1. So Your Staff Needs a Self-Care Program?
Presenters:
Lynn Skubiszewski, LCSW and
Nicole Perry, LCSW
#NASWIL

2. Welcome to Our Presentation
Ask Audience: How did you feel hearing this, watching this? We would compare this to the effects and the contagion that a self care group could have for your staff and our goal today is to review self care concepts, a research study on a starting a self care group and give you the tools and resources to use this for yourself and your organizations.

3. Presenter Biographies
Lynn Skubiszewski, LCSW Palliative Care Social Worker,
JourneyCare
Lynn is a graduate of Aurora University School of Social Work and has worked in the academic, geriatric, and healthcare fields for over 20 years. She has an interest in coaching the helping professionals in self care and encouraging social workers in healthcare settings to embrace leadership roles in their multidisciplinary settings.
Nicole Perry, LCSW
Social Worker and Team Manager,
JourneyCare
Nicole has an MSW from the University of Wisconsin – Madison. She has worked as a Social Worker since 2006 in the fields of aging and hospice. Nicole enjoys leading an interdisciplinary staff team to provide excellent end of life care and symptom management to the patients of JourneyCare.
Who is in the audience today? School SW, private practice, hospice SW? Other disciplines? Why are we the right people to talk about this topic? – SW, nurses are at the front lines – whether it be a community agency, the Red Cross, a staff in the ER, etc. In hospice, SW are the front line when there are intense interpersonal, psychosocial, traumatic issues.

4. Why is Self Care Important?
Poor Quality of Life
Poor self-care = burnout/dissatisfaction = drop out of SW field
“In light of recent and significant research indicating that social workers engaged in direct practice are likely to develop symptoms of secondary traumatic stress, it is imperative that the social work profession devotes greater attention to and creates greater awareness of these issues.” (Professional Self-Care and Social Work, policy statement approved by the NASW Delegate Assembly, 2008)
Poor self care = reduced ability to be empathic

5. “The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through the water without getting wet.” ~ Remen
Hospice examples – Hospice SW example: A hospice SW is called by the RN CM to meet with a new hospice patient. Upon arrival, the SW meets with the patient, an 80 y/o woman with severe dementia. Family talks about their grief at seeing their loved one decline which has happened over the past 10 years. The patient’s eldest daughter discloses that she has been using alcohol and drugs to cope with her feelings of grief. The daughter and her own young adult children are currently living with the patient and when the patient dies, they will have nowhere to go. The family all discloses that in addition to the loss they are experiencing now, they have experienced multiple other losses/deaths in the recent past.
Ask audience – who is here? School SW, private practice?

6. Outline
Define burnout, compassion fatigue, compassion satisfaction, secondary trauma, vicarious traumatization/post traumatic stress.
Research Project
What is self – care?
How can you start self care?
Resilience, Personal Self Care, and Realistic Expectations
How to Expand Self-Care to the Organization Level
Summary and Review Resources/Tools

7. What is Burnout?
“A relatively frequent outcome of chronic stress that has received considerable attention.”
Refers to the gradual extinguishing of energy of a Social Worker.
What leads to burnout?
Schaufeli, Leiter, & Maslach, 2009, p 205.
Maslach and Leiter, 2005
Cox and Stiner, 2013
Burnout is caused by lack of fit between a person and their job in these six areas: workload (excessive work with inadequate resources) control (little influence, high accountability with limited power); reward (low pay, recognition or satisfaction), community (social isolation, interpersonal conflict); fairness (inequality, preferential treatment); and values (little sense of purpose or meaning, ethical conflicts)

8. Burnout is the opportunity to re-discover what makes you happy.
Silver Lining?
Burnout is the opportunity to re-discover what makes you happy.

9. A compulsion to prove oneself, working harder, neglecting one's own needs, displacing conflicts by ignoring the root cause of the distress, revision of values in which friends or hobbies are ignored, denial with emergence of cynicism and aggression, withdrawing from social contacts and/or using alcohol or substances to cope, inner emptiness, depression, and actual Burnout Syndrome.
10 Phases of Burnout
"Preventing Burnout" by psychologists Herbert Freudenberger and Gail North
: Long-Term Living 59.5 (May 2010):

10. How do you know it is burnout?
Listen to others who know and care about you
Use assessment tools to help you see the truth
Self awareness – know when you are crossing a line
How do you know it is burnout?
Difference between compassion fatigue and burnout vs. the job.
Is it really the client or is it more than that? Is it your organization? Is it unrealistic productivity expectations?

11. Ask yourself these simple questions…. 1
Ask yourself these simple questions…. 1. How often are you tired and lacking energy to go to work in the morning? 2. How often do you feel physically drained, as if your batteries were dead? 3. How often is your thinking process sluggish or your concentration impaired? 4. How often do you struggle to think over complex problems at work? 5. How often do you feel emotionally detached from coworkers or customers, and unable to respond to their needs?

12. What Does Burnout Look Like?
TOP 10 SIGNS OF BURNOUT
#10 – Shopping at Kmart feels like you’re taking good care of yourself.
#9 – Patients frequently startle you by waking you up during home visits.
#8 – Find yourself saying, “You think you’ve got problems, lady?”
#7 – You become aware of a reluctance to go to work and don’t go to work.
#6 – You accidentally drop your beeper from a high bridge.

13. What is Burnout, cont’d. #5 – You jump after the beeper.
#4 – Giggling during team meetings.
#3 – Not giggling during team meetings.
#2 – Eating an entire bag of Dorito chips while making bereavement phone calls.
#1 – Who cares about this list anyway?
Larson, National Hospice and Palliative Care Organization

15. What is Compassion Fatigue?
Similar to PTSD
Easily frustrated, irritable, annoyed
Symptoms of depression
Feeling over alert, restless
Feeling ineffective, negative, inadequate
Compassion Fatigue Scale

16. Compassion Fatigue and Compassion Satisfaction
Also called Secondary Traumatic Stress
A set of behaviors and emotions that can occur when the SW is seeking to help a suffering person.
“a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering?
Figley, 1995
Teater, 2012
Larson
Defined as the pleasure derived from helping others.
Sounds like:
I have happy thoughts about those I help
I like my work
I enjoy and trust my co-workers
I am effective
Craig and Sprang, 2010
Compassion fatigue is the trauma you experience as a result of being exposed to someone else’s trauma. The cost of caring, the cost of doing what we love, being traumatized by concern about the suffering of others, profound emotional and physical erosion, indirect trauma

17. Compassion Fatigue Scale
Although the world is full of suffering, it is full also of the overcoming of it.- Helen Keller

18. Compassion Fatigue and Compassion Satisfaction
Also called Secondary Traumatic Stress
A set of behaviors and emotions that can occur when the SW is seeking to help a suffering person.
“a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering?
Figley, 1995
Teater, 2012
Larson
Defined as the pleasure derived from helping others.
Sounds like:
I have happy thoughts about those I help
I like my work
I enjoy and trust my co-workers
Compassion fatigue is the trauma you experience as a result of being exposed to someone else’s trauma. The cost of caring, the cost of doing what we love, being traumatized by concern about the suffering of others, profound emotional and physical erosion, indirect trauma

19. 50% of child protection staff suffered from high or very high levels of compassion fatigue
70% of staff expressed a high or good potential for compassion satisfaction
Conrad and Kellar-Guenther (2006)
CF and CS Can Co-Occur

20. What Creates Compassion Satisfaction?

21. Secondary Trauma and Vicarious Traumatization – Post Traumatic Stress
Social workers are affected by exposure to their clients' traumatic life experiences and behaviors. Research has demonstrated that secondary traumatic stress (STS) - also referred to as vicarious trauma, compassion stress, or compassion fatigue - is prevalent among mental health professionals who work with traumatized clients
(Fahy, 2007; Figley, 2002b;Jacobson, 2006;Jenkins & Baird, 2002; McCann & Pearlman, 1990)

22. Symptoms of Secondary Traumatic Stress Increased sensitivity to violence Not laughing as easily Trouble sleeping Difficulty thinking, concentrating or making decisions Intrusive thoughts and traumatic images Feeling emotionally numb Physical complaints Use of alcohol, drugs Detachment Lack of Empathy Ting, L., Jacobson, J. M., & Sanders, S. (2011). Current levels of perceived stress among mental health social workers who work with suicidal clients. Social Work, 56(4),

23. Vicarious Traumatization
(VT) common when population exhibits:
Suicidal Behavior –
Fatal and Non Fatal -
Reported feelings of guilt, failure, professional self-doubt regarding their clinical competency, and anger directed toward the client
(Chemtob et al., 1988, 1989; Ellis & Dickey, 1998; Grad, Zavasnik, & Groleger, 1997; Kleespies, Penk, & Forsyth, 1993; Ruskin, Sakinosfsky, Bagby, Dickens, & Sousa, 2004;Yousaf, Hawthorne, & Sedgwick, 2002)
Vicarious Traumatization

24. Secondary Trauma for Social Worker
Highest for those who work with:
Sexual Offenders
Trauma Victims
Natural Disaster Victims
Victims of Terrorist Attacks
Suicidal Clients
Refugee Populations
Violence against Families/Children

25. Hunter, S. V., P.H.D. (2012). Family Process, 51(2), 179-92.
… findings suggest that the experience of compassion satisfaction and the development of vicarious resilience counter-balanced the intense difficulty of bearing witness to clients' traumatic experiences and the potential for vicarious traumatization.
Hunter, S. V., P.H.D. (2012). Family Process, 51(2),

26. Secondary Trauma and Vicarious Traumatization – Post Traumatic Stress
Secondary Traumatic Stress – “the natural and consequent behaviors and emotions resulting from knowing about a tramatizing event experienced by a significant other – the stress resulting from helping or wanting to help a traumatized or suffering person.” Figley (1993, 1995)
Vicarious Traumatization – “the transformation in cognitive schemas and belief systems as a result of empathic engagement with survivors of traumatic experiences.” McCann and Pearlman, 1990

27. Pilot Study at Journey Care
Research Study
Pilot Study at Journey Care

28. Participant Demographic Data
5 Advanced Practice Nurses/Nurse Practitioners in Palliative Program part of Palliative/Hospice Agency
Average Years as APN = 6 ½
Palliative Care and Hospice Experience = 7 months to 10 years
Ages: 45 to 60 years of Age
Question: Do you currently practice Self Care?: 4 out of 5 = Yes
Question: How long have you engaged in Self Care as a Nursing Professional? Average 2.5 years
Coordinator Data
Palliative Care LCSW with 2 years with experience on team – 20 years as social worker

29. 5 Advanced Practice Nurses on a Multi-Disciplinary Team completed Assessment Surveys/Tools
Step One
Assess if your Staff or Team is in need of
Self Care

30. Burnout Self Test

31. Resilience Assessment

32. Self Care and Lifestyle Inventory

33. Self Care Assessment

34. Self Care Assessment

39. Objective: Create Emotionally Healthy and Centered Palliative Staff
Purpose: Help Staff De-Stress, Explore Negative Feelings re: Loss, Expectations, Alleviate Burnout, Stress Work/Life Balance
Objective: Create Emotionally Healthy and Centered Palliative Staff
Details: Meet every 4 to 6 weeks for 30 to 60 minutes during Work Day
Varied Interventions Used
Pre-Test/Post-Test
Program Description:
Palliative
Self Care

40. Quantitative Assessment Results – How Did They Score?

41. The APNs said….
Qualitative Data…
And the

42. Research Project – Palliative Care Staff
In order to determine effectiveness of Interventions and Collect Data to bring to Agency Leadership a simple Pre-Post Test was administered before the Self Care intervention began and immediately after. We utilized a 1-10 Scale.
1. Perception of Stress from today’s work day
(1) meaning No Stress (10) Very High Stress
2. Perception of Stress after today’s Self Care Program
3. Would you Practice this Technique again – either on own or in group setting?

43. Pre and Post Test Scale

44. Self Care Interventions Used in Pilot
Spiritual – 1) Mindfulness Exercise: Leader demonstrated Breathing and Loving Kindness Meditation Stahl & Goldstein
Spiritual – 2) Connect with Nature: Participants walked around a Natural Setting noting what they could: See, Hear, Smell, Touch, Experience. APN’s then shared their favorites.
Relational – The Guilts: Group shared any unresolved guilt, professional regrets, etc. and placed same on paper to be ritually burned.
Opportunity to Express Self - To Soothe and Release each APN shared the Ups and Downs of caring for patients and “doing the job” – then took turns reading uplifting quotes and affirmations on small pieces of paper in a basket.
Physical – Group participated in stretching, breathing, listened to leader explain various health benefits of various ingredients - then participated in making fruit/greens smoothies – then tasting smoothies.
Individual vs. Group Activities

45. Efficacy of Self Care Interventions
Most Effective APN Self Report
Least Effective APN Self Report
Meditation: Loving Kindness
Sharing stories/ideas/frustrations and group Affirmations
Stretch and Smoothie
Connect with Nature
Discuss “The Guilts”
Note: Average Stress Level Decreased by at least 2 points on scale for each of the Interventions

46. Starting Your Own Self-Care Program
It’s not that hard…..

47. What Is Self Care? Definitions vary (affected by different factors)
Common theme is that consumers take a more active role in their own care instead of relying on others to provide care
Can be easier to say what it is NOT:
NOT: just for burned out workers, the weak, the maladjusted.
NOT something we don’t have time to do
DOES NOT mean we focus on ourselves and ignore others
NOT about numbing ourselves
DOES NOT indicate narcissism
IS NOT a luxury and does NOT mean we are self-indulgent.
Cox and Steiner, Self-Care in Social Work (2013)

48. You Know You Don’t Have Good Self Care When…
Page 34 of book – struggles with self-care
Funny example – medical experimentation
Audience examples
Attendee Examples???
Boundaries Exhaustion Calling in sick Loss of Hope Depression Stress Eating Thoughts of leaving profession Unprofessional Behavior Sleep Issues Can’t Separate Work from Home

49. Boundaries and Professionalism
When you are stressed/burned out you may find yourself:
Sharing too much personal data with clients
Sharing information about other staff members
Complaining about your agency or workload
Developing dual relationships
Upstaging their problems/issues with your own
Downplaying other team members or disciplines

50. Physical Psychological Emotional Spiritual Professional Balance
What is good self care?
Basic Framework
Page 32 in Cox book

51. Wellness Wheel

52. In Balance Wellness Wheel

53. Start with You Self Assessment of Your Self-Care Patterns – PROQOL
Develop Your Own Plan – Research what activities work!
Implement the Plan
Test – Tweak for Effectiveness
Start with You

54. Self Care Tools

55. Resources/Tools for Self-Care
John Kabat-Zinn and Mindfulness
You Tube Video

56. What is Mindfulness Meditation?
Can be practiced in 2 ways: Formally and Informally
Formal means taking time each day to intentionally:
Sit
Stand
Lie Down
And Focus on Breath
Bodily Sensations
Sounds
Other senses - thoughts - and emotions
Stahl & Goldstein 2010
What is Mindfulness Meditation?

57. Mindfulness Meditation cont’d
Informal Mindfulness is…
Bring mindful awareness to everyday activities such as:
Eating
Exercising
Chores
Work
Relating to Others
Basically any action
Mindfulness Meditation cont’d

58. Mindfulness and Physical Pain
The practice of mindfulness is particularly effective because it “decouples” the physical sensations of pain from mental and emotional processes that heighten suffering. Pain comes to be seen as “just another sensation” and the fear of pain is significantly reduced. The development of mindfulness, as Buddhists have known for 2,500 years, brings about mental and emotional freedom and a decrease in suffering.
But if we are mindful of the pain – won’t focusing on it
Just increase it?

59. Meditation with Music Get comfortable and close your eyes…..
From Caregiver Stress by Belleruth Naparstek 2008

60. Setting Realistic Expectations
The Guilts
Remind yourself that what you do makes a difference.
Set Realistic goals – “If Only I were….”
Accept your shortcomings and take action in areas you can improve.
Do not take yourself so seriously
Arrange for regular vacation time
Attend career nurturing events
Share your thoughts with a trusted friend
If overwhelmed for long period of time – see a counselor or EAP
Larson, National Hospice and Palliative Care Organization

61. Top Self-Care Tips for Helpers
Take Stock of Where Things Are – What’s on Your Plate?
Start a Self Care Idea Collection
Find Time for Yourself Every Day
Delegate and Learn to Ask for Help
Have a Transition from Work to Home
Learn to Say Yes or No More Often
Assess Your Trauma Inputs – Work/Non-work Related
Learn more about Compassion Fatigue and Trauma
Supervision/Peer Support
Workshops and Training
Consider Working Part Time
Exercise
Mathieu, F. (2007)

62. What Else Can You Use?
Physical Self Care – eat well, exercise, get enough sleep, get medical care
Psychological Self Care – reflect, journal, engage in leisure activities, let others help you
Emotional Self Care – have pleasant thoughts about your self, engage in laughter/play, express emotions in appropriate channels
Spiritual Self Care – pray, meditate
Create team rituals – Healing Circles, Drumming, Light a Candle, Burn Regrets
Professional Self Care – take a break, take a vacation, balance case load
Balance Plan – among work, family, relationships, play, rest
Supervision
Cox and Steiner, 2013

63. Takin’ it to the streets Self Care on Agency Level

64. Expand Self Care Beyond You
Explain why it is important to organizations:
Poor quality of life, burnout/dropout
More satisfied employees have lower absenteeism rates, high productivity and better service to clients.
Research shows enormous costs (financial and human being costs) with unhealthy organizations.
The Corporate Executive Board places the cost of employee turnover as high as “200 times annual salary for certain positions.” But even if your lowest-level workers cost just $4,000 to replace and absorb their lost productivity, aggregating this cost for a full year likely produces a total cost number in the hundreds of thousands or millions, a number that would stagger most executives.

65. Facts your agency’s leadership need to know…
Facts your agency’s leadership need to know….. How does burnout affect your heath? “most disenchanted employees developed heart problems at a 79% higher rate than their less- stressed peers.” Earlier research had shown that job burnout can lead to a range of health problems, including obesity, insomnia, and anxiety. Colleague and supervisor support contributed significantly to explaining the variance in burnout intensity. Hamama, L. (2012) Journal of Counseling and Development : JCD, 89(2), Anne Fisher, contributor April 2, 2013 Fortune 500 Magazine

66. So why are we so stressed?
1. United States of America – 13 days
2. Belgium – 20 days
3. Japan – 25 days
4. Korea – 25 days
5. Canada – 26 days
6. United Kingdom – 28 days
7. Australia – 28 days
8. Brazil – 34 days
9. Austria – 35 days (42 for elderly)
10. Germany – 35 days
11. France – 37 days
12. Italy – 42 days
So why do Americans have work stress?
We retire at an older age than other countries
We work more job
Identity tied to job/career
We work longer hours
We have less vacation days
We have less national holidays
So why are we so stressed?

67. Within a Larger Organization
Create a Proposal
Use Facts from this Presentation
Do a Needs Assessment
Collaborate with others who are like-minded
Get a decision-maker/leader to buy in
Do a small sample/test project
Can do quantitative analysis to show effects of self-care program participation (ex: monitor employee sick days in relation to number of self-care programs attended)

68. What Can Organizations/Employers Do?
Encourage/pay for Supervision
Create Task Force to Develop Self Care Program
Encourage – allow time for staff to meet with Mentors
Create Wellness Programs
Create a climate where sharing frustrations is “Normal” and help staff develop ways to Let the Frustrations Go!
Offer skill building opportunities
Employee Recognition Programs
Flex Time – Generous Vacations – Realistic Productivity Expectations
Improve Orientation and Performance Reviews
Schwartz Rounds

69. Schwartz Rounds
…offers healthcare providers a regularly scheduled time during their fast-paced work lives to openly and honestly discuss social and emotional issues that arise in caring for patients. In contrast to traditional medical rounds, the focus is on the human dimension of medicine.
Caregivers have an opportunity to share their experiences, thoughts and feelings on thought-provoking topics drawn from actual patient cases. The premise is that caregivers are better able to make personal connections with patients and colleagues when they have greater insight into their own responses and feelings.
Schwartzcenter.org
In healthcare settings -

70. If you are a small group or private practice?
Research your partners in community
Forge relationship and create small SELF CARE consortium
Share resources across agencies
Join professional associations
Social Work Supports in Social Media such as Linked In
NASW
If you are a small group or private practice?

71. How to be more resilient
Take this cup,
I’ve filled it up,
With love and joy and laughter.
Now it’s empty,
Fill it up.
Repeat,
Forever after.
First, so full
I’m giving
All my love and joy in living
Then near empty,
Tired of living,
And I’m the
One who needs the giving.
This cup, this cup,
This cup of life,
It’s always overflowing;
We give and get
And get and give,
Life’s balance
Keeps on going.
Repeat, By: Laura Byrnes
Forever, after.

72. Thank You for Attending Questions May I be filled with loving kindness
May I be well
May I be Peaceful and at ease
May I be happy
Stahl and Goldstein, 2010
Closing