutes, it’s doable, but you have to choose to make the time.

Active mental relaxation includes mindfulness—or focusing on something simple like breathing or walking, staying quiet; meditation, guided imagery, calming music that is timed to the breath. Make yourself a playlist of music that is timed to a slow breath so that you can listen whenever you anticipate needing it or after a difficult day.

These are a few examples that can help you. There are a couple of apps that might be helpful as well: Calm, Insight Timer, Headspace are a couple of examples of those you can check out to help you get started in the practice of breathing and mindfulness.

Research shows that social supports and close relationships are good for our physical and mental health. Make time to visit those you support you- who understand and accept how you feel- not people who invalidate your concerns. And check in with family members and other loved ones, even a text or a brief call or a postcard can make us feel more connected. How do you connect with those that you care about on a regular basis?

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April: Determine what change you want to focus on. Ask yourself:

• What’s one thing I would like to work on to reduce stress and burnout?
• Do I need anyone to help me?
• What cues or reminders can help me to take action?
• When in my day will I most likely be able to do this?
• What resources do I need?
• And how can I use my self care plan to remain resilient during disaster work?

It’s recommended that each person write out their own action plan and start fairly small with easily achievable goals, then grow into a more comprehensive plan once the early planning goals are met. Remember, it’s important to include the written self care plan as part of your “go kit” to access and use while working during a disaster.

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April: Let’s do a short exercise together. All you need is a piece of paper and a pen or an electronic device. Note three leisure activities that allow you to destress - make it simple, routine things that you know help to relax you. 

Then put a date next to each activity within the coming week when you expect to be able to engage in that activity and then put the exact time that you can engage in that activity next to the event. 

It doesn’t matter if you carry out the activity at the exact time that you have written down there.  You can easily change it if you need, but the act of creating these details are what will help you act upon the plan.  If things don’t work out one day, just do it again and keep trying. Don’t give up.

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April: As mentioned earlier, monitoring your stress levels, your compassion fatigue, secondary traumatic stress and burnout can be a helpful and objective way to monitor how you are doing. You can do this by using a tool called the ProQOL 5.

The ProQOL self assessment tool is the only scientifically valid and reliable tool designed for those in the helping professions specifically. You are the only person who can control your stress levels, so if you have a reasonably accurate idea of how you are doing, you are more likely to be able to address it realistically.

This is a tool that is accessible online and free to use. The author, Dr. Beth Stamm just asks that you do not change it and provide proper citation if you refer to it or copy it. There are only 30 questions in total and you can score it yourself. Be honest and open with your responses.
The scale is broken down into three subscales. Compassion fatigue and secondary traumatic stress is the first subscale, the second is compassion satisfaction, which is known to counter some of the negative effects of compassion fatigue, and the third subscale is burnout, which is a measure that looks at how much the administrative issues may be interfering with the satisfaction that you get from the work itself.

The link to the ProQOL is www.proqol.org and it is recommended that staff use this tool every few months or so to help monitor how they are doing. Also, use the ProQOL during or following a disaster assignment.  The interesting thing I have observed about people engaging in this assessment is that they are often very pleased to find that they are managing better than they thought they were and this seems to spur them on to commit to their stress management plan.

This scale can help you get an outside perspective of where you are and learn something about yourself from it that can lead you towards the right direction in terms of professional development, making you a more competent and confident counselor and healthcare professional.

SLIDE 33

April: Now that you have an understanding of and know how to monitor compassion fatigue and secondary traumatic stress and how to engage in self care planning, let’s look at some skills you can develop both personally and professionally that will help get you to carrying out your action plans.

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April: Start by interrupting the physical stress response.

Specifically, plan and maintain a balanced lifestyle as an active part of your professional commitment. Know how to control your breathing in a way that destresses you- and I will walk you through a couple of examples of this in a minute.  Engage in body movement– stretching and walking are two of the simplest ways you can interrupt the automatic stress response. Integrate some low impact brief exercises that may get you on your way to regularly practicing how to manage your work stress so it doesn’t interfere with your relationships at home, with your spouse, your partner, your kids, parents, friends. So that it doesn’t build to the point of causing you to lose your job or your health in terms of a stroke, a heart attack or secondary problems like diabetes from a poor diet, or emphysema from smoking or liver disease from excessive drinking - some of the most common health problems that many adults in the U.S. suffer from and which are directly connected to stress.

Then as mentioned in the Core Four, evaluate the meals you eat at the workplace and away from work. What we eat is one of the ways that many of us control our stress levels.  Can we plan better so we’re less stressed when deciding what to eat?

Also, sleep is a very significant player in stress and performance levels. Know how much sleep you need to function well.  What helps you go to sleep and stay asleep? Is it soft music, or a white noise machine? Is it making sure the television is off and that you haven’t had any sugar in the two hours prior to sleep? You probably already know these things about yourself. Are you acting on them?

And again, the research is very clear that social supports are critical for good physical and mental health. These are basics that we need to include here and they are a personal responsibility.

SLIDE 35

April: Then we move to changing our cognition because stress is all about perception. One person can see a situation as stressful and the other does not. Our thinking controls our actions, thus we can actually control how our body responds to stress. Cognitive behavioral therapy is one of the most effective ways to change how we perceive things, therefore changing our cognition.  We will be looking at ways to change and to strengthen our cognition in another webinar in the series so we can focus on those skills.

Some simple ways to teach your mind to focus is with the use of mindfulness, meditation, affirmations and guided imagery. These tools are great because you don’t have to do anything, you can turn them on. You don’t even have to consciously listen as your mind will take in the messages, but they are even more powerful when you do focus on them.  Listen to different voices and messages to see which ones you like. And as mentioned earlier, there are different apps that are online and several are free. Try them out for yourself.

So when you look back at your self care plan and see what you identified as helping decrease your stress, decide what action you are going to take. That is, what behavior will you engage in to decrease your stress? It can be as simple as saying no to going out on a night when you’re most exhausted, and your defenses are down, so that you don’t drink too much and just ruin all your self care plans for the weekend. 

Whatever behavior change you make, start somewhere. Remember none of these skills - personal or professional will work if you don’t use them. Self care planning is particularly important to practice during and following a disaster assignment.

SLIDE 36

April: I promised to show you a couple of simple breathing techniques. One of the most important stress management skills is breathing in a way that helps get rid of toxic stress. Are you a shallow breather? That is someone who normally doesn’t take in full breaths, thus, not really ever getting a good amount of oxygen in the body. This is so important because full and deep breaths help us to get toxic hormones out of our body.

You should know how to breathe fully and deeply, and practice this. It’s especially helpful when under the stress of a disaster because it controls the nervous system, it keeps the rapid heartbeat under control, which is so uncomfortable when it happens and usually makes us think we are having a heart attack. You cannot have an anxiety driven rapid heartbeat and breathe deeply at the same time. It’s physically impossible. So learn some breathing exercises.

On the screen is a simple one that tells you to take in a normal breath through your nose with your mouth closed and then to exhale very slowly through your mouth, concentrating on a calming word like ‘calm’ or ‘relax’; and then count to 4 before taking the next breath. Do this about 10 times, and it will reduce the rapid heartbeat from anxiety and stress and slow your breathing.

Alternately, you can do another one that’s very simple to remember, it’s called the box breathing because it is 4x4x4x4. Start by counting to 4 slowly while breathing in, hold it for 4 seconds, release the breath to the count of 4 and then count slowly to 4 before beginning again. Doing this several times a few times a day will help keep stress down and get oxygen flowing through your body, pushing toxic stress out. Working on a disaster can be an extraordinarily busy and stressful assignment for healthcare professionals.  You may not have time for much, however taking a few moments to focus on simple breathing techniques is doable in a disaster setting.

SLIDE 37

April: Another way to address stress is to figure out when you need to take a break. If you remember this Acrostic HALT, it spells out the need to recognize when you are Hungry, Angry, Lonely or Tired. Each of these means it’s time to stop, breathe, take a break and implement self care. If you recognize you’re hungry, take a short break to eat something. If you’re angry, do some breathing exercises or counting to calm yourself. If you’re lonely, seek out your buddy or make a quick call home. And if you are tired, figure out when the earliest time is that you can get rest. Can you take a break right away or do you need to cancel your evening plans and get some much needed sleep? What is it that you need to do?

SLIDE 38

April: Research tells us that we can decrease stress and build our own personal resilience with this list of attributes. While we might not all be able to develop all of these characteristics, we can focus on increasing several of these abilities to strengthen our capacity to deal with and even decrease stress both in the workplace and in our personal lives.

Create a positive attitude: Give yourself positive messaging. For example, remind yourself that you’re strong and you can grow stronger and more wise as you handle life’s challenges. We tend to believe what we tell ourselves.

Develop self-awareness: Understand what you’re feeling and why. The self care planning process can help increase your self awareness around stress management.

Develop internal control: Know that while you can’t control all the circumstances that occur around you, you can control how you respond to those circumstances, and that makes all the difference. Internal control helps create a better attitude and the course that our lives take

Developing optimism can help you become more resilient by giving you a sense of competence, confidence and control in how you view the world.

Social Support: Those with strong networks of social support tend to stay healthier and happier throughout life, and they tend to cope well with stress.

And those with a sense of humor about life tend to experience life as less stressful, are able to bond with others during difficult times, too. If you can take a step back from a difficult situation long enough to maintain your sense of humor, you will be more resilient, too.

Exercise has been correlated with stronger levels of resilience. This may be due to the effects the endorphins have on one's mood, or the physical health benefits to those who exercise, or both.

Studies have shown that those who are more spiritual tend to be more resilient.

Perseverance: Don’t give up on your situation; don’t stop working towards getting through it. Trust the process.

Patience is a perception and thus can be controlled by how we think. For many healthcare providers, we can much more easily be patient with others. The gift here, is to be patient with yourself - just do your best and know that’s ok, you’re human.

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April: So, to summarize what you can do personally, start by taking the time to create a written self care plan and schedule the activities within each of the different areas that you would like to address. Use the plan as a regular part of your professional practice and step it up even more proactively during and after a disaster assignment.

Make time for personal social support.  Family support has been related to less emotional exhaustion at work, and social support is related to a sense of efficacy.

Talk about your self care plan with someone in your personal support circle and check your plan routinely. Are you engaging in the self care activities you identified as helpful? How often are you doing so? Is the plan realistic or do you need to make some adjustments so that you can actually meet your goals?

Seek your own therapy if you’re distressed. Cognitive-behavioral therapy has resulted in positive effects on traumatic stress, burnout, and produced greater effects than other types of workplace interventions.  This type of treatment is usually very focused and short term. Take the time.

And monitor your self: your levels of stress, your attention to self care. We will talk about another tool to do so in just a minute.

SLIDE 40

April: Let’s look at ways to increase your professional stress management skills. One of the top suggestions is to utilize collegial support. Peer support is emerging as one of the most helpful ways that providers support each other in the workplace.

Mental health professionals report that valuable support comes from peers or colleagues who understand and accept how you feel. This can be done by identifying a buddy. It’s always helpful to have a work buddy - someone who understands you and the work situation - not someone who invalidates your worries.

Peer support can be individual, but also very helpful when conducted in group settings, like group supervision, case conferencing, workgroups. The important part of peer support is to be authentic in sharing your concerns. You can still keep confidentiality by not mentioning patient or client names, brainstorm and problem solve with your peers. Hear their suggestions.  Peers should come from a place of mutual respect and equality - rather than a hierarchy - so there are no titles used in peer settings. Managers, supervisors and line staff can all learn from each other. Peers also check in with each other - especially buddies - providing follow up contact and supportive words or recommendations routinely and most especially after an emergency or difficult incident with a patient or a client.

SLIDE 41

April: Often we hear staff say they are happy to forgo supervision meetings. This is not really to your advantage. Effective supervision has been found to be associated with lower levels of CF and STS and burnout, and higher levels of personal growth and satisfaction, for both new and experienced providers, especially those working with trauma patients and clients.  You are entitled to and deserve to have access to supervision routinely. Take advantage of it and use it well. Bring your agenda items in and prepare to share your concerns in an honest and productive way. Expect feedback and recommendations for follow up actions. Ask for them. What is your advice? How do I best handle this patient or that situation?

Patient and clients caseloads should be varied wherever possible. Certain staff members should not be taking all the most difficult cases. No one needs to be a hero.  Healthcare providers use some of the most integrated team approaches and that’s a great strength. Individuals and supervisors should work to vary every staff member’s caseload, so each person can learn and improve their skills and build more capacity to manage difficult and stressful traumatic situations. Individuals should make every effort to avoid working too long alone without checking in or working long hours routinely.

Practice only within your role and your abilities. If you suddenly find yourself trying to do something you have not done before or don’t really have the skills to do, it may be a sign you are in a stressful situation that is distorting your judgment. Also, stick to the rules of your profession. Remember it’s a rare occasion when the rule don’t apply. Again, if you’re finding yourself thinking, ‘well, this is different,‘ it may be a sign of poor decision making due to stress.

SLIDE 42

April: Make sure students, interns and all staff working with trauma patients and clients are aware of CF and STS and its potential development. Everyone needs to be on the same page in order to support each other through these stressful work environments. Each should have the training, the psycho-education about how to identify the symptoms from each of the contexts, as well as what helps to decrease symptoms. Everyone should be encouraged to seek peer and other supports as they need it.

Common attitudinal obstacles to self-care for healthcare providers include thinking, “It would be selfish to take a break;” “Others are working hard, so should I.”   “The needs of those I’m supporting are more important than my own needs;” “I can contribute the most by working all the time;” and then the famous, “Only I can do x, y, or z.” 

Make sure staff understand and identify personal ways they may protect themselves from patients and clients projections of their pain, anger, fear, frustration and trauma. Mastering this, controlled empathy, is a necessary skill for healthcare providers.

Role play boundary setting as a way of helping staff understand the importance of doing this and how to do it. Whether that means saying no, or delegating, or asking for help, or removing themselves from a heated or conflicting situation. Find out what issues they struggle with most and practice how to handle them. We as a society do not learn how to manage very distressing emotion in others, even in our patients and clients.

Emotions like fear, grief, conflict, disappointment. In the healthcare setting, staff have to deal with these all the time and when asked, most staff tell us they have never learned techniques to help with these everyday occurrences in their workplace.  These would be useful trainings for improving staff’s professional skills in working with patients, clients and their families and would also decrease their stress due to not knowing how to help.

SLIDE 43

April: So, if we look at what you can do on a professional level, we see there is a lot that can help you avoid and address CF/STS and even burnout. 

Use peer supports and professional supervision. This is critical.

Use your breaks and lunch time for stress management, not to catch up on work. Take a ten minute walk in nature on your break, or do some mindfulness exercise, call home, stretch, sing, dance.

Use your benefit time routinely. Schedule time off across the year, those times when you can take your vacation or personal time. Research is very clear we need to be living a balanced life of work time and leisure time. We are more focused and productive when we have sufficient time off, are rested and are less stressed. Even more so when we engage in body movement and mindfulness. It is possible you can do work better or even get more done when you are refreshed and able to think clearly as a result of using time off to recharge.

Take the time to monitor yourself. Use your self care plan and use the ProQOL and feedback from trusted colleagues and loved ones to help you get an accurate sense of how you are managing.

SLIDE 44

April: In summary, all healthcare providers can benefit from learning what to do on both a professional and personal level. How to identify your stressors, create a self care plan for use as a regular part of your professional practice and certainly during and following a disaster assignment. Personal and professional supports will help us mitigate the negative effects of CF and STS, so we need to allow ourselves to seek the type of support we want and then to monitor our self care activities on a regular basis.

There is nothing on any of these lists that is beyond your ability. It’s a matter of education, willingness and practice.  You may be saving your profession and very likely, your health.
Also, know that you are not alone. There are many others struggling with these issues and we can be a help to each other. In addition to using supervision and working with your buddy, access the resources that are out there to increase your understanding of how to tackle these concerns.

SLIDE 45

April: There are many resources that can inform you further about acute stress, posttraumatic stress and secondary traumatic stress and compassion fatigue. ASPR TRACIE and SAMHSA DTAC have Educational Fact Sheets, webinars and podcasts that are free and accessible online. Some are for survivors, other are for helpers, some are for parents and other caregivers. Check them out.

And for those of you who are interested in the research, the National Center for Posttraumatic Stress Disorder’s website will bring you to the Pilots database, which is the most comprehensive collection of literature on these subjects.  These articles are also free and downloadable once you register. 

SLIDE 46

April: Thank you for attending this webinar sponsored by ASPR TRACIE. We hope it was an informative one and useful and that you can use this material to help improve your sense of well being, in addition to improving your confidence in your ability to continue the work that you do in this most important profession.  Our wish for you is to remember your own good will and your heart so that you can continue to take care of your patients, your clients, and yourself in the best ways possible. And we encourage you to access the rest of the videos in this series.

Voiceover:  Produced using taxpayer funding by the U.S. Department of Health and Human Services.

[The video ends.]