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Stress in the hospital setting and the use of critical incident stress debriefing Gough, Marilyn May 1998

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STRESS IN THE HOSPITAL SETTING AND THE USE OF CRITICAL INCIDENT STRESS DEBRIEFING by Marilyn May Gough B. S. W , The University of British Columbia, 1990 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK In THE FACULTY OF GRADUATE STUDIES School of Social Work We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1998 @ Marilyn May Gough, 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Date Qa. <?/0? DE-6 (2/88) A B S T R A C T Unaddressed worker stress among hospital based professionals represents a serious threat to quality health care. Such costly outcomes as increased absenteeism, job turnover and substandard or failed client interventions are only a few of the possible serious consequences. In spite of this threat, minimal attention has been given to developing and implementing comprehensive stress management programs in this setting. Stress management strategies that do exist tend to be short term and focused on high profile incidents and individual coping. Cumulative stress and systemic contributors to stress are given little attention. The purpose of this study was to determine stress levels and related factors among hospital professionals and to explore their experience of Critical Incident Stress Debriefing (CISD) as a stress management strategy. Three issues emerged from the data that represented gaps in the literature with regards to worker stress in the hospital setting. These issues involved gender, cumulative stress and worker empowerment. TABLE OF CONTENTS ABSTRACT ii T A B L E OF CONTENTS iii LIST OF TABLES v LIST OF FIGURES vi A C K N O W L E D G E M E N T vii CHAPTER ONE: INTRODUCTION 1 Overview and Rationale 1 Personal Experience 4 Purpose <& Structure of Study 5 CHAPTER TWO: 7 CONCEPTUAL C O N T E X T 7 A N D REVIEW OF T H E LITERATURE . 7 Stress: An overview. 8 turnout . 11 Secondary Traumatic Stress 12 Vicarious Traumati^ation:... ..: 1.4 Countertransference :. 14 Compassion Fatigue 15 Organisational Context: The potential areas of stress in the hospital culture. 18 Worker and Environmental Characteristics Associated with Stress. 22 Stress at what cost? - 26 Responses to Stress in the Hospital Setting: An overview. 29 CHAPTER THREE: 37 METHODOLOGY.. . . 37 Rationale for Choice of Research Methods 37 Researcher Influence 40 Ethical and Institutional Approvals. 41 Quantitative Methodology ; 42 Qualitative Methodology 51 CHAPTER FOUR: 64 FINDINGS - QUANTITATIVE 64 Response Rate 64 Descriptive Demographic Information 64 Stress Levels ••• 66 Contributors to Stress. 68 Preferred Methods of Stress Management 72 CISMData : :74 CHAPTER FIVE: : : '. 76 FINDINGS - QUALITATIVE 76 Themes in Participant Experiences 76 Becoming aware of a problem 78 Considering CISM as an Option 80 Finding strength in connection 81 Recognising the limitations of CISM 84 hooking at the Bigger Picture 86 Summary and Discussion of Findings: Quantitative and Qualitative 88 CHAPTER SIX: , 94 DISCUSSION 94 Introduction 94 Relevance of Gender 94 Acknowledging Cumulative Stress 97 The Empowerment Factor 99 Limitations and Future Directions 101 Conclusion 106 Bibliography 107 APPENDIX A: A G E N C Y APPROVAL , 118 APPENDIX B: CERTIFICATES OF APPROVAL 119 APPENDIX C: PARTICIPANT INFORMATION LETTER A N D SURVEY 120 APPENDIX D: FOCUS GROUP INFORMATION A N D CONSENT 121 APPENDIX E: FOCUS GROUP A G E N D A A N D QUESTION 122 LIST OF TABLES TABLE 1 VARIABLES ASSOCIATED WITH STRESS 67 TABLE 2 CONTRIBUTORS TO STRESS IN THE WORKPLACE 68 TABLE 3 ORGANIZATIONAL / WORK SETTING CONTRIBUTORS.... 70 TABLE 4 RESPONSES TO STRESS 72 TABLE 5 PREFERRED STRESS MANAGEMENT STRATEGIES/RESOURCES 73 TABLE 6 KEY DISCUSSION TRENDS..' 77 L I S T O F F I G U R E S FIGURE 1: CONTRIBUTORS TO STRESS 69 FIGURE 2: PREFERRED STRESS MANAGEMENT STRATEGIES 73 vi A C K N O W L E D G E M E N T I would first of all like to thank the administration of Surrey Memorial Hospital for their commitment to students and for allowing me to conduct my research in their organization. My sincere appreciation also goes to all the SMH staff, residents and families who provided me with ongoing interest, support and encouragement throughout my school year. Special thanks to Lynne Dowling who so adeptly stood in niy place and always made me feel that I still 'belonged' in spite of my absence. To those staff at SMH who participated in my study, I thank you sincerely for your time, honesty and insights and most especially for the daily caring and compassion you give to your patients and residents. Thank you to my faculty advisor, Deborah O'Connor who not only attended well to my academic needs but also supplied me with tea, soup and a dose of encouragement when my energy flagged. Thank you to all the staff and faculty of the School of Social Work who made my way easier by helping me through the rough times and joining me to celebrate the good times. And finally, to my partner George; words somehow don't seem enough to thank yqu for your eyer present support which you gave in so many different ways. My love and appreciation to you for helping me realize a dream. vu C H A P T E R O N E : I N T R O D U C T I O N Overview and Rationale Workplace stress and related illness has increased substantially over the past two decades and is of major concern to employees and employers alike (Beehr, 1995; Canadian Mental Health Assoc. , 1997). Financial and societal costs, such as absenteeism, reduced productivity and work performance and impaired morale, have reported in several studies to have risen significantly as a consequence of this trend (Beehr & Bhagat, 1985; Corey & Wolf, 1992; Warshaw, 1988). The Mitchum report (1990) on stress in the'U. S. , indicated that nine out often people say they experience high levels of stress several times per week and four out of ten indicate they experience high levels of stress every day. Although other stressors are involved, work related problems were shown to be by far, the most significant source of stress for the people surveyed (Mitchum, 1990). It is therefore no surprise that worker's compensation claims attributing disability to occupational stress have risen substantially, even though they are not yet allowed in many jurisdictions (Warshaw, 1988; Terry, 1996; Pottage & Huxley, 1996). In the occupational stress literature during the past decade, health care workers as a specific occupational class have received a great deal of attention (Gray-Toft & Anderson, 1981, 1985; Hammer, Jones & Lyon, 1985; Leppanen & 1 Olkinuora, 1987). Nursing, as one of these professions, has by far received the most attention. However, stress among other health care disciplines such as social work, occupational therapy and medicine, has also generated a number of studies and clinical writings (Sweeney & Nichols, 1996). In a study regarding occupational stress within 130 occupations, health care workers were grossly over-represented in the high-risk groups (Smith, et al,1977). One of the primary reasons given for this vulnerability is the high degree of day to day exposure to a generally distressed, traumatized and grieving clientele (Miller, et al, 1995; Fagin, et al, 1996). Unfortunately, the literature also indicates that health care organizations such as hospitals have been among the slowest to develop and implement comprehensive programs to address the issue of job related stress (Beehr, 1995; Bailey, 1985). This lack of acknowledgment and adequate response to workplace stress in health care has many serious implications, not the least of which is the difficulty of health care workers to provide a healing environment for their patients. This is a primary stated goal of health care (Arvay & Uhlemann, 1996; Moore & Cooper, 1996; Joinson, 1992). As noted by Moore & Cooper (1996, pp. 82), " best care can only be provided to others by carers who are themselves well". Much has been written, particularly in the social work and nursing fields, about informal caregiver stress and the need for support (Opie, 1991, 1992, 1995; Cox & Parsons, 1994). However, models of comprehensive support programs for formal health care 2 providers are much less evident in the literature. The models that do exist tend to be focused primarily on the need to fix or strengthen the individual, rather than address stress in a more holistic way. This would include such areas as systems and organizational pathology contributing to workplace stress (Cherniss, 1995; Murphy, et al, 1995; Lawrence, 1993; Maslach, 1982; Beehr, 1995). There is increasing evidence in the literature that links workplace stress in health care with such costly outcomes as increased absenteeism, job turnover, and substandard or failed interventions (Cherness, 1995; Patterson, et al, 1985; Patrich, 1981; Zoloth & Stillman, 1987; Celentano & Johnson, 1987). Stress debriefing, as a stress management method, has been introduced to some hospital settings in the past decade and has received substantial favorable feedback from the staff involved to date (Pickett, et al, 1994, Corneil, 1997, Robinson & Mitchell, 1993). This method concentrates on individual support and coping within a group process and is limited to those events deemed as critical. In spite of this narrow mandate, it appears to have potential to be expanded and modified to address such areas as cumulative stress, staff empowerment, organizational change and ongoing problem solving (Pickett, et al, 1994; Corneil, 1997; Robinson & Mitchell, 1993). Social work is one of the disciplines within health care in need of stress management programs. However, it also possesses the skills, education and values to provide leadership in this-area. Moreover, it has a long-tradition of client 3 advocacy, empowerment and community development, which could easily be applied to the area of staff support. Application of the core value of viewing situations and people in context would promote a more holistic approach to the issues of staff stress. It would seem likely that the resultant net gain for the patient/resident population might be quite substantial in terms of the staffs ability to provide a more healing environment. Personal Experience Since 1972, I have worked in the hospital health care setting, first as a Nursing Unit Clerk, and over the last 7 years as a medical social worker. An overriding interest and theme for me during this time has been staff wellness and the connection between this and the ability to meet client needs. As a Unit Clerk, I was in the position to appreciate the difficulties of staff as well as patients/residents and families. As a social worker, I became a strong advocate for the patients/residents and family, only to discover that I had neglected to support and prepare the staff for the changes that ensued. I believe this oversight essentially contributed to a climate of suspicion and resentment between staff and clients, rather than uniting them in a common goal. Since that time, I have worked to include support to staff as an intricate part of my client advocacy activities. One activity that I became involved with as a result of my insights, was the development and implementation of a Critical Incident Stress Management team in 4 the hospital where I work. I became trained in the techniques of stress debriefing and since 1996, have volunteered as a member of this team. One issue that became apparent to me during the staff debriefings was that the degree of stress was often due to an accumulation of events or situations rather than one critical event. I have come to believe that one of the real strengths of this model is the power of the group process and have hence become interested in expanding this model to be more inclusive and usable in situations beyond just critical incidents. To date in my workplace, CISD has been accessed primarily by staff in critical care areas as the resources of the team are limited and the mandate, as indicated by the name, is restricted to the debriefing of critical events. Purpose & Structure of Study The central purpose of this study was to examine the perceptions of workplace stress among hospital based professionals and to explore their experiences with CISD as a stress management intervention. More specifically, this research focuses on stress levels, primary contributors and responses to stress and preferred stress management strategies in this setting. In seeking this information, attention was given to the areas of dual role pressure, absenteeism, practice performance, job turnover and stress levels in emergent and non-emergent areas of the hospital. An explanation of these terms and rationale for use appears in the methodology chapter of this paper. TheMnformation gathered from this 5 research is intended to expand the understanding of workplace stress in the hospital setting and to therefore promote responses to this stress that will ultimately strengthen the staffs' ability to create a healing environment. To provide some background and a conceptual context for the study, the literature is reviewed in the areas of the health care/hospital environment, occupational stress, the impact and patterns of response to the issues, with an emphasis on the developments in these areas over the past ten years. The concept of cumulative stress and ongoing exposure to distressed individuals is explored in relation to such established terms in the literature as burnout, compassion fatigue and vicarious traumatization. Chapter three reviews the methodology utilized in this research study and the rationale for choosing a combination of quantitative and qualitative methods. The processes of recruitment, implementation and data analysis of both methods are also outlined in this chapter. Chapters four and five present the findings from both the questionnaire and the focus group interview in this study. Particular themes are supported by statistical data as well as by direct quotes from focus group participants. Chapter six discusses the findings of particular interest from the study in terms of the implications and relationships to other research. Finally, the limitations of the study and recommendations for the future directions are outlined. 6 C H A P T E R T W O : C O N C E P T U A L C O N T E X T A N D R E V I E W O F T H E L I T E R A T U R E Although worker stress over the past few decades has come to be recognized as a major health hazard in the workplace (Warshaw, 1988), many organizations have been slow to respond to this trend (Beehr, 1995, Bailey, 1985). Repeated studies have shown that each year approximately 15% of the work force will have at least one episode of psychosocial disability and an estimated 10% will have problems related to alcohol and drug abuse (Warshaw, 1988). Stress has been linked with increases in workplace accidents, absenteeism, reduced productivity and impaired morale (Warshaw, 1988; Emmett, 1987; Cherniss, 1995; Moore & Cooper, 1996). This has resulted in an increased inability to adequately meet the needs of consumers. It has become very costly both financially and emotionally through such consequences as litigation costs due to failed or damaging treatments and the psychological and physical pain and suffering of those clients involved (Gray-Toft & Anderson, 1995; Joinson, 1992). Surprisingly, the health care industry is one of the areas which has been slow to respond adequately to this trend (Beehr, 1995; Cherniss, 1995) and this is especially concerning in light of the very nature and focus of the industry. 7 This chapter provides a background for the issues of workplace stress based on the literature and begins to build support for the need for structural change as a necessary component of staff and client wellness within the hospital setting in particular. Stress: An overview. Although the word stress has come to be viewed in a negative light, the literature indicates that not all stress is detrimental and that in fact, some stress is essential to the creative and developmental process in humans (Mitchell & Bray, 1990). Much of what we know about stress has grown out of the early work of researchers such as Cannon, Lazarus and Selye (Seaward, 1997). However, it was Selye who first popularized the concept of stress as it applied to the human condition in his 1976 book The Stress of Life. The general adaptation syndrome (GAS), was developed by Selye to explain the changes that he observed in rats when they were exposed to repeated stressors. Through his research he identified three stages of GAS (alarm reaction, resistance and exhaustion) which essentially framed what he saw to be the physiological dangers of chronic stress. Lazarus later changed the focus from the severity and frequency of stressors to the whole issue of peoples' varying abilities to cope with stress (1984). 8 Stress has been divided into three major categories in the literature, which are called eustress, neustress and distress (Seaward, 1997). Eustress is considered to be positive and beneficial stress, such as that which pushes us to greater creative levels or evokes a sense of joy and well-being. Neustress is disturbing in nature but not personally threatening, such as news of a war or disaster in another part of the world. Distress is characterized as both disturbing and personally threatening. Examples might be personal involvement in a car accident, news of a serious illness or ongoing difficulties at work. Distress is the category most referred to by the general public and has come to be known simply as stress (Seaward, 1997). It is defined generally as a challenge to coping abilities with a perceived or real threat to one's mental, physical, emotional and spiritual well-being, which results in a series of physiological responses and adaptations (Seaward, 1997). Stress is further divided into the two categories of acute and chronic stress. The circumstance that most differentiates these two types of stress is related to the duration of exposure to the stress or stressors (Warshaw, 1988; Celentano & Johnson, 1987). Acute stress is considered to be relatively short lived in nature, whereas chronic stress is more prolonged and can result in exhaustion from repeated physiological responses mediated by the sympathetic nervous system which is known in the literature as the fight or flight response (Warshaw, 1988). This response prepares the body physiologically to fight or flee by secreting hormones' which encourage such reactions as: increased heart rate and blood 9 glucose levels(Lewis, 1994). Unfortunately, this protective response can become damaging when triggered repeatedly with no actual need. Chronic stress in the workplace is the focus of this study and is characterized in the literature as detrimental because of the potential for pathological repercussions such as impairment of the immune system ( Warshaw, 1988; Seaward, 1997, Beehr, 1995, Streepy, 1981; Celentano, et. al, 1987; Cherniss, 1995; Fagin, et a l . , 1996). Stress of this nature has been commonly referred to as burnout. This term was first introduced by Herbert Freudenberger in 1974. He defined it as "to fail, wear out or become exhausted by making excessive demands on energy, strength and resources"(1974, p. 90). Later research shifted the focus to some extent, from the individual to an exploration of negative work settings and situations and found that burnout was particularly prevalent in those working with emotionally needy and distressed people (Maslach, 1978; Kahili, 1988). Information regarding the particular vulnerability of human service professionals, such as health care workers, to stress, is very much evident in the literature. This is of significant concern because of the potential serious individual and social consequences (Celentano & Johnson, 1987; Smith, et. al. , 1977; Cartwright, 1979; Leppanen, 1987; Maslach & Jackson, 1982; Patterson, et. al., 1985). 10 In relation to this occupational vulnerability, recently researchers have introduced a number of new terms to the literature, such as secondary trauma, vicarious traumatization, counter transference and compassion fatigue, to better describe particular experiences of stress among human service staff. Although these terms have distinct features, there appears to be a large degree of overlap and applicability across and between definitions. The following is a brief description of these terms, beginning with the recent literature regarding burnout and its relative position among these terms. Burnout Burnout is conceptualized as a state of exhaustion, - mental, emotional and physical, which arises out of long term involvement in situations of high emotional demand (Maslach, 1992). It is seen as a process that develops over time and gets progressively more severe (Maslach, 1992; Kahili, 1988; Lieter and Harvie, 1996). It is most often associated with high work demands, a low sense of achievement and control over the situation and results in negative changes in attitudes and values toward the work (Maslach, 1992; Kahili, 1988; Lieter and Harvie, 1996). As well, it has been widely associated with those who have had a long accumulation of intense contact with persons in distress (Corneil, 1997). McCann and Pearlman (1990) described some of the major symptoms of burnout among therapists exposed to traumatized clients. These included: depression, cynicism, 11 boredom, loss of compassion and discouragement. A study by Fagin, et. al. (1996), of 648 ward based mental health nurses revealed a strong connection between burnout and the degree of client distress, the time spent interacting with clients, time pressures in terms of workload demands and an inability of staff to cope with or control their circumstances. Environmental issues have also been shown to be of significance in a study by Miller, et. al. (1995), which indicated that peer cohesion, sense of accomplishment, autonomy and involvement in decision making were negatively correlated with burnout across a wide number of organizational contexts and human services. Secondary Traumatic Stress The term secondary traumatic stress (STS) was initially used to describe the symptoms and behaviors of those close to persons suffering from post traumatic stress such as families of Vietnam veterans (Maloney, 1988); families of Holocaust survivors (Danielle, 1988) or therapists of trauma victims (McCann & Pearlman, 1990). Corneil (1997), proposes that STS is in fact an overlapping term which is used to distinguish between the symptoms of primary and secondary victims of trauma. The terms of burnout, counter transference, vicarious traumatization and compassion fatigue are essentially subcategories which are used to distinguish between the various manifestations of STS. Primary trauma refers to the individual who is directly exposed to traumatic events, i . e. persons who have 12 gone through a natural disaster or been assaulted. Secondary trauma is that which arises from exposure to the impacts of the event on others, who are primary victims (Figley, 1983). Over time, those considered to be effected by STS has expanded from those close to primary victims, to include the formal and informal helpers of primary victims and has been referred to as a natural consequence of caring work (Figley, 1995). In relation to burnout, secondary traumatic stress is characterized as developing after one incident, whereas burnout is attributed to an accumulation of incidents and situations over time (Corneil, 1997). Also, the event which gives rise to secondary traumatic stress is seen as more intense and emotionally shocking in nature (McCann & Pearlman, 1990). It is suggested in the literature that burnout may be a consequence of repeated exposure to STS that is not worked through or adequately addressed (McCann & Pearlman, 1990; Figley, 1995). This suggestion has significant implications when considering the repeated exposure of health care workers to trauma which goes unacknowledged. It is only relatively recently for example, that some hospitals have introduced the concept of critical incident stress debriefing. Additionally many of these debriefing teams are voluntary and limited in resources so are often caught in a dilemma of being reluctant to raise the awareness of the service to the point where staff demands for debriefing exceed the resources (Spitzer & Burke, 1993). This raises the possibility that reactions to 13 certain events might be potentially far more intense if experienced by staff who have an accumulation of unaddressed stress. Vicarious Traumatization Vicarious traumatization (VT) was first introduced by McCann and Pearl man (1990) to describe the reactions of trauma therapists to the graphic and painful material presented by trauma victims. VT implies that exposure to hearing anothers traumatic experiences will go beyond STS and actually trigger primary traumatic stress disorder symptoms in the listener (McCann and Pearlman, 1990). Reactions of listeners are seen as dependent on the unique beliefs, expectations and assumptions about self and others. This impacts the very core of their personhood (McCann and Pearlman, 1990). A focus group study by Betcher (1996) supports McCann & Pearlman's (1990) model of vicarious traumatization. Thoits (1994, p. 16) noted that " i f a stressor is central to one's self image, then the experience of that stressor will have a more detrimental effect on physical and psychological health". Compared to burnout, VT appears to be more personal, intense and acute in nature and more closely parallels the symptoms of primary victims of trauma. Countertransference Another possible consequence of working with people in distress is termed countertransference and was first introduced by Freud in 1910 (McCann and 14 Pearlman, 1990). It refers to the emotional response of the therapist to the client's story and behaviors that relate to an unresolved aspect of the therapist's past. It results in negatively effecting the therapist's ability to respond appropriately to the client and often times causes a resurfacing and/or a re-experiencing of the therapist's unresolved traumas and conflict (McCann and Pearlman, 1990). Some research suggests that exposure to secondary trauma, such as living with the survivor of the holocaust or combat veteran, and hearing others recount similar experiences, may also result in symptoms of countertransference (Danielli, 1985; Figley, 1983). In a study of nurses who had previously been personally effected by primary or secondary trauma, Crothers (1995) discovered that the nurses tended to become overly involved by the material brought forward by patients suffering from trauma. They seemed to experience to a lesser degree the same terror, rage and despair as their patients. In comparison to burnout, countertransference tends to be more personal and intense in nature, as with vicarious traumatization. However, countertransference differs from VT in that it is related to one client and involves an attempt to meet personal needs through work with the client (Corneil, 1997). Compassion Fatigue The term 'compassion fatigue' was first used by Joinson (1992) in an article discussing; the challenges to nursing, of coping with ongoing exposure to 15 distressed, grieving and traumatized patients. She describes compassion fatigue as a form of burnout unique to the caring professions such as health care workers, ministers and counselors because of their continual and unavoidable exposure to emotionally demanding situations. Figley (1995) popularized the term in his book entitled Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in those who treat the traumatized. He differentiates compassion stress, which he describes as a "manageable tension or demand associated with feeling compassion and empathy" from compassion fatigue. He characterizes the latter as "a sense of deep sorrow and sympathy for the victims accompanied by a strong desire to alleviate the pain or its cause, and a sense of inability to do so and a loss of energy or commitment which may lead to withdrawal or isolation" (Figley, 1995b, p. 82) He fiirther identifies compassion fatigue as "the cost of caring" (Figley, 1995b, p. 88). Although he argues that compassion fatigue is different than burnout, the differences appear to be very subtle in nature. He describes burnout as being more related to organizational issues and workload and compassion fatigue as being a "normal response of anyone who listens with empathy to the expression of the terror and horror of primary trauma"(Figley, 1995, p. 32). It would seem possible that compassion fatigue may be a significant component of burnout, especially in a setting such as a hospital where front. line staff are exposed to distressed individuals on a daily basis. Figley's definition of the term appears to differ from 16 Joinson's original intent. Figley's definition refers less to exposure to the lower profile traumas experienced by patients, such as the diagnosis of a chronic or terminal illness and more to exposure to clients experiencing high profile, emergency traumatic events such as car accidents, assaults and natural disasters. He seems to agree with Joinson's view of compassion fatigue as being cumulative in nature but discernible from burnout in that it has a relatively quick onset with little or no warning (Figley, 1995). An interesting aspect of compassion fatigue as pointed out by Miller, et. al. (1988), is that the very skill which makes human service workers more effective and good at their jobs (the ability to empathize), is also a potential source of vulnerability if their responses move from "feeling for" to "feeling with" their clients. The therapeutic use of self through the use of empathy is a key construct of self-psychology as originated by the psychoanalyst Heinz Kohut in the late 1970s. He referred to this use of empathy as "vicarious introspection, an attempt to experience the inner life of another while simultaneously retaining the stance of an objective observer"(0'Connor, 1993: 121). In order to achieve and maintain this therapeutic position, it would seem imperative that health care workers themselves be supported and assisted to preserve a healthy sense of self. It is clear from the descriptions of the above terms that those working in the helping professions are particularly vulnerable to stress on the job. Hospital based 17 professionals are continually exposed to traumatized and grieving clients. In spite of this, few programs are in place to address this significant area of risk. Some of the other major factors contributing to workplace stress in the hospital setting, the impact and current state of response to the issues is discussed in the remainder of this chapter. Organizational Context: The potential areas of stress in the hospital culture. The context within which hospital staff function is influenced by the medical model of health care. Although slowly changing due to consumer demand, this model remains for the most part highly structured, rigid," hierarchical and paternalistic in nature (McDonald, 1985; Hamilton, 1993). Some of the assumptions inherent in this model which directly effect the work environment are: professional as authority; cure valued over care; mind secondary factor in organic illness; environmental and social issues of limited importance; technology valued over alternative methods of healing; professionals to be neutral and objective and professional caring not seen as part of the healing process (McDonald, 1985). These assumptions can lead to unrealistic expectations being placed on medical care staff and to a sense of inadequacy and powerlessness through a combination of excessive demands, few rewards and a limited amount of control in their jobs (McDonald, 1985; Aitken, 1995; Hamilton, 1993). The lower down a worker is in 18 the organizational hierarchy, the more chance that this may occur. Front line staff are vested with a great deal of responsibility and accountability but with little or no concurrent autonomy or decision making power (Aitken, 1995). In the past, staff enjoyed a certain degree of control and certainty in their role as the authority on medical care and teacher. However, increased consumer knowledge and demand has shifted the power somewhat away from the professional to the consumer, which for many is seen as a positive and necessary trend. Unfortunately, educational institutions and employers have not adequately prepared the workers for this change and the result has been a climate of uneasiness and conflict between formal care providers and their clients, rather than creation of a new partnership in healing (McDonald, 1985; Aitken, 1995; Bailey, 1985; Emmett, 1987). Not surprisingly this has many serious consequences that will be discussed later in this chapter. The emphasis on cure over care and quantity of life over quality, is especially distressing in light of the increase in the aging population (Cox and Parsons, 1993). It is estimated at some hospitals that as high as 40% of all admissions involve elderly clients who most often require stabilization of chronic or terminal diseases and strategies for coping with health challenges (SMH statistics, 1996). This change in focus creates a sense of helplessness and frustration among some workers who continue to hold the expectation of 19 eradication of disease as their primary source of accomplishment on the job (McDonald, 1985; Aitken, 1995). The continued emphasis on an individualistic and physiological approach to health care taught in many educational and training facilities, has further created a barrier for health care workers to be able to cope with the extremely complex health care issues of the 90s (Aitken, 1995). Health requires a much broader definition in order to include the psycho/social/environmental/cultural and political factors that are often involved in illness (MacDonald, 1995). Effective diagnosis, treatment and/or care is less likely i f this broad approach is not understood, making it less likely that health care workers will be successful in their efforts. Rapidly advancing technology has added to this complexity, especially in the area of ethical decision making around end of life issues. The ability to prolong life which technology has afforded us has also created many dilemmas around quantity of life vs quality and the client's right to choose their own destiny in this regard (Aitken, 1995; Joinson, 1992; Cherniss, 1995). Many of these advancements are necessary and important but require quite a different skill set for the formal care givers than has been traditionally taught (Aitken, 1995). Overlaying this organizational structure is the recent political agenda to increase health care efficiencies and reduce costs (Cherniss, 1995; Beehr, 1995). Staff cut backs and continual organizational restructuring not only leaves workers with an ongoing sense of insecurity, but also with a situation where fewer are 20 doing more (Cherniss, 1995; Beehr, 1995; Seaward, 1997). Additionally, in an attempt to respond to consumer demands, health care bureaucracies are introducing much needed client centered care models but at the same time, are neglecting to provide the needed resources to staff to be able to deliver such care (McDonald, 1985; Aitken, 1995). Again, this is creating a serious rift between formal care givers and their clients which is not at all conducive to a healing atmosphere (Cox and Parsons, 1994; Pottage and Huxley, 1996). In spite of the rhetoric of the last number of years regarding the benefits of flatter management structures to worker morale and improved quality of care, hospitals for the most part, retain a top down style of management (MacDonald, 1985; Globerman, et. al. , 1996; Spitzer and Burke, 1993). The locus of power tends to be primarily with male administrators and physicians, even though the majority of health care workers are female (Murphy and Pardeck, 1986; Bailey, 1985; Cherniss, 1995). This places staff in a position of feeling little control over their work lives and minimal opportunity to influence decisions made for themselves and their patients (Aitken, 1995). Training facilities and educational institutions have been slow to implement interdisciplinary study which encourages understanding among disciplines and a desire to work as a team to achieve the best possible outcomes for the client (Sweeney and Nichols, 1996; Gray-toft and Anderson, 1981, 1985). New graduates are expected to enter the hospital environment and immediately function 21 effectively in a team setting where they are unlikely to be aware of all the other disciplines' values, goals and roles and the processes involved in team building and maintenance. This often results in a climate of competitiveness among disciplines and a struggle for control of positions and resources, rather than a collaborative and supportive partnership in healing (Globerman, et. a l . , 1996). A l l of the above factors have the potential to contribute to workplace stress, the consequences of which are becoming of increasing concern in terms of human and financial costs in the health care industry (Celentano and Johnson, 1987; Cherniss, 1995) Worker and Environmental Characteristics Associated with Stress The environment of the hospital can be characterized as one of bright lights, 24-hour activity and a general sense of urgency, high anxiety and distress. It is a place where people come when they are in trouble and need help. Interestingly enough, these very characteristics which would seem quite negative to some, are precisely what attracts many individuals who enter health care professions (Lewis, 1994; Mitchell and Bray, 1990) Some researchers have proposed a personality profile of the health care professional as persons who tends to enjoy challenges, are task oriented and like to be physically active, have a strong need to help others and to feel valued and appreciated for this help, have strong rescuer motivations, tend to put others needs before their own and are much more comfortable in the role of 22 helper than helpee (Lewis, 1994; Snelgrove, 1998). Meaning in their job is often as important as money (Cherniss, 1995). Problems begin to arise for these individuals with these particular characteristics and expectations, which are reinforced by the systems that surround them, when they begin to feel powerless, out of control, unappreciated and ineffectual in their quest to ameliorate the distress of their clients (Lewis, 1994; Mitchell and Bray, 1990; Snelgrove, 1998). Not only are systems not in place to assist staff to emotionally process the distress of others to which they are continually exposed, but also there exists a belief embedded in the medical paradigm that health care professionals should be immune to the distress of their clients and the situations that surround them (Lewis, 1994; Mitchell and Bray, 1990; Figley, 1995). The consequences of this belief inherent in the system, is often a kind of 'machismoism' that prevents staff from recognizing the signs of burnout and seeking help and a reluctance of health care organizations to provide needed resources to adequately address the problem (Figley, 1995; Corneil, 1997). The assumptions underlying the medical model are not the only factors associated with work place stress. Rather stressors in the hospital setting include: shift work; inflexibility of work schedules; physical demands such as lifting of patients; time constraints and workload demands; anxiety related to the danger of injury or infection and coping with physical, sexual and racial abuse (Croners Health and Safety Special Report, 1997). 23 One critical factor that is seldom explored in the occupational stress literature in health care is the fact that the vast majority of health care workers are women. Understanding the political and social implications of this factor is essential, I believe, to beginning to adequately address the issue of workplace stress in health care for several reasons. First, the issue of dual role pressure that many female employees face is of particular concern in this setting (Walker, 1989; Greenglass, 1991). Studies show that in spite of women's' increased full time involvement in the paid work force, they continue to have the primary responsibility for parenting and housekeeping tasks in the home (Walker, 1989; Greenglass, 1991; Baines, 1991). Additionally, women are increasingly becoming the informal care givers of aging.parents and in-laws at the same time that they are raising their own family (Cox and Parsons, 1994; Opie, 1995). New policies in elder care that promote 'community care' actually involve downloading of institutional responsibility of care giving to family members, who are most often women (Walker, 1989; Greenglass, 1991). In a comprehensive review of the stress literature on gender related differences in burnout, Greenglass (1991) found that primary predictors of women's' burnout includes work and family, whereas for men the primary predictors are work sources. The whole issue of caring work being natural to women and not to men and the devaluation and invisibility of this work at home and in the workplace is of 24 major concern as well. Walker (1989, p. 34) in a paper on women's' work and burnout stated: "Caring, care giving, is work wherever we do it; it is mental work involved in planning, organizing and managing, emotional work in listening, understanding, feeling for and supporting and physical work in cleaning up peoples mess, cleaning them up, feeding them, nursing them and so on. And this work is not valued or seen as skilled, even by ourselves; it is assumed to be somehow just an extension of who we are. It becomes obvious that it is not just what care is, but also who does it that is devalued". I would propose that the patriarchal nature of health care and the devaluation of caring work in general, may play a significant part in the lack of adequate services to support this work and the people who do it in the hospital setting. Evidence of this can be seen in the following areas. The emphasis on technological interventions in healing as opposed to caring, supportive interventions is evident in the hospital setting (Aitken, 1995; MacDonald, 1985). The actual bedside care in the case of nursing and the personal face to face relationship to clients that is the basis of the helping process in social work, are seen as less important and the first areas to be marginalized in times of fiscal restraint (Walker, 1989). An example of this is the shifting of these caring tasks such as spending time listening and understanding the patient, from the professional to less qualified personnel or even the volunteer sector. This pulls the professional away from a focus on personal interactions with clients toward such activities as administration of medications/treatments in the case of nursing and for 25 social work an emphasis on paperwork, meetings and the discharging of clients as quickly as possible to free-up over taxed hospital beds. The positive outcomes from caring work are more difficult to capture in terms of empirical evidence such as the prevention of a readmission to hospital and therefore administrators are often not convinced of its necessity unless of course they happen to have a revealing personal experience with illness and hospitalization. Stress at what cost? As is evident from the information above, the tasks, organization and nature of health care work provide an environment that is rich in its potential to engender stress reactions (Celentano and Johnson, 1987). The rewards are at times rare and the burdens are high (Zoloth and Stellman, 1987). The worker suffering from burnout or compassion fatigue may display a number of different behaviors as a result of their situation. The most common ones identified in the literature are decreased energy and concentration, increased problems with communication with patients, co-workers, supervisors and family at home, depersonalization of clients, reduced ability to perform the job to professional standards and lowered productivity (Patrick, 1981, Streepy, 1981, Wallace and Brinkerhoff, 1991, Corneil, 1997). Depersonalization is defined as the presence of a blaming attitude in a worker toward clients, a decrease in empathy and compassion, and a tendency to stereotype (Wallace and Brinkerhoff, 1991). It goes beyond the emotional 26 distancing that health care workers sometimes find essential to carrying out their tasks, such as in emergency situations, to a level of cynicism about the client and the job that can create a significant barrier to the provision of quality care (Constable and Russell, 1986). Not surprisingly, communication often then becomes problematic and creates even more sources of strain for the fatigued worker and those around them Wallace and Brinkerhoff, 1991; Snelgrove, 1998). A lack of concentration, especially during the performance of highly technical tasks, exposes the worker to the potential for error, which may have very serious consequences when dealing with human life (Zoloth and Stellman, 1987). The end result of unaddressed cumulative stress for the worker may be increased emotional and physical problems that might ultimately lead to family breakdown, Increased drug and alcohol use, job turnover and increased absenteeism (Streepy, 1981; Warshaw, 1988; Bailey, 1985; Croners Special Report, 1997). A l l this of course, can have a potentially devastating impact on clients and the delivery of services. As stated by Rapp and Poertner (1989), "it is difficult to imagine a tired, angry, cynical front line health care worker facilitating improved client outcomes. In fact, the potential to do harm would seem likely."(p.l25). For those health care workers who perceive their work to be well supported by management and their contributions appreciated, their ability to assist patients to mobilize internal healing resources has been shown to be significant in promoting 27 positive patient outcomes, even in situations where the workload remains relatively high (Bame, 1993). Some of the major consequences of burnout and cumulative stress to the health care system are rapidly increasing costs due to increased employee sick time and injury on duty, litigation costs due to failed or damaging treatments, and countless hours spent trying to repair customer relations after damage has been done (Gray-Toft and Anderson, 1985; Joinson, 1992). There also can be created a revolving door of patient admissions due to an emphasis on output rather than outcomes (Joinson, 1992; Hammer, et. al, 1985; Patrick, 1981). When patients do not get the help they need, they are likely to have to return very shortly to the emergency department, setting up a cycle of frustration and failure for both the staff and the patient. In a review of the utilization statistics at SMH (1996-97), readmission rates, especially among the elderly clients were shown to have increased significantly over the past decade. This has increased the pressure on an already overburdened system that must regularly cancel surgeries because of a lack of beds in the hospital. These returning patients are often elderly and are subjected to depersonalization by becoming known as 'bed blockers' in the system (Aitken, 1995; Cox and Parsons, 1994). 28 Responses to Stress in the Hospital Setting: An overview. Until recently, much of the research in work stress has focused on the individual; their personality, their personal history and circumstances and their ability to cope with stress (Celentano and Johnson, 1987). As a result, when workplace stress is acknowledged as a concern in the hospital setting, the interventions tend to be unidimensional in nature and emphasize the education and strengthening of the individual rather than including the organizational, structural and social dimensions of the issue (Taylor, 1997). Workshops and in-service education sessions on how to manage stress in the workplace have proliferated, but have tended to consist of a shopping list of strategies with no exploration of other dimensions of stress and with no follow up sessions to ensure lasting and ongoing results (Jaffe and Scott, 1993; Taylor, 1997). These sessions are expected to be a 'quick fix' for a very complex problem and essentially ends up shifting more of the responsibility for problematic areas in the organization onto the individual. For example, changes in staff performance are expected by managers following education sessions which have little or no followup or attention to organizational factors contributing to stress. Programs such as employee assistance (EAP) have evolved in a number of hospital settings, especially in urban areas, and have been generally well received by employees (Ardell, 1997). However, ongoing structural programs to address cumulative stress are quite rare (Ardell, 1997). 29 The one structural stress management program that has gained some support and popularity in the hospital setting has been the Critical Incident Stress Debriefing program (now known as CISM: Critical Incident Stress Management) (Spitzer and Burke, 1993). Debriefing has its roots in the military when it was first used to assist soldiers to cope with the horrors of war following combat exposure in WW II (Lewis, 1994). It has been reported that this resulted in "profound psychological changes among the soldiers debriefed" (Shalev, 1994, p. 205). A model of debriefing specifically for use with firefighters and paramedics was introduced by Dr. J. Mitchell in the United States in the 1970's and has since spread to use in many different settings, such as hospitals, throughout the world (Corneil, 1997/ Although there are a number of other models of debriefing the Mitchell model, known as CISM, has received the most attention and documentation in the literature to date (Mitchenbaum, 1994). The process essentially involves a structured or semi-structured group session approach with at least two trained facilitators (one being a mental health professional and the other a trained peer) to achieve the following goals: ventilation of intense emotions; exploration of symbolic meanings; strengthening of group support; initiation of grief process in a supportive environment; reduction of the fallacy of uniqueness; reassurance of normalcy of reactions; preparation for the possible continuation of stress reactions over the short term; warnings about potentially serious affective, physical or 30 behavioral symptoms; and encouragement of continued group support and/or seeking of professional assistance (Mitchell, 1995). As the name implies however, it is limited to the debriefing of critical events and is not intended to address burnout or cumulative stress. Because this is a relatively new area of practice, sufficient evidence has not yet accumulated in the scientific literature to be able to make definitive statements about the efficacy of CISD (Corneil, 1987). There is however, a great deal of experiential and anecdotal information to support the usefulness of debriefing (Corneil, 1987). A study by Robinson and Mitchell (1993) among 172 emergency service, welfare and hospital personnel in Australia indicated a significant reduction in stress symptoms post debriefing. They proposed that this effectiveness was derived primarily from the participants telling their stories and in particular, sharing their stories with others whom had experienced the same situation. The limitations of this study were identified by Robinson & Mitchell as the need to obtain information in ways other than self report and a multi-method approach to gathering data which might better address the complexities of the issues. The primary criticism of CISD in the literature is the proliferation of use without sufficient scientific evidence of the helpfulness of such an intervention (Kenardy, et. al. , 1996). In a study by Kenardy, et. al. (1996) conducted in Australia among emergency service personnel and disaster workers following an earthquake, no evidence emerged that-indicated an improved rate of recovery with 31 those helpers who were debriefed. In fact the study found that those who attended debriefing had significantly higher levels of symptoms at 12 months following the event, than those who did not receive debriefing. The response to this study by debriefers was that inappropriate use of CISD and unrealistic expectations could have played a significant role in the lack of effectiveness shown (Corneil, 1997, Snelgrove, 1998). They go on to explain that the Mitchell model of stress debriefing was never intended for use with individuals who have been severely traumatized by extreme situations, such as a real threat to their own lives and these individuals require a more intensive response such as one-to-one trauma counseling. They also suggested that CISD is a beginning point for some, rather than an end in itself. In other words, the more someone is effected by an event, the more likely follow up of some kind will be required. In a review of follow up evaluations of major incidents in North America by Van Goetham (1998), evidence suggested that responders to major incidents who are not debriefed, tend to experience increased relationship problems, emotional and physical difficulties and are likely to leave their jobs at a much higher rate in the months following the event A recent federal government study not only found consistently high levels of satisfaction with CISD among nurses, but also significant financial benefits due to lowered sick time and job turnover and increased morale and productivity (Medical Services Branch Health Canada, 1996). Possible reasons for the disparity of 32 results in this area are varied. Although similar instruments of measurement have been used in studies such as the Impact of Events Scale (Horowitz, et. al. , 1979) and Brief Symptom Inventory (Derogtis & Spencer, 1982), the impact of various events on individuals and appropriateness of interventions in the trauma field is not yet well understood (Corneil, 1998). According to Corneil (1998), research is only now beginning to reveal how the bio/psycho/social mechanisms of trauma manifest themselves in different ways. The one-size-fits-all approach to CISD has been suggested as one of the problems in varying results from studies as no one model can be appropriately used to fit all situations, circumstances, exposures and individuals (Corneil, 1998; Snelgrove, 1997). In fact, Corneil (1998) and Snelgrove (1997) have suggested that used incorrectly, CISD has the potential of doing harm or retraumatizing victims. As an analogy, Corneil (1998) refers to the use of CPR (cardiopulmonary resuscitation) as both a potentially helpful and damaging technique. When used appropriately it can be a life saver but when used in the presence of vital signs, it can do harm (Corneil, 1998). This has implications in terms of training and supervision of CISD teams. I would suggest that a significant strength of CISD, from what is evident in the literature and from my own personal experience with debriefing, is the group process; people being able to share their stories in a safe place and in so doing, being able to gain back a sense of control and perspective and at the same time build bonds with co-workers and*a renewed sense of shared purpose. Comfort and 33 safety is reinforced by the structure which allows for movement from the cognitive (fact phase) to the emotional, (thought/reaction phase) and back to the cognitive again (education phase) (Snelgrove, 1998). The group synergy tends to promote a spirit of self discovery, trust, connection and healing with the skilled direction of the facilitators. It tends in general to be a more positive process than the informal debriefing that occurs in the lunch rooms and hallways of a workplace in that the focus is away from blame and toward more positive, supportive and proactive outcomes. A study by Robinson & Mitchell (1993) regarding stress debriefing bears out these positive outcomes in that the factor which was most frequently identified as helpful was talking to others who had experienced the same situation. Literature in the area of the use of groups in the management of stress also supports the unique power of the group process and its potential to increase employee satisfaction, effectiveness and to inspire positive change within organizations (Reynolds & Jones, 1992; Brown, 1984, 1988; Gladstone & Reynolds, 1997; Parry & Tanner, 1993). Reid (1995) in the book entitled Capturing the Power of Diversity makes the following statement that seems particularly relevant to what can potentially occur in the debriefing process: "It is through a combination of self knowledge and action in group work that members are empowered to act upon their world in a constructive, reasonable, appropriate and life-enhancing manner. " (p. 155) 34 There are two primary criticisms of the CISD process that I have encountered from my experience, training, contacts and reading in the area They are as follows. First, CISD does not tend to be gender or culture sensitive as it was essentially developed for a white, middle class male audience. This can be problematic in that particular cultures may find the sharing of personal stories stressful in itself (Gore & Colton, 1990) or certain events may not be deemed 'critical' enough in nature to warrant debriefing. Ah example of this might be the stress of the ongoing task of assisting patients and residents to deal with disability or degenerative disease (Walker, 1989; Bains, et. al. ,1991). Second, it is not often part of a larger more comprehensive stress management program that considers organizational and social aspects of stress. This unidimensional approach can essentially ignore the many other important aspects of stress and focus responsibility for the problem on the individual. This in turn can result in a lower than expected level of effectiveness and ultimately a threat to survival of the service. There has been acknowledgment in the debriefing field of the need for a broader approach to stress management which is reflected in a recent change in the name from CISD to CISM (Critical Incident Stress Management). Although this represents an important philosophical shift, it appears that this is not yet often carried through to practice. 35 In spite of these perceived shortfalls, I believe CISD has many strengths and with appropriate modification for various circumstances and a more comprehensive approach, can be an effective means to supporting and empowering staff to be able to provide quality health care to consumers. The background information regarding stress and the context of the hospital setting as presented in this chapter, guided the way in which information was assessed in relation to the primary questions of this study which are: What are the perceptions of stress of the hospital based professionals and what is their experience of CISD as a stress management intervention? The rationale for choosing inquiry in these particular areas was as follows. Although a number of studies were evident which related to stress among helping professionals, few were found that related specifically to the hospital setting. Those that were found focused primarily on the disciplines of nursing and social work and generally lacked attention to the issue of gender as an important factor in understanding stress in the hospital environment. Additionally exploration of the experience of CISD in this setting was found to be limited and centered primarily around the factors associated with the perceived helpfulness of CISD. This study not only seeks to verify the findings from similar studies, but also to further expand the understanding of stress and the use of CISD in the hospital setting. The next chapter describes the methodology used in collecting the data in relation to the above research questions. 36 CHAPTER T H R E E : M E T H O D O L O G Y The purpose of this study was to examine the perceptions of workplace stress among hospital based professionals (particularly stress levels, contributors, responses and preferred, stress management strategies) and to explore their experiences with CISD as a stress management intervention. To this end both quantitative and qualitative methods of research were utilized in this study. The rationale for choosing both research methods arose from the basic assumption on my part as a researcher, that each method has merit in particular areas and when used together in a complimentary way, can work to increase the quality and utility of research results. The following chapter describes in greater detail the reasons for the use of both research methods, as well as the specific approaches used in terms of sample selection, procedure, measures/design and data analysis in the quantitative and qualitative portions of the study. Rationale for Choice of Research Methods In research, the terms quantitative and qualitative are used in reference to different methods of data collection which are based on different views of how to understand and capture knowledge (Gambrill, 1995; Hayes, 1991; Krueger, 1994). 37 The quantitative approach is based on the principles of the positivist philosophy of science which includes the assumption that knowledge is acquired through objective observation of external phenomena. The major task of this method is identification and isolation of relevant variables and precise measurement of phenomena (Hayes, 1991). Alternately, qualitative research is based on a postpositivistic philosophy which assumes that the subjective dimensions of human experience are continuously changing and are therefore best understood by fully describing and comprehending the subjective meanings of events to the individuals and groups involved in them (Grinnell, 1988). In spite of these differing views, both methods attempt to describe and explain social reality (Grinnell, 1988). Each have distinct advantages in achieving this end, depending on the context in which the research takes place and the questions to be answered (Geismer and Wood, 1982). Research that utilizes both methods of data collection has the potential to provide greater opportunity to better understand and describe the complexities and many facets of what is being studied (Anderson and Macdonald, 1994). Grinell (1998) suggests that quantitative research is particularly advantageous when "there is extensive prior knowledge of the culture and environment in which the study is taking place and when the area of inquiry has had considerable conceptual development and theory construction" (pi95). In this study, previous information around workplace stress and the hospital culture created a substantial guide for the formulation of specific questions regarding the 38 perceptions of hospital based professionals in relation to stress, the results of which could be compared to the theories and conceptualizations already existing in the literature. Other potential advantages to the quantitative method involve greater opportunities for generalizability of data through random selection, larger sample sizes and the possibility of decreased subjectivity and bias in results through statistical data analysis. The use of a quantitative survey approach at the beginning of this study provided a relatively large pool of data. This data informed the direction and framework of further study by revealing areas that required more clarification and exploration as are discussed later in this chapter. The second part of this study required the use of a research method that was more conducive to exploration of a relatively unknown phenomenon such as the experience of CISD. There is limited information on the actual experience of group debriefing in the hospital setting and qualitative research lends itself to this type of inquiry. Qualitative research is less structured in nature and rather than using known theories and conceptualizations to guide research, the goal is to create theory and concepts from the data produced by the participants. As Hayes (1991) suggests of qualitative research: "An emphasis is placed on collecting information in a holistic manner rather than on isolating and measuring variables in controlled settings or with 39 standardized measures. Typically there is more concern with developing comprehensive descriptions of the research subjects and setting rather than with making generalizations to other people or situations" (p. 38). This method of research works to increase the depth and richness of information gathered, and when used in groups, can add the dynamic of group interaction which is known to be particularly beneficial in stimulating thinking and the verbal contributions of participants (Ashbury, 1995) Researcher Influence The issue of objectivity in research has long been a topic of discussion in the literature (Anastas- & MacDonald, 1994). Although quantitative research has traditionally been viewed as more objective and value free than qualitative research, recent literature indicates that the tests and questionnaires of quantitative research are no more immune to researcher bias than the more unstructured qualitative approaches and that it is therefore important for all researchers to make explicit their particular values and beliefs that they bring to their research (Patton, 1987; Bograd, 1988; Riger, 1992). My own personal experience of being impacted by stress in the hospital environment and my work in assisting staff to cope with stress in this environment, has influenced the way in which I have collected, analyzed and made meaning of the data in this study. My belief in the health of staff as an essential prerequisite to 40 the ability to promote health and well-being in the people they serve and the importance of understanding people and situations within a complex web of influences, underlies the questions and exploration of this study. The influence of the feminist lens that I bring is also apparent in the attention given to the societal and political context of this predominantly female staff workplace and the attempt to redefine some of the issues and the way in which interventions are made to create positive change. Specifically, this feminist lens informs my belief that womens' caring work, whether in the home or in the workplace, is made more stressful by dominant male values that tend to undervalue, under-reward and essentially render invisible much of this work. Ethical and Institutional Approvals The method and design of this study received the approval of the Behavioural Research Ethics Board at the University of British Columbia in January 1998 and May 1998. The certificates of approval can be found in Appendix B. Approval to conduct the study at Surrey Memorial Hospital in Surrey, B. C. was received in November 1997 and the letter giving this approval can be found in Appendix A. 41 Quantitative Methodology Sample The population from which the sample (N=49) was drawn was restricted to hospital based health care professionals in a lower mainland hospital. For the purpose of providing some comparison of responses between staff in different care delivery units in the hospital, interdisciplinary teams were selected from emergent care areas (first response areas where patients are acutely ill) and less emergent areas (where patients have been stabilized enough to proceed with treatment or other forms of care). The reason for specifically sampling from these two areas was to determine if stress levels among emergent care staff differed from that of staff in less emergent areas. Conventional thinking, in the hospital setting has led to a belief that emergent care workers experience higher levels of stress than workers in less emergent areas (Cherness, 1995). Based on this criteria, the following six areas were selected: emergent areas (which consisted of only two areas): Emergency Room, Intensive Care; less emergent areas: Psychiatry, General Medicine, Palliative Care and Extended Care (these areas were selected randomly from a total of eight possible areas in this category). Each of the teams consisted of 8-10 core members from the following disciplines: nursing, social work, physiotherapy, occupational therapy, medicine (physicians), food and nutrition, pharmacy and in some cases, pastoral care, recreation therapy and music therapy. 42 Procedure The managers of the six areas selected were initially contacted by telephone and given information regarding the study. This involved a total of 5 managers (one person managed two of the areas selected) and all agreed to participate. This was followed by written information as seen in Appendix C. Permission was obtained to approach particular teams to request participation in the study. Written information explaining the study, as was provided to the managers, (Appendix C) was posted for staff in unit communication books one week prior to the meeting time selected. The meetings selected were regularly scheduled team conferences and were chosen to minimize the time impact on staff and to maximize the response rate to the study questionnaires. At the end of the meeting, staff were asked to remain together until I was able to introduce myself, give information about the study and request their participation by filling out a questionnaire prior to leaving the room. It was made very clear to staff that their participation was completely voluntary and not expected by management. After information was given, T gave staff an opportunity to leave if they had other commitments. This statement seemed to make some comfortable to leave. I remained in the room while the staff that stayed completed their questionnaires. In general, staff appeared very enthusiastic about the study and often times stayed in the room long after the questionnaires were completed to discuss the whole issue of workplace 43 stress. After leaving the meeting, the questionnaires were numbered in preparation for computer input of data at a later date. Measures The data for the quantitative portion of this study were collected using a two-part questionnaire developed by myself as researcher (Appendix C). As with measures used in similar studies, the information collected was based on respondent self report. Section one was developed specifically for this study and the Stress Scale (Munson, 1982) was used for the second part of the questionnaire. This standardized measure in section two was chosen for three reasons. First, the questions-asked under the five categories of symptoms, unhealthy activities, practice performance, work attitudes and work setting are consistent with some of the reported predictors of stress and burnout in the literature (Kahili, 1988; Maslach, 1982). Second, the self scoring component and the relative brevity of the measure was seen to provide a motivational aspect in that it was easy to complete and provided some immediate feedback with regards to personal stress levels. Finally the questions in the measure were particularly relevant and appropriate to health care workers in the hospital setting. The questionnaire began with questions regarding basic demographic information such as area of work, occupation, gender, age, family status and number of children at home (questions 1-6). Questions related to the~respondent's 44 perceptions of stress were distributed throughout the questionnaire. They involved the areas of stress levels, contributors and responses to stress, preferred stress management strategies and awareness, usage and perceived helpfulness of CISD as a stress management intervention. Stress levels A direct question (question number 13) was chosen to determine the degree to which respondents felt over stressed. Responses were gathered on a three-point scale of: none of the time, some of the time and the majority of the time. Contributors To determine the primary contributors to worker stress, questions were asked that related to findings in previous workplace stress studies and to suspected areas of relevance to this study on my part as researcher. Dual role pressure was a term used to describe those who identified themselves as being more stressed because of having primary responsibility for home and children in addition to their paid employment outside of the home. The literature indicates that women are at particular risk for this kind of pressure because they continue to take on primary responsibility for homemaking and care giving, even though their participation in the paid work force has increased substantially over the last number of years (Baruch, et. al. , 1987; Walker, 1989; 45 Baines & Neysmith, 1991). Because the hospital environment employs mostly women (86% of questionnaire respondents were women) it seemed necessary to explore the contribution of this phenomenon on stress levels. Respondents were also asked to rank order five areas that caused them the most amount of stress in the workplace (question # 16). Theses five areas included: not enough support, workload too heavy, communication problems, aggressive patients/residents and lack of control in job. An opportunity was also given in this question for respondents to specify other primary contributors to stress. The five areas chosen in this question were based on evidence in the literature (Celantano and Johnson, 1987) and information gathered by myself during previous work experience with staff. Questions regarding contributors to stress in the standardized part of the questionnaire, related specifically to the organizational environment (questions 4 1 -50). Evidence in the literature points to this area as being of significant importance in understanding the nature of workplace stress (Cherness, 1995, Bame, 1993). Responses to these questions were collected on a five point likert scale from 1 never, 2 rarely, 3 sometimes, 4 often and 5 always. 46 Responses to Stress-Questions involving responses or reaction to stress included physical, emotional and attitudinal outcomes as well as the specific areas of practice performance, job turnover and absenteeism. The decision to focus on these three particular areas was based on their potential to cause significant damage and evidence from the literature that indicates increasing concern in these areas (Beehr, 1995; Cartwright, 1979; Cherness, 1995). Questions regarding practice performance targeted the effects of stress on the ability to perform a job to the standards of the profession. This seemed particularly relevant to the study considering the potential for very serious consequences of sub standard work in dealing with the health of individuals. These not only include physical and emotional consequences but also financial ones in terms of such activities as investigation and follow up of reported incidents and complaints and litigation costs. The job turnover and illness questions were framed to determine the respondents perceptions of how much stress contributed to yearly sick time taken and movement to new positions. It is well documented that illness and injury in the hospital environment has escalated substantially in the last number of years and that the subsequent costs of this increase has resulted in higher health care delivery costs (WCB, 1996). The costs of recruitment and orientation of new workers following resignations is also reported as being 47 significant in the health care industry oyer the last number of years (Beehr, 1995; Cherniss, 1995). Greater understanding is required in this area regarding the possible effects of workplace stress on these patterns of illness, injury and job turnover. There were four questions in section one relating to practice performance, job turnover and absenteeism (questions 8, 12, 14, 17) and responses to these questions were collected on a three-point scale. The questions involving responses to stress in section two (questions 1-40) were categorized into symptoms, unhealthy activities, practice performance and work attitudes with responses recorded on a 5 point-scale as previously described. Stress Management Strategies Questions regarding preferred stress management strategies and CISD were contained in section one of the questionnaire. A question was asked that listed six stress management strategies including stress debriefing (question #15) and respondents were askedto indicate theirperceptions of the degree of helpfulness of each one on a scale that included: 1-not at all helpful, 2- somewhat helpful and 3-very helpful. There was also an opportunity for respondents to list "other" strategies and the degree of helpfulness. As with previous question choices, these six strategies were selected based on evidence from the literature (Bailey, 1985; 48 Brown, 1988; Celantano and Johnson, 1987) and information gathered by myself in the course of working with staff in the hospital setting. Three questions were designed specifically to obtain information about the awareness, usage and perceived helpfulness of CISD as a stress management intervention (questions 9-11). Responses to these questions were collected on a three-point scale, with two questions including a dichotomous (yes/no) question at the beginning of each. These questions were selected based primarily on suspected trends from my five-year involvement on a hospital based CISD team. Validity and Reliability of Measure Validity and reliability are terms used in research which refer to the degree to which an instrument actually measures what it proposes to measure and the degree to which results can be replicated in similar populations (Carey, 1995, Krueger, 1994; Anastas & MacDonald, 1994). Information regarding the reliability and validity of this measure, which is usually available with a standardized instrument, was not available in this case. However, according to the author (Munson, 1997, personal conversation) it has been found to be sensitive in measuring the stress levels of health care workers, particularly i f they are open and honest in their responses. Munson reported to have used the measure primarily 49 among helping professionals in stress management- workshops and agency consultations to establish baseline measures of stress. In order to establish a measure of face validity for both sections one and two, the questionnaire was piloted with a group of health care professionals meeting the study criteria. Participants did not express any major concerns regarding the questionnaire and their answers appeared,to gather the intended information. Minor adjustments to the questionnaire were made based on suggestions from the participants. Data Analysis Data from the questionnaires was coded and systematically entered into the SPSS Windows statistical package. The data was then analyzed by subjecting it to relevant statistical tests including frequency distributions, correlation coefficients and t-tests with the goal of describing the sample in terms of trends, percentages and relationships between variables. 50 Qualitative Methodology After examining the data collected regarding CISD, it became clear that there were gaps in the information that could best be addressed by a more in depth qualitative approach. These gaps related primarily to the need to gain more insight into the actual experience of CISD among respondents and clarification of seemingly disparate information regarding usage and satisfaction levels. Sample The sample (N=5) was selected from hospital based professionals in the same lower mainland hospital as the quantitative portion of this study. Since the focus was on the experience of involvement in CISD, this particular sample was restricted to those professionals who had experienced at least one critical incident stress debriefing in the course of their career. Representation from at least three different disciplines was also set as a requirement in order to maximize the range of opinions and insights. Based on these criteria, participants were recruited from social work, nursing, recreation therapy, physiotherapy and pastoral care. From my previous involvement with the critical incident stress debriefing team at the hospital and recall of staff previously debriefed, twelve persons in total were requested to participate in the study (2 were approached in person and 10 by telephone). Information was given to the staff members as indicated in Appendix D and they were told that their participation was completely voluntary. Out of the 51 twelve staff members, seven agreed to participate. As a focus group format was selected as the means of data collection for this portion of the study, a mutually acceptable time was set to meet and approval for use of a room was obtained from the hospital administration. Three days prior to the scheduled meeting, one of the participants was hospitalized with a serious illness. Interestingly, and perhaps significantly, this person actually offered, to leave her hospital bed long enough to attend the focus group. This offer was of course declined. Another staff member who had agreed to participate did not show up for the group and later called to say that she had an urgent situation on her unit which preempted her attendance. The sample size was therefore reduced to five but fortunately remained representative of four different disciplines (social work, nursing, recreation therapy and physiotherapy). Procedure At the beginning of the focus group interview, participants were again informed of the details of the study and asked to sign a consent form (Appendix D). Al l five participants signed the consent and were each given a copy of the consent form. The group was audiotaped with the permission of all of the participants. The group was facilitated with the aid of a pre-developed interview guide as seen in Appendix E. Refreshments were served to encourage a relaxed and open atmosphere for discussions. 52 The total time taken for the focus group was 60 minutes. Immediately following the termination of the group, notes were taken by myself on any recalled non verbal communication during the meeting such as facial expressions and body posture. These were then added to the verbatim transcript from the audiotape. Transcription of the audiotape began the same day of the meeting and was completed two days later. Design Qualitative research and the focus group method in particular was selected as a means of data collection for this portion of the study for five primary reasons: First, it provided the opportunity to explore and probe into unanticipated areas in a way that was not possible in a structured questionnaire (Krueger, 1994). The initial use of the questionnaire was helpful in that results guided the choice of further research methods. Although the questions in the survey portion of this study revealed certain trends and patterns among health care professionals, such as lack of awareness or usage of CISM, it did not reveal any underlying reasons for this phenomenon. Considering that satisfaction levels were reported to be quite high among those who had utilized debriefing, it seemed important to explore further the experience of CISD among respondents and the reasons for limited usage. The qualitative interview process seemed a logical next step to begin exploring the perspectives of staff in these areas at greater depth. 53 Second, previous involvement in CISM as a debriefor and debriefee also seemed to increase my potential as a facilitator to better understand the participant responses and probe for important details during the course of the interview (Carey, 1995). More specifically, my familiarity with the debriefing process gave me a greater sense of what questions and probes might best reveal the respondents' perceptions with regard to debriefing. Third, the focus group method in particular was chosen over individual interviews because of the potential for obtaining more information in greater depth through the synergy of the group process (Krueger, 1994; Asbury, 1995). The greater possibility of stimulating thought in a variety of areas beyond the guiding questions of the interview seemed more likely with the dynamic of interactions between group members. Fourth, this group interaction also provided an opportunity for staff to feel supported through the validation and normalization of common experiences (Carey, 1995). This created the possibility of a mutually satisfying and worthwhile experience for both participants and myself as researcher. Finally, the choice of one session as opposed to several individual interviews was also appealing as it provided the efficient use of available researcher resources such as interview time, use of space and rental of equipment (Krueger, 1994). 54 Although the original intent was for a larger sample size in the focus group, some of the recent literature indicates that smaller group sizes (5-7 participants) show considerable potential in terms of greater opportunities for individual input and greater ease of set up and management (Krueger, 1994; Carey, 1994; Sandelowski, 1995). To compensate for the smaller group sizes, the literature recommends an increase in the number of groups conducted to detect anomalies that may occur in a given population. Although this study involves only one focus group, the fact that this method is used as an extension and expansion of previous findings within the study may provide some compensation for the lack of multiple groups. A semi structured interview format was selected for the, focus group. Two guiding questions were developed with a series of probes that could be used if deemed necessary to further explore the participant's experience. The interview questions and probes are found in Appendix E. The questions were designed to explore the essential areas of the research question without unduly inhibiting the free flow of thoughts and connections within the group, because this is of particular value in the focus group method (Krueger, 1994; Gambrill, 1995; Asbury, 1995). Although the traditional concepts of validity and reliability as defined earlier in this chapter, have been dismissed by some as inappropriate to qualitative research and better examined in terms of credibility and usefulness (Carey, 1995), 55 some literature indicates value in considering validity and reliability (Krueger, 1994; Marshall & Rossman, 1995). Krueger (1994) suggests that "focus groups are valid i f they are used carefully for a problem that is suitable for focus group inquiry"(p. 31). The purpose and needs of this study are consistent with the literature's identification of research which is most suited to the focus group method. There are four primary reasons why this method was most appropriate. First, the literature suggests it is most appropriate when the purpose is to strengthen research design and expand data by combining quantitative and qualitative procedures (Krueger, 1994, Gambrill, 1995) The quantitative data was used in this study to determine general trends, patterns and percentages among a larger sample which then led to a smaller sample research design at more depth to further explore and clarify areas of particular relevance to the study, such as the use of debriefing. Second, when the purpose is exploration of unanticipated areas through group synergy and facilitator probes (Gambrill, 1995; Krueger, 1994; Asbury, 1995). The focus group interview portion of this study allowed for a less structured, more contextual process which lent itself well to stimulating discussion in areas beyond those necessarily expected by myself as facilitator. In other words, group members stimulated each other to reveal new information or insights that may not otherwise have arisen. These new insights were further probed by myself as facilitator, according to their particular relevancy,or importance to the study. 56 Third, when self disclosure is essential to understanding a phenomenon from the participants' own perspectives (Asbury, 1995; Krueger, 1994). Both quantitative and qualitative methods in this study relied on the subjective views of the participants. The later method however, provided greater opportunity for clarification of views and exploration of the subtleties of the debriefing process from those who had been previously involved in a debriefing. Fourth, when there is group homogeneity and facilitator experience and familiarity with the topic area (Krueger, 1994; Gambrill 1995; Asbury, 1995). Participants in the focus group in this study were all front line workers at the same supervisory level./ Although they had all previously met, they did not work together on the same teams at the time of the interview. As facilitator of the group, I was familiar with the debriefing process in the hospital setting and had previous training and experience with CISM. Another step to increase the validity of this research was taken by showing the interview questions to a staff member, who met the participant criteria and requesting feedback as to whether the questions might adequately elicit information and discussion in the desired areas. The staff member's feedback indicated satisfaction with the questions and no changes were made. One phenomenon that is reported as a concern in focus groups in terms of validity of findings is what is termed 'groupthink' (Krueger, 1994; Carey, 1995; 57 MacDougall & Baum, 1997). This is described as the tendency for group members to modify their own behavior in response to their impressions of other group members (Krueger, 1994; MacDougall & Baum, 1997; Carey, 1995). Three strategies used in this study to reduce the likelihood of this occurring were: 1) Ensuring that participants were of similar status to reduce the amount of influence of one group member over another (Carey, 1995). Although from different disciplines, all participants chosen were front line staff of equivalent rank and status. 2) Reinforcing the importance of individual opinions no matter how divergent, to the validity of the study (Carey, 1995). Prior to beginning the interview questions, 1 as facilitator emphasized the importance of individual and honest opinions to the quality and ultimate utility of the outcomes of the study. 3) Sharing a personal experience at the beginning of the session which was likely to be opposite to what the group members might have expected considering my experience with stress debriefing (MacDougall & Baum, 1997). This was linked with the above strategy and how it was executed in this study is described below. The latter strategy is similar to that discussed by MacDougall & Baum (1997) which recommends the selective use of 'devils advocate' behavior to avoid groupthink and to stimulate discussion. Although my familiarity with stress debriefing was beneficial to the process in many ways as previously discussed, 58 there was also a danger that participants might assume a positive bias on my part toward debriefing and unconsciously want to align themselves with this view. My attempt at using this "devils advocate' technique involved making remarks regarding my own experience which involved describing my fear, apprehension and general reluctance to participate in a critical incident stress debriefing for the first time. I did not go on to discuss my actual experience of being debriefed. A strategy which is recommended in focus groups to increase the level of reliability of results is the audiotaping and videotaping of the sessions (Krueger, 1994; Carey, 1995). Although videotaping was planned for this focus group session, booking of the necessary equipment was canceled two days prior to the meeting based on the objections of one of the'participants; The session was audiotaped and transcribed verbatim and notes regarding non-verbal communication were added to the transcript based on recall. This ensured that the participants experiences were captured accurately and fully documented in their own words, rather than relying completely on note taking and recall. As a further measure of reliability, participants were given the opportunity to read the completed transcript, however all declined stating time pressure as a factor in their refusal. Although generalizability and transferability of focus group results can be increased by conducting multiple groups, qualitative data in general is not thought to be readily comparable across groups (Carey, 1995). The data collected from this 59 focus group does however, represent the subjective reality of the experiences of the participants involved even though it is specific to the unique dynamics and membership of the group. Krueger (1994) and Carey (1995) suggest that cautious generalizations may be possible in similar settings when several groups have been conducted and no new information is revealed. Data Analysis Qualitative data analysis involves a series of processes including preparation, analysis and interpretation of the data collected (Sandelowski, 1995). These processes have been defined as a way of bringing structure, order and meaning to data, (Marshall & Rossman, 1995) with the ultimate goal of extracting new knowledge about a phenomenon that is not always apparent at first glance (Sandelowski, 1995). Unlike quantitative methods which are more linear and sequential, qualitative data analysis tends to be more iterative and emergent in nature (Sandelowski, 1995). Analysis of focus group data is unique in that it is important to consider the context of group interaction as well as individual comments (Asbury, 1995; Sandelowski, 1995). Carey & Smith (1994) suggest a two stage analysis whereby individual responses and behaviors are examined initially without regard for the group context and then at a group level. This two stage analysis was employed in this study and is described below. The decision to type the verbatim transcript for 60 this focus group was a deliberate one which resulted in an intimacy and understanding of the session in its entirety that would not have been possible if typed by someone else. Repeated listening and reviewing of the session content during typing triggered ideas and connections with regard to the analytical process even before formal analysis began. Individual level analysis Individual level analysis involved examination of participant responses and behaviors to the exclusion of the group context. The completed transcript was reviewed line by line and words and phrases that were thought to be significant were highlighted. These words and phrases were then categorized according to their similarities. From these groups, five main themes emerged with a series of sub themes under each. These themes seemed to best capture the essence of the larger trends which permeated the entire discussion and are reported in Table 6 in Chapter five of this paper. Group level analysis Group level analysis then consisted of re-examination of the entire transcript with the emphasis on capturing the relationship of individuals to the group. To promote greater contextualization of data, notes had been made on the transcript regarding such dynamics as pauses in discussion, level of.individual participation, 61 voice inflection, body language, agreement of group members and consistency of individual views immediately following the focus group session (Carey, 1994; Asbury, 1995; MacDougall & Baum, 1997). Particular attention was given to the influence of the dynamics of the group on individual statements. Although the group members appeared somewhat self-conscious and stressed from the days activities in the beginning of the session, this seemed to change about 10 minutes into the interview. Participants started to hear statements that obviously triggered memories from their own experience. Cross talk started to occur, body postures relaxed and there were fewer pauses and more laughter. From time to time looks of obvious recognition would flash across participant's faces and they would proceed-to relate an experience which, although connected with what the previous person said, would often take the conversation into unexpected areas. As these experiences were shared, less attention was focused on myself as facilitator and more on each other. Increased signs of relaxation, energy, trust and collegiality were palpable in the room as evidenced by more spontaneous story telling and willingness to enter into more sensitive areas. Although some conformity existed in terms of the use of similar or identical words and phrases from one person to the next, participants did not seem reluctant to also bring up unique experiences in the course of the discussion. The literature indicates that a significant threat to the focus group method of data collection is the tendency of individuals within the group to censor or conform 62 (Carey, 1994; Krueger, 1994; Asbury, 1995). Censoring involves the withholding of contributions and conforming involves changing contributions to be more consistent with the majority views as with the phenomenon of 'groupthink' as described on page 47 (Carey, 1994; Krueger, 1994; Asbury 1995). The familiarity of participants with my views as researcher was of particular concern in this case and steps were taken as previously described to prevent the group from unduly aligning with these views. The willingness of most of the participants to relate some negative aspects of their debriefing experience and to occasionally disagree with each other, seemed to indicate a low level of censoring and conformity. In addition to the five main themes that emerged in the individual analysis, which generally moved back and forth between the effects of stress on themselves and their families and the ways used to cope, the focus group itself seemed to become the embodiment of what the participants were describing as the beneficial aspects of stress debriefing; specifically the normalization of feelings and subsequent letting go of tension and building of renewed energy over the course of the session. This will be discussed in more.detail in Chapter 5. 63 CHAPTER FOUR: FINDINGS - QUANTITATIVE Response Rate Questionnaires were distributed to six areas within a lower mainland acute care hospital. A total of 49 out of 60 questionnaires were completed, yielding a response rate of 82%. Descriptive Demographic Information The sample consisted of 11 different professional health care disciplines in both emergent and less emergent areas of the hospital. The majority of the respondents were nurses (n=24) and social workers (n=10). Other professionals included two pharmacists (n=2), two physicians (n=2), two occupational therapists (n=2), three physiotherapists (n=3), one chaplain (n=l), one music therapist (n=l), two dietitians (n=2) and two recreation therapists (n=2). In comparison to the staffing numbers in this hospital, which are reported to be approximately 35.6% registered nurses, 2% social workers and 5% other disciplines (SMH Finance Department, 1998) this sample was significantly over representative of social workers and other disciplines. However, social work and other disciplines tend to be under represented in the literature in comparison to nursing with regard to stress in the hospital setting. 64 Of "the 49 respondents, the vast majority (86%) were female, which is consistent with much of literature involving the helping professions (Wallace & Brinkerhoff, 1991; Streepy, 1981; Laurence, 1993; Gilbar, 1998). Although there was a range in ages, almost two thirds (61%) were between the ages of 40 and 59. Two thirds were married or living with a partner and one half had 1 to 4 children living at home. Only 10% reported single parent status. Area and Discipline Comparisons Respondents from emergent and less emergent areas were grouped into two separate categories and subjected to t-tests with respect to the variables of stress levels, practice performance, absenteeism and job turnover. Although, the results need to be viewed with caution due to the low numbers, no statistically significant differences were seen between the two groups. Using the same variables, the various disciplines were grouped into 3 categories (1- nursing, 2-social work, 3-others) and subjected to an Anova test. No significant differences were found between the three groups. Again, the results were viewed with caution because of the limited sample size. 65 Stress Levels The vast majority of respondents (86%) reported that they were stressed some of the time and a smaller number (8%) the majority of the time. Six percent reported to be stressed none of the time. Stress levels as indicated in this question and data from other questions was then tested for associations or relationships between stress and other variables by applying the Pearson r statistical test (Refer to Table 1 below). Although the interpretation of numbers in this sample requires some caution, this test revealed some statistically significant correlations between stress levels and other variables such as dual role pressure, practice performance arid job" turnover. In other words, the higher the level of stress, the more likely respondents reported problems in the variables shown. Out of 14 variables that indicated an association with stress, a high percentage were related to organizational problems (1-4 & 11-13). 66 TABLE 1 VARIABLES ASSOCIATED WITH STRESS V A R I A B L E r V A L U E 1. Feel this is generally not a good place to work. . 47* * 2. Do not have any privacy at work. . 45* * 3. Working conditions in our hospital are generally poor. .43** 4. Feel organization is overrun with problems. .41** 5. Unable to perform my job to the standards of my profession. .40** 6.1 have primary responsibility in the home for caregiving and homemaking. .39* * 7. Feel trapped in my job. .36** 8. Hate going to work. . 34* 9. Tense at end of workday. .33* 10. Left job in last 10 years due to stress . 34* 11. Things at work depress me. . 30* 12. Do not feel supported at work. . 30* 13. Lack of control in job. . 29* 14. Muscle tension or cramps. .28* **p<. 01 *p<. 05 67 Contributors to Stress Out of the five contributors to stress as provided in question number 16 of the survey, heavy workload was reported to be an area that significantly contributed to the stress of a large percentage of the respondents as seen in Table 2 below. Under the category of 'other', the two issues of shift work and dealing with distressed people were each indicated once but no score was assigned to them. On a six point scale (6 being most stressful), only scores four and above were tabulated. Once again, organizational issues emerge as being significant factors. T A B L E 2 CONTRIBUTORS T O STRESS IN T H E WORKPLACE CONTRIBUTORS TOTAL PERCENT (%) 1. Workload too heavy 2. Communication problems with co-workers, patients 69.4 and their families 53. 1 3. Not enough support at work 4. Lack of control in job 5. Aggressive patients/residents 53,0 49.0 32.7 (*only scores 4 and above were tabulated) 68 Figure 1 below indicates a more visual representation of Table 2 with the added advantage of seeing responses 4, 5 and 6 separately. F I G U R E 1: C O N T R I B U T O R S T O STRESS No Suprt Heavy WL Com Prob Agress Pt With regards to the question relating to dual role pressure, two thirds of the respondents (94% female) reported that they were the primary person responsible for caregiving and homemaking duties in the home and 67% of them indicated that this added to their level of stress at work. Also, as previously indicated, in Table 1, dual role pressure was positively correlated with stress levels. 69 Out of the ten questions relating specifically to organizational or work setting contributors to stress in the survey, the data from four of the questions yielded relatively high percentages in areas that generally support the findings from question #16 in terms of stress being effected by organizational issues. See Table three below. On a five point scale, only scores 3 and above were tabulated (3- sometimes, 4- often, 5- always ). T A B L E 3 ORGANIZATIONAL / WORK SETTING CONTRIBUTORS CONTRIBUTORS TO STRESS TOTAL PERCENT (% c , (3,4,5) (4,5) 1. Try to do too many things at once. 91.8 51.0 2. Feel organization is overrun with problems. 75. 5 26.6 3. Feel paperwork is excessive. 73.5 26.5 4. Do not feel supported at work. 51.1 12.3 (*only scores 3 and above tabulated) Responses to Stress In the area of practice performance, 71. 4% of respondents reported that stress levels sometimes or often prevent them from performing their job to professional standards. Indications of negative attitudes toward clients were shown in that 53% of respondents thought that patients and residents create their 70 own problems sometimes and often (3 and 4 on the 5 point scale) and 51% thought that patients and residents sometimes and often do not want to change. Although illness and injury was not shown to be correlated with stress levels in the Pearson r test, 71. 4% of respondents attributed somewhat (2 on the 3 point scale) of their personal illness or injury to job stress and 12. 2% attributed most all (3 on the 3 point scale) of their personal illness or injury to job stress. In response to the question about how much paid sick time had been taken in the last year, 53. 1% of respondents reported 1-5 days and 16. 3% reported more than 5 days. In terms of symptoms, unhealthy activities and work attitudes, some high percentages appeared in both physical and psychological areas (see Table 4 below). Some of these areas have been linked with illness and injury in the literature, such as lack of exercise and illness and muscle tension and injury (especially when lifting). On a five-point scale, only scores of 3 and above are tabulated (3-sometimes, 4-often, 5 always) Job turnover in the last ten years for reasons of stress was reported to have occurred 1-2 times by 10. 2% of respondents and more than 2 times by 4. 1%. 71 T A B L E 4 RESPONSES T O STRESS Symptoms, Unhealthy Activities and Work Attitudes* TOTAL PERCENT % Tense at end of workday 83. 7 Muscle tension or cramps 59.2 Lack of adequate daily exercise 75. 5 Eat too fast or too much 67. 3 Work OT or take work home 69. 4 Feel overwhelmed by my j ob 67.4 (*only scores of 3 and above are tabulated) Preferred Methods of Stress Management The six stress management strategies as listed in question # 15 of the survey are ranked below in Table 5 using only the responses from the score of 3 (very helpful). Figure 2 below graphs the top four preferred strategies among respondents with reference to all three categories (not at all helpful, somewhat helpful and very helpful). 72 T A B L E 5 PREFERRED STRESS M A N A G E M E N T STRATEGIES/ RESOURCES STRATEGY / RESOURCE PERCENT(%)RESPONSE RATED AS V E R Y HELPFUL 1. Relief staff made available to allow regular staff to attend workshops/in-services. 69. 4 2. More input into decision making in the organization. 65. 3 3. Ongoing stress debriefing.(CISD) 46. 9 4. Conflict resolution skills in-services. 40. 8 5. Communication skills in-services. 26. 5 6. Team building in-services 24. 5 (*only the score of 3 is tabulated) F I G U R E 2: P R E F E R R E D STRESS M A N A G E M E N T STRATEGIES CISMData Four questions were asked specifically in reference to Critical Incident Stress Debriefing. Out of the four, the data from one question was rendered unusable because of the particular reaction of the respondents to this question. Specifically, when the respondents read the question "Is there a stress debriefing team in the hospital?", I observed that the vast majority of respondents consulted with others regarding the answer. This did not occur with any other question and the response would seem to indicate a general lack of awareness of the existence of this service. This question had a second part that was only to be completed if respondents answered 'yes' to part one. Again, this rendered the results less useable. In spite of this, a response to the question 'would you access the CISD team for cumulative stress ?' was given by 86% of the respondents and showed 36. 7% for 'none of the time', 44. 9% for 'some of the time' and 4. 1% for the majority of the time. The number of respondents that reported involvement in a debriefing at the hospital was 42. 9% and of this percentage 36. 8% found it somewhat and very helpful in coping with their stress. Only 6.1% found it to be not at all helpful. In response to a question regarding the perceived usefulness of debriefing on a regular, ongoing basis as a means of stress management in their work setting, 57. 1% of respondents indicated that they would find it somewhat helpful and 38. 8% indicated that they would find it very helpful. 74 The disciplines of social work and nursing were shown to access CISD more than other disciplines and there was an association shown (r. 34, p=. 03) between those who had accessed CISD and those who expressed a desire to have ongoing stress debriefing as a means of stress management. This was determined through the application of a correlation matrix on the data regarding CISD. Although the questions regarding CISD produced data indicating awareness, usage and helpfulness of debriefing, more information was needed in terms of the actual experience of accessing and participating in debriefing. For example, why do staff find it helpful and why is it not accessed by more staff? This kind of exploration required a different research approach, which was the reason for the choice of a qualitative component in this study. To further highlight the connectedness and flow of these two approaches in this study, quantitative and qualitative findings are summarized, and discussed together at the end of the next chapter. 75 CHAPTER FIVE: FINDINGS - QUALITATIVE Themes hi Participant Experiences The experience of involvement with CISM was revealed by the participants of the focus group in a progressive way, moving from an awareness of stress as a problem in their lives, to retrospective thoughts regarding the process of involvement in CISM and ideas for improvement. Five major themes emerged repeatedly in this journey: 1) Becoming aware of a problem 2) Considering CISM as an option 3) Finding strength in connection 4) Recognizing the limitations of CISM 5) Looking at the bigger picture Sub themes within each of these themes as outlined in Table 6 as follows, further developed a picture of the overall experience of CISM for these participants and reveal some interesting insights, some of which are consistent with the 76 literature on CISM and some which have not been evident to date. The following is a discussion of these insights based on the themes and sub themes identified. T A B L E 6 K E Y DISCUSSION TRENDS 1. Becoming aware of a problem: • Reflecting on the experience of stress • Challenge of fixed messages 2. Considering CISM as an option: • Entering uncharted territory 3. Finding strength in connection: • Normalization through sharing • Awareness of numbing • Building team • Letting go/moving on 4. Recognizing the limitations of CISM: • Messages in the name • What about cumulative stress 5. Looking at the bigger picture: • Need for structural change 77 Awareness of a Problem This theme encompassed two sub themes within the participant's experience: reflections on the experience of stress and challenges of fixed messages. The reflections on the experience of stress was an expression of the difficulty of day to day coping with stress and included statements which reflected the pervasiveness of the problem and the interplay between work and the responsibilities at home. There is an overall sense of being overwhelmed in their statements and a degree of tension between work and home responsibilities. /find that I run all day and then run even when I get home... its hard to calm down. ( J . I . ) When you leave work you need to de-stress somehow. . . because there is often stress meeting you right at the door at home. (A. P. ) / make so many decisions all day at work. . . some of them small. . . but happening all day. When I get home a simple question (from my family) can make me really upset because I just can't make another decision! (L.O.) The stress seems to be something you bring to all your communications.. ... with patients, families, staff and family at home. (J. I. ) The non verbal language of the participants while making these statements generally indicated a sense of fatigue (lots of sighs) and yet a need to keep going and keep up with the demands being placed on them (shallow breathing and 78 darting eyes). Some statements elude to a level of awareness of the impact of these ongoing demands on their behavior and communication with others. The sub theme of the challenge of fixed messages refers to the difficulty of being able to see beyond the erroneous messages of perfectionism that exist in the community at large, such as the belief that health care workers should somehow be immune to the emotion laden work of their jobs. This supposed ability to not need to acknowledge the stress created by daily exposure to human suffering is often referred to in the medical field as professionalism and is generally encouraged and rewarded (MacDonald, 1985; Pottage & Huxley, 1996; Moore & Cooper, 1996). These messages tend to be reinforced in overt and covert ways by such actions as the rewarding of the selfless behavior and the questioning of competency in response to complaints regarding excessive demands. The statements of the participants reveals the bind within which staff can be placed when unrealistic expectations are present. Their comments imply that this thinking can potentially create a reluctance to access remedial interventions such as CISM. References to the importance of self,sufficiency and a tendency toward self blame are also evident. I was ttpset... but 1 thought 1 should be able to handle it... maybe it is just me. . . fighting my own mind. (L. O. ) We never had such a thing before (CISM). . . we managed without it. . . that was our job. (A. P.) 79 I deal with stressful situations every day. . . thatsmy job,.. I should be able to handle it. (L. D. ) I am used to keeping things to myself.. solving my own problems. (L. O.) Evidence of some conformity of language in the group is seen with repeated use of the same words/phrases such as "I should be able to handle it"; however this did not seem to indicate conformity of thought as much as a struggle to find the words to express their expectations of their professions and of themselves. Considering CISM as an Option Participant statements indicated some reservations regarding the introduction of stress debriefing as a coping strategy, which is not surprising considering the expectations on themselves as expressed above. Entering uncharted territory is a sub theme that seemed to best describe the anticipatory thoughts of participants faced with the prospect of engaging in CISM. I'was unsure of what would be expectedfrom me.... the emotional component. I didn't want to break down in front of the people I work with ...(}. I.) I'm expected to fix the problems.... can I admit in front of others that I am having problems too?.. . (L. D. ) Willi be able to relate to the others?.. . will I feel comfortable?. . . or safe?... (R. W.) 80 My first thought was. . . do I need this? Is this a critical incident? (A. P.) A general sense of apprehension of perhaps having to reveal too much of themselves to others is expressed along with some anxiety around the possibility of rejection by the group. Questioning of the appropriateness of the use of CISM to the situation is also expressed. Strength in Connection After having discussed the issues leading up to the use of CISM, the theme of strength in connection encapsulated the sub themes of awareness of numbing; normalization tru-ough sharing; building team and letting go and moving on. Awareness of numbing was reflected in statements that indicated a realization of the depth of the impact of stress on themselves after connecting with others during debriefing. Although aware of the presence of stress, one coping mechanism appeared to be to deny, to some extent, the effects of stress on themselves and their behaviors. Interactions with others seemed to assist the participants to uncover these feelings and to bring them into their consciousness. There is evidence that this new found awareness was not expected in the direct and indirect references to a sense of surprise. It has to do with personal experience. . . you don't even think about other peoples experience until you here them talking about it. You just don't register how much things bother you until someone else talks about it... and then... you realize.... gee... I felt that way too. It 81 really surprised me how my mind works. (L. O. ) / wasn 't even going to go to the debriefing. . . I mean I thought. . . what is the point. . . it's for other people not for me. But then when I got there.. . it was my own group.. . and as they started to talk.. . / realized the impact on myself.. it was a surprise to me. (L. D. ) When I related some of the experiences from my area of the hospital to an emergency room nurse she mentioned how stressful she thought my job was. . . imagine. . . an emergency room nurse saying that! (R. W . ) My manager noticed a change in my mood and work performance. '. . . I didn't know how it was effecting me. . . I couldn't see it. . . / thought I could handle it. . . then I found out others were feeling similarly. . . it was then I realized talking about it helped. . . (L. O.) Normalization through sharing is a sub theme which emerged that was related to Connection with others. From the participant's statements, dealing with stress in isolation appeared to promote a self-blaming view of situations which often resulted in feelings of inadequacy. The debriefing brought the issues more into the collective realm and appeared to empower the participants simply by being aware of shared experiences. When I heard that many of the others were feeling the same way as I was...... I felt really good about it.. . 1 guess I felt. . . . hay I'm normal after all. I thought I was the only one crazy enough to feel what I was feeling. ... (laughter & agreement from other participants). (L .O . ) I felt guilty... / blamed myself... what really helped was the facilitator and her ability to make us feel safe and comfortable and able to share these feelings... she established that environment. . . (J. I. ) It felt good. . . especially being with the whole team and communicating with each other about where we were coming from and what was 82 happening. . . . instead of having whispering in the hallways. . . ( A . P. ) Building team was also an area of importance to the participants and is talked about in the literature as the strengthening of group support (Corneil, 1997). Statements regarding this area seemed to evoke renewed energy and enthusiasm for the job in spite of the stresses that exist. I got a good sense offeeling support for each other. .. like it really seemed to bring us closer together.. . as a team. . . . by sharing our common experiences. . . it was worth it. . . just to experience that. (L. D. ) It made me. . . I think. . . more human to the people I work with. . . and they were a lot easier on me after that. (R. W.) In a debriefing, you click with people in different ways. . . and you find there is someone you can go to after for more support and follow up. (J. 1. ) It felt so goodjust knowing that people I cared about as team members were OK (R. W.) Letting go and moving on was another important sub theme in the focus group discussions which was part of the overall strength in connection theme. Acknowledging the stress collectively seemed to promote a redirection of energy from a place of suppression and immobilization to movement forward with a renewed sense of understanding. / was able to forget about the incident after the debriefing. Before that.. . the same thoughts just seemed to keep occurring. It was just before my holidays and it was really helpful tome before I left. . . 83 otherwise. . . it might have ruined my holiday (L. O. ) /felt a lot of support from everyone and. ., . some resolution and soldidn't have to think about it anymore (sigh of relief) (R. W . ) Once you say it is OK.. .you know. . . subconsciously. . .I've been trying to hang on to this situation and. . . if its OK. . . then I can let it go... then that gives you permission to let go of it. I can carry on the next day . . . you know, (agreement from all members of group) (L. O. ) Recognizing the limitations of CISM This theme began to emerge toward the end of the discussions although there were some hints of it earlier on such as: Do I need this? Is this a critical incident? (A. P.) The sub themes were identified as messages in the name and what about cumulative stress? As previously mentioned, the focus group seemed to parallel what the participants were describing as the central aspects of the debriefing experience; specifically, as they shared information with each other they became empowered to see stress as more than an individual issue. They began to examine the systems that might contribute in some way to the difficulties that they as individuals were experiencing. There actually is a problem in the name I think. .... critical incident. . that implies that you actually have to have a critical incident before you are allowed to be stressed, (enthusiastic agreement from the group as if had struck a familiar chord in them as well) (L. D. ) 84 / think the name critical incident stress management doesn't really address the kind of stress we experience in extended care. . . . like sitting with a dying person, (agreement from others) (L. O.) The participant statements indicated not only a barrier to accessing debriefing but also the perception of an underlying message that their stress was not always significant enough to warrant attention. The issue of cumulative stress, although also eluded to earlier in the conversation, grew primarily out of the statements regarding the name. The statements indicate a growing awareness of some of the sources of their stress beyond those created by a critical incident. It is not always the big things. .. it can be the little things too. . . you don't even realize how it bothers you. (L. O.) It seems to be something. . . . this accumulation of things. . . that you bring each time to all your communications.. . (J. I. ) You don't realize that what you bring home is still your emotions from work. . . and then it effects your family as well... and then it builds up and builds up. . . . (pause). . . until you burst! (L. O.) There is a perception in the statements that this accumulation of stress goes unaddiressed and sometimes unacknowledged. 85 Looking at the Bigger Picture The focus group session culminated in a discussion of the need for structural change in order to maximize the staffs ability to provide quality care and in so doing, maintain a sense of satisfaction from their work. The discussion began with the importance of organizational acknowledgment of the demands of dealing with people in distress on a daily basis. Many of us have been working in this environment for a long time... we can handle it... but it would be nice to know they (senior management) can see how hard it is. . you know. . .. just to hear someone say. . . its OK to cry. . . its OK to feel. . . . (L. O. ) The institution or organization doesn 't give that kind of support or permission.. . . there is no kind of common thing.. .. like they really care up there about what we do. . . about us. •, . and making sure we are fit enough to do a goodjob. . . so then you tend to go to your colleagues for support. . . . instead of realizing that it is everybody. . . . that this is a difficult job emotionally.. . we all need it. (L. D.) The recognition of the way in which systems can be organized to perpetuate stressful environments rather than to ameliorate them is evident in J. I. 's statement. // seems like we build up this whole structure... where. . . you even even feel bad about taking offan hour to participate in something like this (focus group). . . or even education sessions.. . like. .. I don't know if I can do this because I have so much work to do. . you know. . . (general agreement from the group). .. and its the same when something stresses you. . . I don't have time to feel bad or deal with this. . . I just have to keep going. . . (J. I . ) 86 The need for the organization to broaden its mandate in terms of employee wellness in general provides the closing comments of the group. The desire to do more than just cope with the job is evident. We need the organization to provide us with information. . . about what to expect. . . and how to cope. . . they know it is a hard job. . . . we are just sort of coping from day to day. . . . ( L . O . ) / think different people react to different incidents differently. .. and there are different degrees of the seriousness of the impact on staff. .. 1 mean. .. 1 can almost envision something more holistic than just CISM. . . . something that would include ongoing stress management. . . more health promotion. . . like the employee wellness centers set up by large corporations. . . (enthusiastic agreement from other participants) (J. I. ) By this point in the conversation, energy and enthusiasm was considerably increased from the beginning of the session and participants almost seemed reluctant to leave. It was like the session in some small way, had become a brief sanctuary for them. 87 Summary and Discussion of Findings: Quantitative and Qualitative Quantitative data indicate a high percentage of female respondents, primarily between the ages of 40-49. Two thirds of these women appear to have primary responsibility in the home for care giving and housework and well over half reported that this added to their level of stress. This finding is consistent with the literature in the area of burnout and gender, particularly among the helping professions but is often overlooked as an issue of concern by organizations when planning stress management programs (Greenglass, 1991; Walker, 1989). For women, the data from past studies indicates that stressors tend to originate from both family and work settings and that role conflict is a major predictor of women's burnout but not men's (Greenglass, 1991; Cleary & Mechanic, 1983). In terms of the overall perception of stress, a vast majority of respondents (94%) indicated that they were overstressed some or the majority of the time at work. This seems high in comparison to a Canadian Mental Health Survey (1997) conducted among a cross section of occupations which indicated that 58% of Canadians found their work or workplace to create a moderate to major amount of stress in their lives. Although a direct comparison is not possible because of variations in the studies, the difference is nevertheless worth noting. It would appear that the high numbers support the assertion in the stress literature that indicates the occupations within health care are at particularly high risk for stress 88 and burnout (Smith, et al, 1977; Gray-Toft & Anderson, 1981, 1985; Hammer, et al. ,1985; Leppanen & Olkinuora, 1987; Sweeney & Nichols, 1996). Data gathered on contributors to stress and preferred methods of stress management, were grouped to a large extent under organizational and communication issues. Excessive workload, lack of support from the organization, communications issues and lack of control in decision making ranked particularly high as contributors to stress. Interestingly, the more obvious suggestions for stress management strategies that were anticipated, such as the hiring of more staff and the reduction of workload was not directly mentioned. Rather greater control over their environment by way of decision making and opportunities for ongoing education and group support were rated most highly. There appeared to be no statistically significant difference between disciplines or areas of work in terms of stress levels. Although these results must be viewed with caution, because of the limited sample size, it is worth noting that this finding does not support the assumption in the CISD literature that emphasizes the need for stress reduction among those in more fast pace, emergent response work such as firefighters, police and paramedics (Lewis, 1986; Mitchell, 1986; Mitchell & Bray, 1990). This assumption would seem to indicate that hospital professionals working in more emergent care areas, such as the emergency room and intensive care would report higher levels of stress. Responses to stress such as problems in practice performance, absenteeism and job turnover revealed 89 percentages that warrant concern in these areas in terms of the potential physical, emotional and financial costs within the organization. This is consistent with the literature that suggests that problems in these particular areas have increased substantially in the last decade and are creating costs and barriers within the health care system (Beehr, 1995; Cherness, 1995; Celantano and Johnson, 1987). Statistically significant evidence supported an association between high stress levels and reduced practice performance and increased job turnover. Although no significant correlation was found, between overstress and illness, it is noteworthy that a large number of staff (84%) reported that they attributed some (71. 4%) and most (12. 2%) of their illness and injury to stress. Awareness and use of the CISM team appeared to be somewhat limited to nursing and social work but in general was well received by those who had utilized the team. Satisfaction of the past participants in the debriefing process, was associated with the desire to have more regular debriefing available. A limitation of this portion of the study was the lack of data on the specifics of CISM such as why and how it was found to be helpful yet limited in usage and at the same time, indicated as a preferred form of stress management. This limitation lead me to pursue further investigation at greater depth. The less structured qualitative focus group approach lent itself well to eirpioriiig the experience of respondents with CISM and in so doing, addressing some of the areas in question. 90 The primary strengths of the debriefing process as described by the participants of the focus group closely paralleled many of those reported in the CISM literature, such as normalization of reactions, strengthening of group support and validation of feelings. However, one area touched upon by the group which is not evident in the CISM literature is the concept of debriefing as a form of empowerment. The group described a phenomenon similar to the feminist view that the personal is political (Walker, 1989), in that the shifting of workplace stress from the individual realm to the collective through the debriefing process, engendered a renewed energy, strength and perspective on the issues. This was evident not only in their descriptions of their debriefing experiences but also in the way in which they responded non verbally within the focus group. Participants gradually became more animated, enthusiastic and willing to share. The tone of self blame gradually changed to that of greater awareness of unrealistic expectations on their part as well as those of others. Another area that emerged as a significant part of the participants experience was the barriers to using CISM. These were primarily related to a lack of information on the CISM process and a subsequent fear of the unknown; the presence of entrenched messages such as "I should be strong enough" or "I should remain detached and objective" that run counter to the whole concept of CISM; the phenomenon of numbing of feelings as a coping mechanism; the implication in the name that stress is only significant and worthy of debriefing if it is based on a 91 critical incident and the presence of structures that do not acknowledge or make time for stress management in all areas of the hospital setting. The issue of occupational immunity to stress is one which is discussed particularly in the health care workplace stress literature (Lewis, 1994; Mitchell & Bray, 1990; Figley, 1995). It is a belief which characterizes the successful professional helper as one who is detached, objective, self reliant and capable of giving ongoing support to others with little or no attention to personal needs. This belief has been and in some cases still is, reinforced by training institutions and social service organizations alike (Figley, 1995). Reduction in the fallacy of uniqueness and reassurance of normalcy of reactions were evident throughout participant statements as a significant benefit of debriefing and are two stated goals of CISM (Mitchell, 1995). Studies and clinical writings in the area of CISM indicate that this normalizing response is one of the primary reasons for the effectiveness of the process (Corneil, 1997; Robinson & Mitchell, 1991; MSB, 1996). However, what is less evident in the literature is the concept of empowerment through the sharing of common experiences. The focus group participants were visibly energized when they talked about their experiences of shifting the problem from the individual realm to the collective. This shift from a position of self blame to one of awareness of other forces at work, such as organizational responsibility in the management of stress seemed to engender a sense of freedom which allowed them to look at the issues in a whole new light. 92 The issue of cumulative stress as a major factor in their day to day coping was an indicator that more than just critical incidents need to be acknowledged. The topic of cumulative stress is not dealt with to any great extent in the CISM literature as it is for the most part, seen as an entirely different category of stress which is more akin to burnout and more appropriately dealt with separate from the debriefing process. However, considering the importance of cumulative stress as indicated by the focus group participants, it would seem unlikely that critical incidents can be viewed in isolation of the effects of cumulative stress. Through a integration of both quantitative and qualitative findings, particular issues emerge from the data of this study that are especially noteworthy in terms of increasing the understanding and management of workplace stress in the hospital setting. The implication and importance of these issues are discussed in the next chapter along with recommendations for the future. 93 CHAPTER SIX: DISCUSSION Introduction The focus of this study was to explore workplace stress in the hospital setting and the use of CISD as a stress management strategy among professional interdisciplinary staff. From this research, three areas of particular interest arose from the findings which involved the issues of gender, cumulative stress and empowerment. The importance and relevance of these issues are discussed in this chapter, as well as the limitations of the study and future directions. Relevance of Gender As indicated in this study and in the literature, the majority of institutional health care workers are women (Baines, et al. , 1991; Walker, 1989). In spite of this fact, few studies or clinical writings in the area address this issue as an important factor in understanding workplace stress in health care settings. A particular area of importance in relation to predominantly female workplaces concerns the issue of added burden and role conflict. Keeping in mind the limited sample size of this study, it is never the less interesting that two thirds of the female respondents reported that they have primary responsibility in the home for homemaking and caregiving duties and over half of these women reported that this 94 added to their level of stress. In comparison, the majority of male respondents, which amounted to 12% of the overall sample, indicated that they did not have primary responsibility for homemaking and caregiving duties. This is consistent with research results which indicate that the bulk of 'caring work' continues to be done by women in the home in spite of their increased involvement in the workforce (Greenglass, 1991; Walker, 1989; Baines, et. al. , 1991). There is also some indication in the literature that this caring work in the home now often extents to the care of aging parents and in-laws (Opie, 1995; Walker, 1989). Additionally this caring work at home and in the workplace is often devalued as it is seen as relatively unskilled and simply a natural extension of the female character and role (Baines, et. a l . , 1991; Walker, 1989; Greenglass, 1991). Such a view tends to render much of this caring work invisible to others, including the women caregivers themselves. This not only has the potential to minimize the importance of this work to the smooth and successful operation of domestic and work life, but also can lead to a sense of inadequacy on the part of women caregivers who are caught between the competing forces of home and work life responsibilities (Baines, et. al , , 1991; Walker, 1989). In light of these assertions, it would not be surprising that in a predominantly female workplace such as the hospital setting, that stress levels might be particularly high, especially i f one considers the additional strain of continual exposure to people in distress. From this study and from others related to 95 health care workers, findings point to a relationship between stress and such outcomes as increased job turnover, illness and injury and difficulty in performing work to professional standards (Beehr & Bhagat, 1985; Corey & Wolf, 1992; Warshaw, 1988). These outcomes have repeatedly been shown in the literature to have costly human and financial consequences, which contribute to a rapid increase in costs of operation. Consideration of factors contributing to stress in a particular setting are essential to the development and implementation of stress management interventions that adequately meet the needs of staff. Critical Incident Stress Debriefing is an example of a stress management intervention which has been introduced to a number of hospital settings over the past few years. Although it was shown to be generally well received by staff in this study and others, it is an intervention that was developed for a predominantly white male audience. As the name implies, it is intended to address those incidents deemed to be 'critical' and does not claim to deal with the debriefing of those occurrences which involve the lower profile caring work such as helping patients and families to cope with disability and death. This type of work represents a large portion of what women do in the health care field. Although not evident in CISD literature, this study indicated a perception among respondents that the presence of a debriefing team limited to 'critical' incidents only as the sole stress management measure, had an effect of discounting the importance and strain of the majority of their work. Even 96 though an unintended consequence of CISD, awareness of this perception among some staff would seem to me to be essential in adequately exploring and addressing staff needs in this area. Also, formal review of the intervention of CISD for gender sensitivity is not evident in the literature and would seem necessary to ensure maximum effectiveness in work settings that are predominantly female. Cultural sensitivity is another issue that is not addressed in the literature with respect to CISD and would seem to be an area of importance for future exploration as well. Acknowledging Cumulative Stress One of the issues that arose from this study that is given limited consideration in CISD literature is the concept of cumulative stress. In spite of evidence that indicates a high degree of satisfaction with the process of CISD as a measure to ameliorate stress, the name in itself appeared to create a type of exclusivity in the perceptions of some of the respondents which not only tends to discount the nature of the majority of work done in this setting as previously mentioned, but also underestimate the importance of the accumulation of stress created by day to day demands. As one respondent stated "its not just the big things. . . it can be the little things too. . . you don't even realize how it bothers you". Some of the writings and research on CISD elude to cumulative stress as a factor in overall workplace stress, however for the most part it appears to be 97 relegated to a place of relative insignificance (Snelgrove, 1998; Van Goethem, 1998). The whole structure of the debriefing process is geared to coping with the trauma created by a particular incident. In my experience over the past five years as a member of the CISD team in the hospital setting, the incident itself was often only the 'tip of the iceberg' and a number of other issues, which had accumulated over time, seemed to effect the way in which staff reacted to a given incident. This cumulative effect is referred to by Robinson & Mitchell (1993) in a study involving 172 emergency service, welfare and hospital personnel in Australia. They state that: "It is interesting to note that responding to several difficult situations in a short space of time created stress response in more people than did a single incident. This suggests that more attention needs to be given to those situations where staff experience a series of incidents, none of which may be major, but collectively may lead to an accumulation of effects." (p. 372-73) In the cases where accumulation of incidents is a factor, it is necessary to modify the structure of the CISD process to suit the needs of the particular group. For many voluntary team members, including myself, this shift in. gears can be rather disconcerting and not always all together successful when specific processes or training are not in place to deal with these occurrences. This is especially true for those members who do not have experience or training in group work techniques. The importance of the issue of cumulative stress to overall stress levels as reported by respondents in this study and the indications that stress levels are similar across 98 emergent and less emergent areas highlights the need to consider a more comprehensive and inclusive stress management program that acknowledges and addresses stress from many different sources. To date, emphasis has been placed on the debriefing of 'critical incidents' and 'emergent' care workers. Little or no attention has been given to the cumulative stresses that exist in the less emergent areas of the hospital. The Empowerment Factor An issue of primary importance to myself as researcher that emerged from this study was the concept of group debriefing as a means of empowerment. In addition to the previously well documented benefits to CISD, such as normalization of reactions and validation of feelings, the respondents in this study also reported a strengthening of the collective through group interaction that seemed to ultimately lead them beyond examining stress as a purely individualistic problem. CISD, as a stress management technique described in the literature, tends to emphasis the strengthening of the individual in a one to one or group setting (Corneil, 1997). In spite of this focus, the group debriefing sessions as described by the participants seemed to go beyond a strengthening of self to shifting thinking away from a state of self-blame to an awareness of the concept of shared responsibility. The realization of the existence of unrealistic expectations and stress inducing organizational structures as part of the broader workplace stress 99 picture, were some such insights that the participants described as outcomes of their group debriefing experience. This shift seemed to lead to ideas for stress management strategies which encompassed more than just responses focused on the individual, such as organizational change. According to the literature, the majority of stress management interventions in the public and private sectors that do exist, tend to focus primarily on the individual in spite of evidence that suggests that a broader approach has much more potential for success (Cherniss, 1995; Murphy, et. a l . , 1995; Lawrence, 1993; Beehr, 1995). Also of interest in this study was the non-verbal communication demonstrated in the focus group session as participants described their debriefing experience. It seemed to parallel that of their reported changes during the actual debriefing process. As they began the focus group session, they were relatively apprehensive and guarded in nature and as the session progressed they moved gradually to a state of greater animation, enthusiasm, energy and creative thought, which seemed similar to some of the characteristics associated with the empowerment process in the literature (Brown, 1984, 1988; Cox & Parsons, 1994; Opie, 1995). This transformation would seem to be a necessary precursor to not only being able to successfully carry on in the job but also to the ability to strategize for stress management in the future. An unfortunate limitation of CISD when used in isolation however, is the absence of a problem solving component that would encourage staff involvement in decision making and needed change 100 within the organization. There is a danger that this lack of opportunity for political action beyond the debriefing sessions, which is a natural next step in the empowerment process, might result in a sense of cynicism and discouragement among staff over time if they perceive that needed change has not occurred. Limitations and Future Directions Although this study revealed some interesting and important points with regard to workplace stress in the hospital setting, it contains some limitations that need to be taken into consideration. First, the small sample size of both the qualitative and quantitative portions of the study limit the range of opinions, generalizability and strength of the findings. A larger number of survey respondents and focus group sessions would have given greater confidence in results and increased the opportunities for gathering a broader range of opinions and experiences. Second, more questions around the specific issues of dual role pressure, practice performance, job turnover, illness and the use of CISD as a stress management strategy which were central to the study, would have increased the likelihood of greater specificity and clarity in these areas and their particular relationship with workplace stress in the hospital setting. Data from one of the questions regarding CISD on the survey (question number 10) was rendered less 101 usable because the way in which the first part of the question was asked did not encourage independent and unbiased responses. Third, the use of more sensitive scales in part one of the survey (minimum of 5 point scale), would have been helpful in greater accuracy of respondent perceptions. Finally, although the majority of health care workers are women, a larger sampling of the men in this population would have been beneficial in better understanding the role of gender in workplace stress in the hospital setting. Issues of culture would also be important to include in future studies, especially considering the generally ethnocentric approach taken to stress and stress management strategies in the literature to date (Heaney and van Ryn, 1996) A number of areas for possible improvement emerged from this study. First of all, there appears to be a need for senior administrators in health care to begin to more fully appreciate the linkages that exist between increasing costs in the system and inadequately addressed stress levels among health care workers. Comprehensive staff wellness programs, although expensive to initiate, are shown in the literature to be effective in reducing overall costs (Beehr, 1995; Bailey, 1985). A comprehensive wellness program could expand the concept of CISD to acknowledge and address ongoing stressors as well as attend to other areas of identified need, such as increased control in the job and 102 opportunities for problem solving, organizational change and resource supported ongoing education. Few such programs exist in health care, as one might expect they would considering the very nature and purpose of the industry. However, the cost of implementation of this type of program is difficult to justify in hard economic times and significant benefits would not likely be immediately evident. One possible financially feasible option might be to partner with a university graduate or doctoral program that would allow for an action research project regarding the application of a wellness program in certain areas of the hospital that addresses the primary issues of staff concern. These areas could then be evaluated against non-participating areas at the end of the study to determine the efficacy of such a program in this setting. Another area with room for improvement relates to the issue of co-worker support and professional training. As is evident in the findings of this study and in others, support on the job is reported to be an important factor in stress management. The literature suggests that the support of co-workers is important and can improve ones ability to cope with stress (Cherniss, 1995; Corey & Wolf, 1992; Kahili, 1988). However, in spite of the number of disciplines that have entered the hospital setting over the last number of years, few have had the opportunity to learn much about each other or how to work together in a co-operative and complimentary way. This has often times resulted in a climate of competitiveness and unnecessary overlap in service to clients, which benefits 103 neither staff nor customer. Considering the increasing complexity of health care today, collaboration between disciplines is even more important in order to maximize the quality of patient/resident care. Although interdisciplinary study and team work are becoming recognized as essential skills in many educational institutions, there does not yet appear to be a real commitment to the funding of such programs. This continues to result in graduates being isolated in their own disciplinary area, rather than benefiting from the supportive atmosphere of a well functioning interdisciplinary team. Both educational institutions and employers need to encourage this co-operation to help staff deal with stress and improve client outcomes. Workers compensation regulations also need to be reviewed and broadened to acknowledge worker safety as encompassing emotional and mental well being as well as physical. Currently, very few jurisdictions throughout the world recognize psychological stress as a compensatable injury, even though the numbers of claims have risen dramatically over the past decade (Warshaw, 1988; Terry, 1996; Pottage & Huxley, 1996). B.C. does not currently recognize stress as a compensatable injury but is beginning to address the need for debriefing as an integral part of the job of fire fighting. When it comes to physical work conditions, workers compensation agencies require organizations such as hospitals to meet certain standards in this area. If these standards are not met, fines or increased costs to the organization can result. This essentially works as a powerful incentive 104 to monitor and comply with these standards. In light of findings that indicate a relationship between stress and such costly consequences as increased illness and injury, it would seem important for these agencies to review their policies on worker health and safety and expand them to include some minimum standards in the area of psychological stress that workers can be exposed to in a work setting. Although this study has some limitations and results need to be viewed with some caution, the areas that emerged around gender, cumulative stress and empowerment provide important directions for future exploration. It would seem reasonable that based on the results of this study, that consideration be given to expanding the CISD model in the hospital setting to be more inclusive of less emergent areas and cumulative stress. This would require adopting a more structural, preventative and proactive approach toward stress management. Examples of this might include ongoing debriefing as an integral part of the staffs' shift routine (similar to the requirement in Extended Care to stretch and limber up at the beginning of a shift) and ongoing education sessions by the CISM program regarding the process of debriefing and its importance to maintaining a healthy and healing environment. Although I believe that voluntary peer support on such a team would continue to be a valuable component, a greater commitment of resources in terms of a dedicated program with paid staff would be required to successfully develop and maintain a team of this nature. In light of the new organizational structure in 105 health care in B. C. , regional initiatives in this area, with resources shared among all the hospitals in a particular region, might work well and be more financially feasible. Conclusion I believe that a greater commitment to worker health and well being in health care is necessary i f we hope to deliver client care which is effective, timely, consistent and affordable. A broader definition of worker health is required to encompass not only the physical, but also the psychological components of health, such as the management of stress in the emotion-laden environment of the hospital. Support to staff needs to be inclusive, ongoing and extend beyond a focus on the individual, to acknowledgment of the organizational, systematic and social factors involved in worker health. Support for staff needs to be both tangible and emotional to sustain a high level of commitment and caring which is essential to positive client outcomes. 106 Bibliography Aitken, M . (1995). The human cost of performing the nursing assistants role. Canadian Nursing Home 6, (2), May/June, 6-12. Anastas, J. W. & McDonald, M . L. (1994). Research design for social work and the human services. 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Who is the p r imary person in your household responsible for parenting, caregiving and/or homemaking duties? (Check one of the following) yourself your partner equal participation If yourself, to what extent do you think this adds to your stress level?(Check one) not at all somewhat significantly 8. Have you left a job or position because of stress in the last 10 years? never 1 - 2 times more than 2 times 9. Have you ever been involved in a Critical Incident Stress Debriefing? yes no If yes, how helpful did you find it to be in managing your stress? (Check one of the following) not at all helpful somewhat helpful very helpful 10. Is there a stress debriefing team in your hospital? yes no If yes, would you access them If you felt stressed from an accumulation of stressors at work? (Check one of the following) none of the time some of the time majority of the time 11. To what extent do you think ongoing and regular debriefing sessions would be helpful at work? (Check one of the following) not at all helpful somewhat helpful very helpful 12. How much do you attribute personal illness or injury to job stress? (Check one of the following) not at all somewhat mostly 13. Do you feel over stressed? none of the time _ some of the time_ majority of time _ 14. To what extent do you feel high stress levels prevent you from performing your job to the standards of your profession? (Check one of the following) never sometimes often ....2 15. To what extent do you feel the following resources would be helpful in managing your stress? (Mark the number that best describes how you think to the right of each item: 1= not at all helpful 2= somewhat helpful 3= very helpful) Team building workshops/inservices Communication skills workshops/inservices Conflict resolution skills workshops/inservices Ongoing stress debriefing groups with coworkers • Relief staff made available for me to attend workshops/inservices More input into decision making in the organization Other (please specify) 16. What causes you the most stress in your workplace? ( Rank order each item below from 1 (least stressful) to 6 (most stressful) not enough support workload too heavy communication problems.ie: conflict with patients, families, coworkers, etc. aggressive patients/residents lack of control in my job other (please specify) 17. How many paid sick days (illness or injury) did you have off over the last year? None 1-5 days More than 5 days Other comments: ; ....3 iaoc S E C T I O N T W O : This questionnaire is designed to measure stress associated with your work. It has a self scoring component at the end so you can obtain some immediate feedback about your stress level. Persons who score high on the following scales are encouraged to seek professional help. When stress reactions are recognized early and treated, positive outcomes are more likely. Circle the number on the scale to the right of the questions that best describes your experience at this point in time: 1 - never 2 - rare ly 3 - s o m e t i m e s 4 - o f t e n 5 - a l w a y s 1. Headaches : 1 2 3 4 5 2. Colds : 1 2 3 4 5 3. Stomach problems 1 2 3 4 5 4. Dizzy spells 1 2 3 4 5 5. Crying 1 2 3 4 5 6. Muscle tension or cramps 1 2 3 4 5 7. Trouble falling to sleep 1 2 3 4 5 8. Waking too early..... .' 1 2 3 4 5 9. Tense at end of work day 1 2 3 4 5 10. Lose track of what day it is 1 2 3 4 5 S Y M P T O M S T O T A L S (add circled numbers in each column) G R A N D T O T A L O F S Y M P T O M C A T E G O R Y : (add totals from all columns) 1-never 2 - rarely 3 -somet imes 4 - o f t e n 5 - a l w a y s 11. Drink too much 1 2 3 4 5 12. Smoke too much 1 2 3 4 5 13. Use drugs/medications 1 2 3 4 5 14. Lack of adequate daily exercise 1 2 3 4 5 15. Watch too much television 1 2 3 4 5 16. Do not eat balanced meals 1 2 3 4 5 17. Eat too fast/or too much 1 2 3 4 5 18. Try to do too many things at once 1 2 3 4 5 19. Spend too much time atone 1 2 3 4 5 20. Watch television to get to sleep 1 2 3 4 5 U N H E A L T H Y ACTIV IT IES T O T A L S G R A N D T O T A L O F U N H E A L T H Y A C T I V I T I E S C A T E G O R Y 21. Feel unappreciated and used by patients/residents 1 2 3 4 5 22. Feel patients/residents create their own problems 1 2 3 4 5 23. Apprehensive when meeting new patients/residents 1 2 3 4 5 24. Patients/residents make me nervous. 1 2 3 4 5 25. Get mad when patients/residents do not follow instructions 1 2 3 4 5 26. Daydream while interviewing patients/residents 1 2 3 4 5 27. Fail to be helpful to patients/residents 1 2 3 4 5 28. Do not understand patient's/resident's anger 1 2 3 4 5 29. Delay appointments and returning calls.. 1 2 3 4 5 30. Feel patients/residents really do not want to change 1 2 3 4 5 P R A C T I C E P E R F O R M A N C E T O T A L S G R A N D T O T A L O F P R A C T I C E P E R F O R M A N C E C A T E G O R Y ....5 1-never 2 - rarely 3 - sometimes 4 - often 5 - always 31. Feel my job is boring 1 2 3 4 5 32. Feel trapped in my job 1 2 3 4 5 33. Become easily irritated at work 1 2 3 4 5 34. Things at work depress me 1 2 3 4 5 35. Feel overwhelmed by my job 1 2 3 4 5 36. Do not have enough training to do my job 1 2 3 4 5 37. Job tasks are not clearly defined 1 2 3 4 5 38. Work overtime or take work home 1 2 3 4 5 39. Avoid my coworkers 1 2 3 4 5 40. Take days off from work 1 2 3 4 5 WORK ATTITUDES TOTALS GRAND TOTAL OF WORK ATTITUDES CATEGORY 41. Feel this is generally not a good place to work 1 2 3 4 5 42. Feel organization is overrun with problems 1 2 3 4 5 43. Coworkers make me angry 1 2 3 4 5 44. Feel paperwork is excessive 1 2 3 4 5 45. Do not feel supported at work 1 2 3 4 5 46. Hate going to work 1 2 3 4 5 47. Do not have any privacy at work 1 2 3 4 5 48. Take brief daily breaks from work 1 2 3 4 5 49.1 have a feeling of dislike for my coworkers 1 2 3 4 5 50. Working conditions in our hospital are generally poor 1 2 3 4 5 WORK SETTING TOTALS GRAND TOTAL OF WORK SETTING CATEGORY _ _ _ _ _ PLEASE TOTAL THE GRAND TOTALS FROM ALL CATEGORIES NOW TURN TO THE NEXT PAGE AND MARKYOUR SCORES ON THE APPROPRIATE STRESS THERMOMETERS' ...6 STRESS SCALE SCORE SUMMARY SHEET Scoring Instructions En:cr your score for each section o f the Stress Scale on the appropriate "s t ress. thermometer" pr inted b e l o w . Y o u - w i l l have a numer ical v isual measurement of your stress levels in the five areas, as we l l as an overa l l s:ress score. Syrr.ptcrra U n h e a l t h y Act iv i t i e s l o -s e -33-ac-ts-P r a c t i c e P e r f o r m a n c e W o r k A t t i t u d e W o r k S e t t i n g Combined Stress Score 3C0-27J. 2JC 225-20C 175-150-123-100-75 • SO • 2S • 0 • Oingtrous •250 '200 High Strtss • 1 SO Modtm* Strtss •100 Low Strtss •5 0 <D 1993 by the Washington Area Supervision Institute and The Haworth Press, Inc. / a o £ APPENDIX D: FOCUS GROUP INFORMATION AND CONSENT APPENDIX E: FOCUS GROUP AGENDA AND QUESTION Focus Group Agenda/Questions Introduction: Information on study and work done to date: Consent: • Inform re: contents of letter and consent. • Request signature • Copy of consent forms to participants Question: • What has been your experience with CISD? • Was it helpful of not? Probes: • What did you know about CISD before you became involved? • What did you expect ? Was it what you expected? 

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