South Shore Hospital Studies Self-Care in Health Care

Participating in major research projects in order to gather important mental health data may not be possible for all workplaces. Many employers, however, are able to conduct small pilot studies that, combined with other evidence, may help to advance the knowledge base for workplace mental health. One such employer, the State Government of Maine, participated in a large research project with the University of Massachusetts, offering an example of a pilot study in a hospital setting.

Healthcare workers are notorious for caring compassionately for their patients while neglecting their own emotional and physical health. At South Shore Hospital, a busy regional medical center in the suburban Boston area, clinicians in the hospital’s Employee Assistance and Wellness Program (EAP) have struggled with traditional approaches to dealing with the stress associated with providing healthcare. A few years ago, they found they were stuck in a repeating loop of providing Critical Incident Stress Debriefing (CISD) sessions with little positive impact.

The EAP clinicians decided to take a proactive approach to meeting the needs of the healthcare workers they serve. They developed and launched the “Self-Care in Health Care” program and pilot study to explore more effective ways to help employees manage stress.

What Makes South Shore Hospital Distinctive?

South Shore Hospital’s administration is highly incentivized to provide excellent health and wellness care because the hospital self-insures its employees. The hospital is unusual in having chosen to take an evidence-based approach to caring for the workforce, much like the approach it takes in delivering excellent medical care. Instead of “just trying something else,” the clinical social workers in the EAP dug into their clinical experience and went to the literature to explore more effective approaches.

The EAP clinicians came up with several well-validated stress management interventions and combined them into a staff education program. They thought that if they could help key leaders develop a personal toolbox of coping skills to manage stress, it might have a positive ripple effect that would end up being felt across the entire organization. As the pieces began to crystallize, they decided they needed to create a research protocol to test their hunch. They also knew they needed backing for their efforts.

Employer Support

The EAP clinicians first sought administrative approval by approaching their leader, Bob Wheeler, Vice President of Human Resources, with the idea of the Self-Care in Health Care toolbox. He recognized that self-care in healthcare was problematic. Mr. Wheeler had recently launched an employee wellness campaign in partnership with Harvard Pilgrim Healthcare called “Choices for Healthy Living and Four Seasons for Health” to assist staff in moving toward self-care. The idea of a self-care program for managing stress also fit in nicely with the hospital’s strategic plan to improve nurse satisfaction by addressing the stress that is epidemic in the healthcare environment.

South Shore Hospital Wellness programs include:

• yoga

• neuromuscular integrative action (NIA) — a non-impact exercise routine

• non-diet workshops addressing emotional overeating

• smoking cessation clinics

• blood pressure screenings

• health questionnaires

• sun damage screenings

• walking programs

Evidence

Chronic stress is blamed for healthcare worker burnout and is responsible for costly, high staff turnover rates. Multiple studies correlate various measures of stress with medical error rates and other negative patient outcomes, such as increased mortality, failure to rescue, and patient dissatisfaction (Jennings, 2008). Healthcare executives seek creative strategies for mitigating stress and preventing burnout. Creating a positive workplace culture in the healthcare environment requires acceptance of stress as a fact of life. Researchers recommend focusing attention on creating emotional resilience, rather than trying to avoid stress (Sergeant & Laws-Chapman, 2012).

Nurses are reluctant to care for themselves and rarely take breaks (Stephancyk, 2009). One study compared nurses’ perceived stress to job-related nursing stress scale scores and found that even when the nursing stress indicators are lower, perceived stress may remain high. The implication is that the perception of stress among nurses may be related to negative patient outcomes (Purcell, Kutash, & Cobb, 2011). A better understanding of how to reduce perceived stress and increase resilience is needed to craft effective solutions. The success or failure of efforts to reduce stress is reflected in work satisfaction scores, patient satisfaction scores, and ultimately patient safety scores. These scores will have a greater impact on hospital reimbursement as healthcare reform moves toward rewarding institutions with positive patient health outcomes and penalizing those with poor quality indicators.

The success or failure of efforts to reduce stress is reflected in work satisfaction scores, patient satisfaction scores, and ultimately patient safety scores. These scores will have a greater impact on hospital reimbursement as healthcare reform moves toward rewarding institutions with positive patient health outcomes and penalizing those with poor quality indicators.

Critical Incident Stress Debriefing

The idea for the pilot project first presented itself when the EAP clinicians at South Shore Hospital became aware of the increasing number of requests from nurse managers for critical incident stress debriefing (CISD). CISD is requested when there is a trauma and staff members are called together to discuss the incident. The theory is that this type of processing of the trauma makes it easier for the survivors to work through their emotions.

The EAP clinicians found that they and hospital clergy would prepare for a debriefing, but employees would rarely participate. When later questioned, employees would report feeling that talking in a group did not relieve their stress and often made things worse. CISD attendance was low, and effectiveness seemed minimal, despite robust utilization of other EAP services. The hospital’s experience was consistent with the research literature. A meta-analysis of CISD confirmed that this approach did not actually improve natural recovery from psychological trauma and could even exacerbate trauma (Van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002).

EAP clinicians then reviewed previous stress reduction efforts, such as team building, assertiveness training, professional coaching, and stress management workshops. Although hospital staff reported that these seminars were helpful, they shared that the skills were not readily utilized during traumas and other stressful situations. The EAP clinicians knew from their experience that there were other stress management tools that were effective. They came up with the idea of teaching employees how to use a stress management toolbox, with the goal that this would be an ongoing and sustainable way of managing stress.

Stress Management Toolbox

The toolbox consists of well-validated stress management techniques that healthcare workers can use as needed.

The toolbox components are based on:

• Cognitive Behavior Therapy: an approach used to assist people in changing their negative thoughts, thereby positively changing their emotional state (Butler, Chapman, Forman, & Beck, 2006). A study of nurses hypothesized that burnout is related to irrational thinking and found that by disarming irrational beliefs, nurses could foster professional growth and decrease workplace stress (Balevre, 2001).

• Positive Psychology: a relatively new field of psychology that teaches learned optimism (Emmons & McCullough, 2003). The idea is that a capacity for happiness and well-being can be cultivated through gratitude journaling (Seligman, Steen, Park, & Peterson, 2005).

• Mindfulness Based Stress Reduction (MBSR): an approach that promotes a nonjudgmental awareness of moment-to-moment sensations, experiences, and reactions. MBSR employs meditation techniques that promote relaxation and stress reduction (Kabat-Zinn, 1994). This technique has been documented “as an effective tool to support nurses psychologically and to improve work satisfaction” (Penque, 2009).

• The Relaxation Response: another highly effective tool closely related to MBSR that reduces stress. The relaxation response is a state of deep rest that changes the physical and emotional response to stress, e.g., decreases heart rate, blood pressure, rate of breathing, and muscle tension (Benson & Klipper, 2000).

Designing the Pilot

The EAP clinicians envisioned a program where healthcare workers would learn to help themselves by using the tools in the toolbox to manage stress. Before such a program could be put in place on a large scale, the effectiveness of a stress management toolbox had to be measured.

The EAP clinicians wanted access to the nurse managers as a starting point to test their hypothesis. They sought approval from the hospital’s Vice President and Chief Nursing Officer, Tim Quigley, who recognized that nurse managers particularly endure tremendous stress on a day-to-day basis. He responded enthusiastically by sharing literature and arranged for EAP clinicians to pitch the idea to the nursing directors. More important, Mr. Quigley and his nursing directors granted release time for nurse managers to participate in an on-site program.

EAP clinicians contacted the research department for help designing a pilot study. The manager of the clinical research department and Susan Duty, ScD, the nurse scientist at the hospital, helped the EAP clinicians craft their ideas into a researchable question with a measurable outcome that could withstand the scrutiny of the hospital’s institutional review board (IRB). This was no easy task since the target population was nurse managers and the sample size would be small, even if 100% of the nurse managers agreed to participate. Finally, the ideas were designed into a randomized, prospective, quasi-experimental study to evaluate the effectiveness of a proactive approach to reduce perceived stress in nurse managers. The study was approved by the IRB.

The Pilot

The research team, which consisted of two clinical social workers affiliated with the EAP and a research nurse, recruited and organized a small group of nurse managers to meet in a quiet setting, away from telephones and pagers. The nurses began the intervention with a half-day workshop based on the stress management theories and the stress management toolbox described above. Each participant received a guided imagery relaxation CD to promote the relaxation response, a workbook to log the amount of time spent in a state of mindfulness training, and a gratitude journal. Over a three-month period, the nurses met with the team every other week for 90- minute sessions to elaborate on and reinforce the stress management toolbox techniques. (Sample materials are available by request to the authors.)

Intervention Format:

• Half-day workshop

• 90 minute meetings every other week for three months

Materials:

• Guided imagery CD

• Workbook

• Gratitude journal

To measure the effectiveness of the program, the study used a well-validated, 14-item questionnaire called the Perceived Stress Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983). This scale is available for nonprofit academic research or nonprofit educational purposes. A 10-item version of the scale is shown in the inset box. Differences in PSS scores of significant magnitude have been observed in previous studies with numbers of participants similar to that in the hospital’s pilot study (Shapiro, Astin, Bishop, & Cordova, 2005). To reduce self-selection bias, researchers insisted that the participants be randomly assigned to receive the stress management intervention. Seventeen nurse managers volunteered for the study. Twelve participated in the intervention, and all others served as the control group. The control group was offered the intervention after the three-month period. This required two programs to run consecutively. All participants were surveyed before random assignment to study groups, after the intervention period, and/or again after a follow-up period.

Perceived Stress Scale — 10 Item

The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with a check how often you felt or thought a certain way. (Cohen, Kamarck, & Marmelstein, 1983)

Responses: 0=never, 1=almost never, 2=sometimes, 3=fairly often, 4=very often

1. In the last month, how often have you been upset because of something that happened unexpectedly?

2. In the last month, how often have you felt that you were unable to control the important things in your life?

3. In the last month, how often have you felt nervous and “stressed”?

4. In the last month, how often have you felt confident about your ability to handle your personal problems?

5. In the last month, how often have you felt that things were going your way?

6. In the last month, how often have you found that you could not cope with all the things that you had to do?

7. In the last month, how often have you been able to control irritations in your life?

8. In the last month, how often have you felt that you were on top of things?

9. In the last month, how often have you been angered because of things that were outside of your control?

10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Pilot Study Results

The study resulted in some interesting findings:

High level of perceived stress: The baseline PSS scores of the nurse manager participants were double what would be expected for the general population (Cohen & Williamson, 1988).

Reduced perceived stress in the intervention group: The team saw a modest downward trend in perceived stress scores for the intervention group, while the control group’s PSS scores continued to rise. Though all participants’ stress levels remained comparatively high, relative to the general population, the comparative analysis of scores between the intervention and control groups showed a reduction in PSS in the intervention group. Those in the intervention group who most actively applied the stress management tools did better in the short term. However, once the group disbanded, their perceived stress rose again. Without group support, the participants found sustained use of the tools difficult.

Low self-compassion noted: Anecdotally, the research team noticed a low level of self-compassion among the participants. Self-compassion is the ability to view oneself with care, concern, and acceptance. The Self-Compassion Scale was introduced to help participants recognize this concept (Neff, 2003). The team also observed that when a high level of trust was achieved within the group, there was greater satisfaction and adherence to the program.

Group process valued: Program evaluation surveys revealed the group process to be the most helpful aspect of the program. The second most helpful aspect was learning the relaxation response. Subjects commented that time pressures prevented them from completing the gratitude journal, which was the positive psychology tool.

Almost all subjects said they planned to employ the tools they learned in the program. Several expressed desire for continued sessions to maintain these skills. One participant wrote, “I am very appreciative; I fear I will fall back into my old ways without some way to force myself to recall what we have learned.” In general, participants were very positive about the program. For example, one participant provided the following comment on the program evaluation: “Thanks for the time and opportunity. I feel I react to stress better now and am more direct in my conversations with my supervisor.” Another wrote, “Overall, I believe the program gave me some good insight into understanding and managing my stress load personally and professionally.”

Summary

The pilot study confirmed that healthcare workers are challenged with extremely high levels of perceived stress and reluctant to engage in self-care. The high level of perceived stress in this population warrants additional research to enhance understanding of this finding, as well as ongoing efforts to develop effective, sustainable interventions.

Based on previous studies, reducing perceived stress in the workforce should ultimately have a positive impact on patient care (Jennings, 2008). Just as one’s own oxygen mask is required before assisting other passengers on an airplane, caring for oneself is a prerequisite for effectively caring for others. This pilot study suggests that building a self-care toolbox through an on-site, proactive, multipronged group program is effective in reducing perceived stress.

Healthcare employers who are successful in creating a positive workplace culture with lower perceived stress may have a competitive edge in terms of healthcare premium savings and improved quality indicators. South Shore Hospital continues to support its employees with a wide range of wellness services. 

Supporting healthcare workers to build and use a self-care toolbox shows great promise for reducing perceived stress, improving employee satisfaction, and ultimately improving the delivery of patient care.

About South Shore Hospital

South Shore Hospital is a 318-bed, not-for-profit, tax-exempt, charitable provider of acute, emergency, outpatient, home health, and hospice care to the people of Southeastern Massachusetts. South Shore Hospital’s home care division includes South Shore Visiting Nurse Association, Hospice of the South Shore, and Home & Health Resources. The hospital’s 900-member medical staff represents all leading medical specialties. South Shore Hospital employs 3,800 people, supported by a team of 600 volunteers. The hospital is licensed to provide level II trauma care and level III maternal/newborn care.

South Shore Hospital has been ranked among the top three hospitals in Massachusetts, according to the 2012 U.S. News & World Report Best Hospitals report, and named a Top Place to Work by The Boston Globe. South Shore Hospital exists to benefit the people of the region by promoting good health and by healing, caring, and comforting.

Maureen Morgan DeMenna, RN, BSN, is manager of clinical research at South Shore Hospital. Anna Tebano Micci, MSW, LICSW, is a private psychotherapist and EAP consultant. Marguerite Wood, MSW, LICSW, is director of employee assistance and wellness at South Shore Hospital.

Last Updated: October 2012