Caregiver Stress: Research

1. Caregiver Stress: Research Kathi J Kemper, MD, MPH Wake Forest University Health Sciences

2. Objectives By the end of this session, participants will be able to • Contrast rates of stress and burnout in generalist, specialist, and trainee pediatricians • List negative consequences of stress on physical health, memory, and cognitive performance • Demonstrate 3 effective stress management strategies (emotional, mental, spiritual) • Tackle a research study about caregiver stress

3. US residents frequently distressed (2006) % reporting 14 or more days Frequent Mental Distress in past month Least distressed: HI, IA, WI Most distressed: Appalachia

4. Environmental Stress: Water by 2020

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

6. Stress in Caregivers • Medical Issues • Financial issues • 24/7 schedule • Impact on marriage, friendships, work • Social factors: minority status, poverty – worse stress • In US, 13% of children lived in households with at least one parent reporting high parenting stress Raphael J. Child Care Health Dev.2010

7. Stress Symptoms in Pediatricians • Survey of 5704 pediatricians, internists, and family docs • General pediatricians reported higher job, satisfaction on a 5-point scale (P<0.01). • 13% of pediatric generalists and 23% of specialists endorsed symptoms of burnout or job stress (lower than other docs) • 2006 study: Higher stress levels in pediatricians with frequent unpleasant duties (admin/paperwork) and infrequent pleasant work (patient care, research, teaching) Shugerman R. Pediatrics, 2001 Kushner. Work, 2006

8. Stress and Burnout: Trainees • Stress is increased by high demand, low control situations with frequent demands for change • By 2004, 15 articles on stress and burnout in residents; High stress levels associated with: • Depression and substance abuse • Errors, poor quality • Poor communication • Dropping out of medicine • Decreased duty hours have had limited impact on stress and burnout: 68% positive screensfor burnout among pediatric residents in 2008 McCrary LW. Fam Med, 2008 Landrigan. Pediatrics, 2008 Thomas NK. JAMA, 2004

9. Stress Effects • Physical: higher cortisol, lower DHEA; higher epinephrine/NE, BP; shorter telomeres (aging); poor sleep, more pain, GI upset. • Stress is associated with 70% of visits to primary care clinicians; STRESS makes you SICK • Emotional: irritability, anxiety, depression; angry, impatient • Mental: STRESS makes you STUPID; less focused, less PFC activity; more errors; impaired memory • Social: impaired communication • Work: impaired performance

10. Husband During Argument with his Wife: HR Wife said something that got under his skin Heart rate remains elevated after argument ends

11. Sympathetic Parasympathetic Constrict Dilate Stop secretion Secrete saliva Spinal cord Parasympathetic Constrict bronchioles Dilate bronchioles Sympathetic ganglion chain Speed up heartbeat Slow down heartbeat Secrete adrenaline Increase secretion Adrenal gland Decrease secretion Stomach Increase motility Decrease motility Empty colon Retain colon contents Empty bladder Delay emptying Bladder Parasympathetic Stress: Autonomic Nervous System

12. Common, Non-Skillful Stress Management Strategies

13. Stress Management • Mental (meditation – sitting or moving, guided imagery, self-hypnosis, biofeedback, autogenic training, journaling, CBT, etc.) • Emotional (intentionally generate positive emotions) • Spiritual (not necessarily religious; forgiveness; extending compassion)

14. Meditation?

15. Mental Practices: meditation • Growing neuroscience • Clinically: Reduces anxiety; Improves concentration; memory; moods • Few side effects; can combine with other practices • Positive impact in physicians Davidson RJ Psychosom Med, 2003 Krasner MS. JAMA, 2009 Pipe TB. J Nurse, 2009

16. Focus and Count: Sheep or Breath • Reliably induces relaxation (except for some with breathing problems) • In/out: 1 – repeat (relaxation response) • In/out: 1; in/out: 2; in/out: 3; in/out: 4 - repeat

17. Focus and Count: Word or Image • In/out: PEACE • When mind wanders, notice (without judgment) and return

18. Practice • We will practice for 2 minutes • Then share with neighbor for 1 minute • Pick a strategy: count breath, focus on word or image; Sit comfortably • NOTE: It is likely that your mind will start wandering within the 1st 8 seconds. Normal. Just return to intention • OR take a 3 minute break

19. Hypnosis/Guided Imagery Hypnosis: An altered state of awareness usually involving relaxation during which the participant can give himself suggestions for desired changes to which he is more likely to respond that in his usual state of awareness. Guided Imagery involves using the imagination to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization. http://www.healthjourneys.com/

20. Guided Imagery Body responds as if you’re there!

21. Mind-Body: Autogenic Training • Form of hypnosis • Repeat phrases • My hands and arms are heavy and warm • My legs and feet are heavy and warm • My heartbeat is calm and regular • My breathing is easy and free • My forehead is cool • My belly is relaxed • Reduces need for headache medication • Reduces frequency of migraine attacks Zsombok. Headache, 2003 Juhasz. Headache, 2007

22. Biofeedback Use of electronic equipment to measure and feed back information about physiologic functions—which are then modulated in desirable direction Goal-balancing ANS (& CNS) activity Portable vs. PC/Mac Mood rings? “video-games for your body” Nestoriuc. Pain, 2007

23. Home Biofeedback Peripheral Temperature Heart Rate Variability Skin Conductance

24. Emotion-based Stress management

25. Intentional emotions • Affect • Hormones • ANS

26. Generate GRATITUDE intentionally:

27. DHEA(S) Total Free Cortisol 250 14 l l 100% 23% l 12 l 200 l l l 10 l l 150 8 l l l nM ng/ml l l l l l l 6 l l 100 l l l l l l l l l l 4 l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l 50 l l l l l l l l l l l l l l l l l l l l l l l l 2 l l l l l l l l l l l l l l l l l l l l l l l l 0 0 before after before after N=28 Improvements in Hormonal Balance

28. NOT JUST relaxation

29. Impact on Memory Before Placebo Drug Gratitude/ Breathing

30. Impact on executives

31. * HRV Biofeedback - Resources www.heartmath.com www.heartmath.org www.aapb.org www.stresseraser.com www.bcia.org www.stens-biofeedback.com

32. Gratitude Exercise Turn to neighbor and tell him/her three things for which you are grateful As you listen, extend compassion and feel grateful that this person trusts you.

33. Strategies: Spiritual

34. Spiritual Strategies include: • Forgiveness • Extending compassion • Art and music • Time in nature – Grand Canyon perspective • Reading inspirational stories • Healing Touch/Therapeutic Touch/Reiki

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

36. Research for Stress management: questions • Which subjects? • Parents or other caregivers (Special Needs, Cancer, Other conditions; single parents; dads vs. moms; older vs. younger; only child vs. multiple children) • Nurses (Inpatient, Outpatient) • Physicians (Practice, training) • Other conventional (social work, pastoral care, pharmacy, PT, OT, RT) • CAM providers • Combine? Compare?

37. Research for Stress management: questions • Which Intervention? • MBSR • Other meditation • Hypnosis/Guided Imagery • Biofeedback • Positive emotions or intentions (gratitude, compassion) • Control? • Placebo; exercise; music; CBT; education; medication; another intervention?

38. Research for Stress management: questions • Which delivery strategy? • MBSR standard vs. light (4 weeks) • Individual vs. group • In person vs. on-line • Vs. CD, DVD, or You-Tube video • One time vs. ongoing • Delivered by certified trainer vs. peer • Delivered alone or as part of overall strategy (exercise, nutrition, communication skills)

39. Research for Stress management: questions • Which outcomes? • Self-report: Stress, Burnout, Mindfulness, Wisdom, Memory, Serenity, self-esteem, relaxation, connection, QOL (physical, mental) • Biomarkers: cortisol, DHEA, Autonomic balance (HRV, EDA, temperature); inflammation; BP; weight; other? • Quality of care (professional vs. parental) • Relationships (Peers; family) • Cost (Absenteeism; turnover; productivity)

40. Other questions • How do • Experience • Expectations • Marketing • Demographics • Other illnesses/conditions • Preferences for training • Affect response to intervention?

41. Participant-Centered Research? • Among nurses, WHAT ARE • Experiences • Expectations • Demographics, and • Disease characteristics of those interested in stress management? • How do they relate to preferences for training type, delivery, and outcome measures? • Are they willing to be randomized?

42. To take the survey (or borrow it and adapt) • http://www.surveymonkey.com/s/Nurses_Self_Care_with_Mind-Body_Practices • Or email me at • kkemper@wfubmc.edu • IRB approved • Data to be analyzed in July

43. Sneak peek • First 250 responders; >95% women • 94% regularly pray (mostly prayer for another’s well-being or health) • 70% already meditate • 38% did yoga • 65% had received some kind of formal training

44. Greatest expected impact: • Physical health: better sleep; overall better health; lower BP, weight; less pain; more vitality • Emotional: more serenity; less stress, better mood,less anxiety • Mental: more mindful; overall better mental health; more discerning; more focus; better memory; less judgmental; more creativity • Social: burnout; greater kindness; better listener • Spiritual:greater spiritual well-being; better connection with God/Higher Power; more centered; more inner peace; more compassionate; greater sense of meaning and purpose

45. Participant Preferences • 10% unwilling to collect biomarker data • #1 value driving training preference? • Scientific data • Reputation of researchers or institution • Religious or spiritual values • Group vs. individual options • Convenience

46. Importance of baseline assessment • Generalizability • Bias: % reporting anxiety (50%), depression (30%), back pain (42%) at baseline? • Recruitment and marketing efforts • Designing interventions • Selecting outcomes

47. Designs • RCT – good if lots of data already known and one can design simple study with 2 arms and 1 primary outcome with confidence • Comparative cohort: QES • Natural experiment • Participant preference • - outcomes (burnout, other?) • -- intervention (standard group vs. webinar vs. CD)

48. Challenges • Funding • Sample size • Analysis • Delivering across distance • Assessing across distance • Collaboration?

49. Conclusion • Stress is common among pediatric caregivers • Stress has negative effects on well-being and quality of care • Preliminary studies have shown benefits of diverse stress management practices • Given the common use and variability among stress management practices and their potential to improve care, studies in this area are a priority. • Do a baseline assessment to assess experiences, expectations and preferences for CAM therapies! • Opportunity for collaborative, participant-centered research.

50. References • Krasner MS, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-93. • West CP, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-8. • Preference Collaborative Review Group. Patients' preferences within randomised trials: systematic review and patient level meta-analysis. BMJ. 2008;337:a1864. • King M, et al. Impact of participant and physician intervention preferences on randomized trials: a systematic review. JAMA. 2005;293(9):1089-99 • Beattie A, et al. Primary-care patients' expectations and experiences of online cognitive behavioural therapy for depression: a qualitative study. Health Expect. 2009; 12(1):45-59.