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Caregiver Stress: Research. Kathi J Kemper, MD, MPH Wake Forest University Health Sciences. Objectives. By the end of this session, participants will be able to Contrast rates of stress and burnout in generalist, specialist, and trainee pediatricians

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Caregiver stress research

Caregiver Stress: Research

Kathi J Kemper, MD, MPH

Wake Forest University Health Sciences


Objectives
Objectives

By the end of this session, participants will be able to

  • Contrast rates of stress and burnout in generalist, specialist, and trainee pediatricians

  • List negative consequences of stress on physical health, memory, and cognitive performance

  • Demonstrate 3 effective stress management strategies (emotional, mental, spiritual)

  • Tackle a research study about caregiver stress


Us residents frequently distressed 2006
US residents frequently distressed (2006)

% reporting 14 or more days Frequent Mental Distress in past month

Least distressed: HI, IA, WI Most distressed: Appalachia



Some stress is normal
Some stress is normal

If you have experienced NO stress at any time in the past 30 days, please raise your hand.


Stress in caregivers
Stress in Caregivers

  • Medical Issues

  • Financial issues

  • 24/7 schedule

  • Impact on marriage, friendships, work

  • Social factors: minority status, poverty – worse stress

  • In US, 13% of children lived in households with at least one parent reporting high parenting stress

    Raphael J. Child Care Health Dev.2010


Stress symptoms in pediatricians
Stress Symptoms in Pediatricians

  • Survey of 5704 pediatricians, internists, and family docs

  • General pediatricians reported higher job, satisfaction on a 5-point scale (P<0.01).

  • 13% of pediatric generalists and 23% of specialists endorsed symptoms of burnout or job stress (lower than other docs)

  • 2006 study: Higher stress levels in pediatricians with frequent unpleasant duties (admin/paperwork) and infrequent pleasant work (patient care, research, teaching)

    Shugerman R. Pediatrics, 2001

    Kushner. Work, 2006


Stress and burnout trainees
Stress and Burnout: Trainees

  • Stress is increased by high demand, low control situations with frequent demands for change

  • By 2004, 15 articles on stress and burnout in residents; High stress levels associated with:

    • Depression and substance abuse

    • Errors, poor quality

    • Poor communication

    • Dropping out of medicine

  • Decreased duty hours have had limited impact on stress and burnout: 68% positive screensfor burnout among pediatric residents in 2008

    McCrary LW. Fam Med, 2008

    Landrigan. Pediatrics, 2008

    Thomas NK. JAMA, 2004


Stress effects
Stress Effects

  • Physical: higher cortisol, lower DHEA; higher epinephrine/NE, BP; shorter telomeres (aging); poor sleep, more pain, GI upset.

  • Stress is associated with 70% of visits to primary care clinicians; STRESS makes you SICK

  • Emotional: irritability, anxiety, depression; angry, impatient

  • Mental: STRESS makes you STUPID; less focused, less PFC activity; more errors; impaired memory

  • Social: impaired communication

  • Work: impaired performance


Husband During Argument with his Wife: HR

Wife said something that got under his skin

Heart rate remains elevated after argument ends


Sympathetic

Parasympathetic

Constrict

Dilate

Stop secretion

Secrete saliva

Spinal

cord

Parasympathetic

Constrict bronchioles

Dilate bronchioles

Sympathetic

ganglion

chain

Speed up heartbeat

Slow down heartbeat

Secrete adrenaline

Increase secretion

Adrenal

gland

Decrease secretion

Stomach

Increase motility

Decrease motility

Empty colon

Retain colon contents

Empty bladder

Delay emptying

Bladder

Parasympathetic

Stress: Autonomic Nervous System



Stress management
Stress Management

  • Mental (meditation – sitting or moving, guided imagery, self-hypnosis, biofeedback, autogenic training, journaling, CBT, etc.)

  • Emotional (intentionally generate positive emotions)

  • Spiritual (not necessarily religious; forgiveness; extending compassion)



Mental practices meditation
Mental Practices: meditation

  • Growing neuroscience

  • Clinically: Reduces anxiety; Improves concentration; memory; moods

  • Few side effects; can combine with other practices

  • Positive impact in physicians

    Davidson RJ Psychosom Med, 2003

    Krasner MS. JAMA, 2009

    Pipe TB. J Nurse, 2009


Focus and count sheep or breath
Focus and Count: Sheep or Breath

  • Reliably induces relaxation (except for some with breathing problems)

  • In/out: 1 – repeat (relaxation response)

  • In/out: 1; in/out: 2; in/out: 3; in/out: 4 - repeat


Focus and count word or image
Focus and Count: Word or Image

  • In/out: PEACE

  • When mind wanders, notice (without judgment) and return


Practice
Practice

  • We will practice for 2 minutes

  • Then share with neighbor for 1 minute

  • Pick a strategy: count breath, focus on word or image; Sit comfortably

  • NOTE: It is likely that your mind will start wandering within the 1st 8 seconds. Normal. Just return to intention

  • OR take a 3 minute break


Hypnosis guided imagery
Hypnosis/Guided Imagery

Hypnosis: An altered state of awareness usually involving relaxation during which the participant can give himself suggestions for desired changes to which he is more likely to respond that in his usual state of awareness.

Guided Imagery involves using the imagination to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization.

http://www.healthjourneys.com/


Guided imagery
Guided Imagery

Body responds as if you’re there!


Mind body autogenic training
Mind-Body: Autogenic Training

  • Form of hypnosis

  • Repeat phrases

    • My hands and arms are heavy and warm

    • My legs and feet are heavy and warm

    • My heartbeat is calm and regular

    • My breathing is easy and free

    • My forehead is cool

    • My belly is relaxed

  • Reduces need for headache medication

  • Reduces frequency of migraine attacks

    Zsombok. Headache, 2003

    Juhasz. Headache, 2007


Biofeedback
Biofeedback

Use of electronic equipment to measure and feed back information about physiologic functions—which are then modulated in desirable direction

Goal-balancing ANS (& CNS) activity

Portable vs. PC/Mac

Mood rings?

“video-games for your body”

Nestoriuc. Pain, 2007


Home biofeedback
Home Biofeedback

Peripheral Temperature

Heart Rate Variability

Skin Conductance



Intentional emotions
Intentional emotions

  • Affect

    • Hormones

    • ANS



DHEA(S)

Total Free Cortisol

250

14

l

l

100%

23%

l

12

l

200

l

l

l

10

l

l

150

8

l

l

l

nM

ng/ml

l

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6

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100

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before

after

before

after

N=28

Improvements in Hormonal Balance



Impact on Memory

Before Placebo Drug Gratitude/

Breathing



Hrv biofeedback resources
* HRV Biofeedback - Resources

www.heartmath.com

www.heartmath.org

www.aapb.org

www.stresseraser.com

www.bcia.org

www.stens-biofeedback.com


Gratitude exercise
Gratitude Exercise

Turn to neighbor and tell him/her three things for which you are grateful

As you listen, extend compassion and feel grateful that this person trusts you.



Spiritual strategies include
Spiritual Strategies include:

  • Forgiveness

  • Extending compassion

  • Art and music

  • Time in nature – Grand Canyon perspective

  • Reading inspirational stories

  • Healing Touch/Therapeutic Touch/Reiki


Extend Compassion1. May you be safe and secure.2. May you be happy and peaceful.3. May you be healthy and filled with vitality.4. May life go easily for you today.For self, loved ones, friends, colleagues, patients, all men, all women, all elderly, all young, all suffering, all prisoners, all politicians, etc.


Research for stress management questions
Research for Stress management: questions

  • Which subjects?

    • Parents or other caregivers (Special Needs, Cancer, Other conditions; single parents; dads vs. moms; older vs. younger; only child vs. multiple children)

    • Nurses (Inpatient, Outpatient)

    • Physicians (Practice, training)

    • Other conventional (social work, pastoral care, pharmacy, PT, OT, RT)

    • CAM providers

    • Combine? Compare?


Research for stress management questions1
Research for Stress management: questions

  • Which Intervention?

    • MBSR

    • Other meditation

    • Hypnosis/Guided Imagery

    • Biofeedback

    • Positive emotions or intentions (gratitude, compassion)

  • Control?

    • Placebo; exercise; music; CBT; education; medication; another intervention?


Research for stress management questions2
Research for Stress management: questions

  • Which delivery strategy?

    • MBSR standard vs. light (4 weeks)

    • Individual vs. group

    • In person vs. on-line

    • Vs. CD, DVD, or You-Tube video

    • One time vs. ongoing

    • Delivered by certified trainer vs. peer

    • Delivered alone or as part of overall strategy (exercise, nutrition, communication skills)


Research for stress management questions3
Research for Stress management: questions

  • Which outcomes?

    • Self-report: Stress, Burnout, Mindfulness, Wisdom, Memory, Serenity, self-esteem, relaxation, connection, QOL (physical, mental)

    • Biomarkers: cortisol, DHEA, Autonomic balance (HRV, EDA, temperature); inflammation; BP; weight; other?

    • Quality of care (professional vs. parental)

    • Relationships (Peers; family)

    • Cost (Absenteeism; turnover; productivity)


Other questions
Other questions

  • How do

    • Experience

    • Expectations

    • Marketing

    • Demographics

    • Other illnesses/conditions

    • Preferences for training

  • Affect response to intervention?


Participant centered research
Participant-Centered Research?

  • Among nurses, WHAT ARE

    • Experiences

    • Expectations

    • Demographics, and

    • Disease characteristics of those interested in stress management?

  • How do they relate to preferences for training type, delivery, and outcome measures?

  • Are they willing to be randomized?


To take the survey or borrow it and adapt
To take the survey (or borrow it and adapt)

  • http://www.surveymonkey.com/s/Nurses_Self_Care_with_Mind-Body_Practices

  • Or email me at

  • [email protected]

  • IRB approved

  • Data to be analyzed in July


Sneak peek
Sneak peek

  • First 250 responders; >95% women

  • 94% regularly pray (mostly prayer for another’s well-being or health)

  • 70% already meditate

  • 38% did yoga

  • 65% had received some kind of formal training


Greatest expected impact
Greatest expected impact:

  • Physical health: better sleep; overall better health; lower BP, weight; less pain; more vitality

  • Emotional: more serenity; less stress, better mood,less anxiety

  • Mental: more mindful; overall better mental health; more discerning; more focus; better memory; less judgmental; more creativity

  • Social: burnout; greater kindness; better listener

  • Spiritual:greater spiritual well-being; better connection with God/Higher Power; more centered; more inner peace; more compassionate; greater sense of meaning and purpose


Participant preferences
Participant Preferences

  • 10% unwilling to collect biomarker data

  • #1 value driving training preference?

    • Scientific data

    • Reputation of researchers or institution

    • Religious or spiritual values

    • Group vs. individual options

    • Convenience


Importance of baseline assessment
Importance of baseline assessment

  • Generalizability

  • Bias: % reporting anxiety (50%), depression (30%), back pain (42%) at baseline?

  • Recruitment and marketing efforts

  • Designing interventions

  • Selecting outcomes


Designs
Designs

  • RCT – good if lots of data already known and one can design simple study with 2 arms and 1 primary outcome with confidence

  • Comparative cohort: QES

  • Natural experiment

  • Participant preference

    • - outcomes (burnout, other?)

    • -- intervention (standard group vs. webinar vs. CD)


Challenges
Challenges

  • Funding

  • Sample size

  • Analysis

  • Delivering across distance

  • Assessing across distance

  • Collaboration?


Conclusion
Conclusion

  • Stress is common among pediatric caregivers

  • Stress has negative effects on well-being and quality of care

  • Preliminary studies have shown benefits of diverse stress management practices

  • Given the common use and variability among stress management practices and their potential to improve care, studies in this area are a priority.

  • Do a baseline assessment to assess experiences, expectations and preferences for CAM therapies!

  • Opportunity for collaborative, participant-centered research.


References
References

  • Krasner MS, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-93.

  • West CP, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-8.

  • Preference Collaborative Review Group. Patients' preferences within randomised trials: systematic review and patient level meta-analysis. BMJ. 2008;337:a1864.

  • King M, et al. Impact of participant and physician intervention preferences on randomized trials: a systematic review. JAMA. 2005;293(9):1089-99

  • Beattie A, et al. Primary-care patients' expectations and experiences of online cognitive behavioural therapy for depression: a qualitative study. Health Expect. 2009; 12(1):45-59.



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