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596459 research-article2015

PMJ0010.1177/0269216315596459Palliative MedicineO’Mahony et al.

Short Report

Posttraumatic stress symptoms in palliative care professionals seeking mindfulness training: Prevalence and vulnerability

Palliative Medicine 1­–4 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216315596459 pmj.sagepub.com

Sean O’Mahony1, James I Gerhart2, Johanna Grosse2, Ira Abrams3 and Mitchell M Levy4 Abstract Background: Vicarious exposure to trauma is ubiquitous in palliative medicine. Repeated exposure to trauma may contribute to compassion fatigue and posttraumatic stress disorder symptoms in medical and supportive care professionals such as physicians, nurses, and social workers. These symptoms may be intensified among medical and supportive care professionals who use avoidant or rigid coping strategies. Aim: This study aimed to provide an estimate of posttraumatic stress disorder symptoms in a sample of professionals who work in palliative care settings, and have already been enrolled in mindfulness-based communication training. Design: Palliative care providers provided self-reported ratings of posttraumatic stress disorder symptoms, depression, and coping strategies using validated measures including the Acceptance and Action Questionnaire, Cognitive Fusion Questionnaire, and the Posttraumatic Stress Disorder Checklist–Civilian Version. Setting/participants: A total of 21 professionals working with palliative care patients completed assessments prior to beginning mindfulness-based communication training. Results: Posttraumatic stress disorder symptoms were prevalent in this sample of professionals; 42% indicated positive screens for significant posttraumatic stress disorder symptoms, and 33% indicated probable posttraumatic stress disorder diagnosis. Conclusion: Posttraumatic stress disorder symptoms may be common among professionals working in palliative medicine. Professionals prone to avoidant coping and those with more rigid negative thought processes may be at higher risk for posttraumatic stress disorder symptoms.

Keywords Posttraumatic stress disorder, compassion fatigue, burnout, traumatic stress, experiential avoidance, cognitive fusion

What is already known about the topic? •• Palliative care professionals encounter substantial trauma in their work. What this paper adds? •• One-third of professionals enrolled in mindfulness-based communication training reported clinically significant posttraumatic stress disorder (PTSD) symptoms. Implications for practice, theory, or policy •• Palliative care professionals may benefit from further assessment of their coping and traumatic stress. Resilience training that targets avoidant and rigid coping needs to be enhanced in order to reduce PTSD.

1Section

of Palliative Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA 2Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA 3Shambhala Meditation Center of Chicago, Chicago, IL, USA

4Warren

Alpert Medical School, Brown University, Providence, RI, USA

Corresponding author: James I Gerhart, Department of Behavioral Sciences, Rush University Medical Center, 1725 W. Harrison St. 950, Chicago, IL 60612, USA. Email: [email protected]

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Careers in palliative medicine offer opportunities for professional and personal growth. However, recurrent vicarious exposure to trauma is associated with compassion fatigue, including reactions to the trauma of patients that produce symptoms very similar to posttraumatic stress disorder (PTSD) including re-experiencing, avoidance, and hyperarousal.1,2 PTSD occurs as a person experiences or witnesses an event that involves actual or threatened death or serious injury, or a threat to the physical integrity of self or others.2 Experiencing the death of a family member in Intensive Care has been shown to evoke symptoms of PTSD in family caregivers.3 Death of patients may have a similar impact on professionals as up to 78% in one sample of hospice nurses reported compassion fatigue.4 These symptoms may manifest in the form of exaggerated startle responses, irritability, and feeling dissociated from patients, peers, and family. PTSD has been documented in professionals working in mental health,5 oncology,6 and emergency/trauma specialties,7,8 but less is known about these symptoms and their risk factors in palliative care professionals. Several risk factors may uniquely contribute to PTSD in palliative care professionals. Professionals who work in critical care and are involved in end of life decision making may experience stress and burnout as a result of their responsibilities, including the decision to maintain or discontinue life extending interventions.9 Palliative medicine professionals may also experience distress around ethical decision making, but their involvement in shared decision making and postgraduate training may help professionals feel more confident and supported in their decisions, and prevent these experiences from translating to clinically significant levels of burnout.10 Palliative medicine professionals are especially vulnerable to more frequent exposure to traumatic situations due to the high densities of patients that result from the shortage of professionals with training in palliative medicine.11 Because mental health stigma is common in medicine, professionals may attempt to hide or suppress responses to trauma. Experiential Avoidance refers to the tendency to suppress uncomfortable experiences, and Cognitive Fusion refers to the tendency to hold inflexible beliefs.12 Both tendencies may increase risk for PTSD to the extent that attention and coping become fixated on traumatic events.12 Finally, trauma is common in the general population, and personal trauma may compound the effects of vicarious trauma experienced at work.13–15 Given the implications of professional PTSD for continued empathic care of patients and families facing illness,16 and growing public awareness of PTSD,17 this study reports prevalence rates of PTSD in a sample of palliative care professionals enrolled in mindfulness-based communication training.

Methods This study’s ethics and protocol were reviewed and approved by the Institutional Review Board at Rush Medical Center.

The convenience sample included doctors, nurses, advance practice nurses, chaplains, and social workers enrolled in mindfulness-based communication training. Participants were recruited from a cohort of professionals enrolled in a palliative care training fellowship, and more generally through word of mouth and emails to several local palliative care departments. Emails were sent to several organizations that together employed over 200 professionals working within the field of palliative medicine.

Participants A total of 21 participants responded to the email and consented to participate. The mean age was 53 years (standard deviation (SD) = 9 years), and 81% were female. There were 10 nurses, 5 physicians, 4 social workers, and 2 listed their profession as other. In all, 15 described themselves as primarily palliative care providers, and 6 had contact with palliative care patients through multidisciplinary work. In all, 71% were married, and 29% were single. All 21 consenting participants responded to the assessment before beginning the mindfulness-based communication training in order to limit the potential of biased reporting as a result of the training experience.

Measures The Acceptance and Action Questionnaire–Version II. The Acceptance and Action Questionnaire–Version II (AAQII) measures experiential avoidance or the tendency to avoid or suppress one’s subjective experiences.18 The measure converges with other measures of psychopathology. An example item is “I’m afraid of my feelings.”13 The scale demonstrated adequate internal consistency, α = .88. A value of 24 has been suggested as indicating the presence of clinically significant experiential avoidance.18 The Beck Depression Inventory. The Beck Depression Inventory–II (BDI-II) measures cognitive, affective, and physiological depression symptoms.19 An example item is “I don’t feel particularly guilty”; “I feel bad or unworthy a good part of the time”; “I feel quite guilty”; “I feel as though I am very bad or worthless.”14 The scale demonstrated adequate internal consistency, α = .79. The Cognitive Fusion Questionnaire. The Cognitive Fusion Questionnaire (CFQ) measures the tendency for thoughts to be perceived and true and distressing.20 An example is “I get upset with myself for having certain thoughts.” The CFQ is validated in community, occupational, and mental health settings.15 The scale demonstrated adequate internal consistency, α = .97. The PTSD symptom checklist.  The PTSD symptom checklist (PCL-C) assessed PTSD symptoms for screening and assessment purposes.21 Items addressed PTSD symptoms

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Frequency of PTSD Scores 4

3

Sub Clinical

2

At Risk

1

Probable PTSD

0 18.00 19.00 20.00 22.00 23.00 24.00 26.00 27.00 31.00 33.00 36.00 37.00 41.00 46.00

PTSD Total Score

Figure 1.  PTSD total score.

including intrusive thoughts, avoidance, hyperarousal, and numbing. An example is “Repeated, disturbing memories, thoughts or images of a stressful experience from the past.” Because the prevalence of PTSD is unknown in palliative care professionals, a cut score of 30 was utilized as this has been suggested as an optimal cut-off in civilian primary care settings.21,22 The scale demonstrated adequate internal consistency, α = .92. Analysis. Descriptive statistics assessed the frequency of PTSD symptoms and levels of Experiential Avoidance and Cognitive Fusion.

Results The average BDI-II score of 8 indicated that professionals endorsed minimal depressive symptoms; however, 4 of 21 (19%) reported at least a mild mood disturbance. The average PTSD score was 26 and above the screening cut-off of 25 for civilian and primary care settings. Nine of 21 (42%) had scores above 25, and 7 of the 21 (33%) had PTSD scores above 30 (see Figure 1). Among the 15 primary palliative care professionals, 8 (53%) had scores above 25, and 6 (40%) had PTSD scores above 30. The average AAQ-II score of 19.38 (SD = 7.65) suggested most providers seldom engage in experiential avoidance. However, 4 (19%) endorsed scores greater than 24 which suggested that they experienced clinically significant levels of Experiential avoidance. The average CFQ of 22.76 (SD = 9.75) indicated that most professionals were seldom distressed by their thoughts.

approximately four times higher. Palliative care professionals may be at increased risk for PTSD symptoms to the extent they support traumatized patients, routinely witness medical trauma and death, and take responsibility for difficult decisions at the end of life.4,9 Common personal experiences with trauma may also evoke PTSD symptoms,13,14 and sensitize professionals to workplace stress.15 These symptoms such as numbing, avoidance, and hyper vigilance may be detrimental to effective communication and contribute to burnout and staff turnover. This pilot study is the first of our knowledge to report PTSD symptoms among a sample of palliative care professionals enrolled in mindfulness-based communication training. Validated and internally consistent measures were utilized, and the sample included a variety of professionals involved in the provision of palliative care. The sample was small, and inventories did not include measures that elicited the specific source of traumatic stress. Further multi-site studies with more representative samples of palliative care professionals are necessary to determine the generalizability of findings. Qualitative research is also needed to assess how PTSD symptoms are triggered in palliative care work settings, and to inform further intervention, support, and training for professionals in this challenging but meaningful field. Previous research suggests that multidisciplinary decision making and specialized palliative care training may buffer against distressing aspects of this profession.10 Interventions that promote team building, enhance communication, and reduce Experiential Avoidance and Cognitive Fusion are promising for reducing PTSD.12

Discussion

Declaration of conflicting interests

The lifetime prevalence of PTSD is approximately 7%,13 and professionals in this sample reported rates

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Funding This article was funded by the Prince Charitable Trusts.

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