Patient Navigation During COVID-19

August 8, 2020

The importance of nurse navigation and patient navigation through the COVID-19 pandemic.

Nicholas Bove: Hi, everyone. It is such a pleasure to be with you all today. I'm Nick Bove from Pfizer Oncology. Thank you to Komen, to CURE, to the speakers, to all of you for allowing me to participate in this event. On behalf of Pfizer, we are so proud to be a sponsor for this event for the fourth year in a row, I believe since its inception. More importantly, I wanted to express my thanks to all of you for the work that you do. Pfizer and I are very committed to supporting patient navigation. We see it as a critical role in supporting patients and ensuring they have the best possible care. So, thank you to that. And I also want to take a moment to highlight a tool that might support some of your efforts as navigators, Jennifer, I'm not sure if we can pull it up or not. But you might see on your screen now or if not now later a screenshot of our patient navigation tool, which some of you are familiar with. This is actually a toolkit that was developed in collaboration with AONN and is now available as a free download on a website. You might see it but it's patientsnavigation.com. I can't actually believe that we got that domain name but it's patientnavigation.com. There is a main toolkit which does a great job of reviewing ... There it is, it does a great job of reviewing the history and evolution of navigation, the core competencies of navigators, different models of navigation. As many of you know, there's so many different types of you out there and community health workers and the role of the navigator along the care continuum. And also have some very practical guidance on metrics and professional development. And new this year are two additional inserts that focus specifically on metastatic breast cancer and advanced prostate cancer. So those are just in addition to the main toolkit. They're wonderful resources, we hope you can take advantage of them and if you really wanted a hardcopy, you can reach out to me or any of your local Pfizer Oncology representatives or account managers will find a way to get you a hard copy if you do want that. But now on to the main attraction. Now I am happy to introduce the upcoming session on the topic of compassion, fatigue and burnout. This is also a topic that myself and Pfizer believe is very important. We hope you'll learn a bit more about it, how to recognize burnout, and ultimately learn some tips on how to make sure you're taking care of yourself so that you can take care of your patients and your loved ones. We need you guys healthy. So, our amazing emcee Dr. Jennifer Klemp will be our speaker on this topic. She needs no introduction. But I did want to thank her for all her hard work and support. She's just done so much behind the scenes. So, thank you, Dr. Jennifer Klemp. You're awesome. I'm, I'm happy to have you here to give a mini version of this lecture on compassion, fatigue, and burnout. So please, without any further ado, take it away, Jennifer.

Dr. Jennifer Klemp: And I'm going to pop back here one second because I think what you brought up about the navigation toolkit is such a great resource. As you mentioned, you've been working on this for over a decade as a company, I'm really committed to these above brand discussions where, you know, all of us are struggling with implementation of services and advancing care. I think that because you've aligned with the Academy of Oncology Nurse and Patient Navigators, to really hone in on the metrics and, and build this toolkit, and it helps with some of our afternoon discussion, where we talk about certification, and really dive into some of that standardization. So, I think we're a segue to take care of yourself, take care of the role of navigators and thank you for that introduction and those kind words. So today we will talk a little bit about compassion, fatigue and burnout. This is my disclosure statement. I think it's always important in this world of transparency. I have research funding; I do work with several companies including Pfizer and I personally have a vested interest through my endeavors of committing to helping distribute and disseminate point of service care. So that is what I am committed to. Because I think it's so important for patients to get the best evidence-based care they can close to home. So today we'll talk a little bit about kind of compassion fatigue and burnout. What are the risk factors we should look for? What's the cost of this? And how do we sharpen our tools and really get our toolkit ready to go, not just for COVID, but when we work in oncology, when we kind of live in a world that's constantly changing and is pretty stressful. I think these tools can be pretty universal. And we really do need to focus on how we develop and implement tools for ourselves and our family. So, I wanted to start with just some right sizing. I think it's important to know that pretty much all of us experience compassion fatigue at some point, but burnout is sort of the next step to that. And so, compassion fatigue and burnout are sort of on a continuum. And all of us every single one on a single individual on this call today, and participating in the town hall, everyone really, who works in patient care of any sort, we have compassion, we work and are drawn to oncology because we want to care for others. Maybe we have a personal story, someone close to us, whether it's a friend or a family member, and we really do have that need to advocate on behalf of others. And I think the important part is that this kind of under compassion, somewhat defines navigation, right? We advocate we promote, and really have that empathy for our patients. Compassion fatigue is where that best intention now gets to the point where we're a little bit exhausted physically, emotionally. We start pulling back a little, it's a little much. And we're not probably the happiest or the best version of ourselves. We're starting to sort of tip over into burnout, which is full-on we're done. We've had it, we are exhausted mentally, physically. Now we're isolating. And we're pretty cynical. So, I think the important part about this continuum is it's just like any other continuum. We need to identify the risks, we need to intervene, we need to get educated, and we hopefully need to mitigate so that we don't tip to that final point of burnout. And we're really stopping things before we hit that point. So, let's normalize this discussion. Compassion fatigue is common. It is on the rise. It affects all types of health care workers, and in particularly those who are more on the front line, it often affects them more. There is a high cost and when we talk about cost, there is a significant cost to the health care system, which maybe we don't think about. But there was a study done just looking at physician burnout. And we're talking in the billions, anywhere between almost $3 to $6 billion worth of lost productivity and revenue to the health care system because of burnout. And so when we put it at that level, there is a bigger incentive and motivation to really address this. But we also have to look at our personal cost, what is the cost to our satisfaction, to our family? What are we giving up? What are we impacting in a negative way? And so, there's an enormous cost in the universal term, to really think about how this impacts the larger social picture, but also what's more in our backyard. And then obviously, this has increased due to COVID-19. So, there's a lot of sort of awareness that's been made around compassion fatigue, and burnout. Not only because oncology and cancer care, and really dealing with populations that are potentially more at risk and challenging, but now we throw in a pandemic. And that's really kind of taken us over the edge. So important to think about in general, and then even more so during COVID-19. So, there's a really nice resource. And I recommend that you guys kind of look at this, these slides and that resource will be available to you after the talk, but it's by the National Academy of Medicine, and it's literally called "burnout among healthcare professionals a call to explore and address this unrecognized threat to safe, high quality care." And so it highlights not just physician burnout, but it talks about nurses, it talks about sort of across the field, different types of health care professionals, and how you know, it's more common than we think, how it impacts us, and really some strategies and other organizational sort of priorities of how this should be brought into our organizations, our hospitals, wherever we reside as a health care professional. But I definitely think that this tool is worth reviewing, and unfortunately shows the increase in higher incidence and risk than we probably would think about in regard to the symptoms and signs of compassion fatigue and burnout. So, do access that resource. It's free and worth downloading. So, what are some of the risk factors? What are the things that are leading us to sort of this potential state of compassion fatigue, well, long hours, right? And it's not just long hours at work, it's long hours, you know, once we get out of work as well. So, we have sort of these competing factors. We have the time pressure we see here, we have family responsibilities, how many of you with children at home, you've become teachers, you've become educators. And so, there's really a lot of competing factors that you didn't have maybe six months ago. Maybe you're also dealing with the isolation of not seeing your parents or your older family members like you used to. So there's a lot of competing factors for long hours, that don't just have to do with the workplace, but also have to do with the additional responsibilities, or sort of the situations that we're dealing with that have really exacerbated our risk and symptoms of compassion fatigue. The additional workload, I think we've heard some prime examples today. Within two weeks, you've gone from being maybe okay at telehealth, maybe you use some zoom, maybe you use some WebEx, but now you're living on Zoom. I think my average per day is seven hours on some web platform. So not only do I feel unhealthier, sitting in this chair in my little home studio I built, I also feel like I'm fatigued. And I don't know if others feel this way, but I know my colleagues and I, when we sort of get together often on Zoom, we talk about how sometimes we almost feel more exhausted after being on Zoom all day with patients and meetings, versus being in-person where you seem to have a little bit more of a ebb and flow to your day. So, the administrative workload, how we are documenting, how most people feel like their days have actually gotten a lot busier. But then you also have individuals and different employers who've had to furlough employees. So maybe you're trying to pick up additional work to make ends meet. So, these are a lot of competing factors that really put a lot of pressure on us in regards to workload. When we talk about patient care, and we're laying layering on, you know, safety measures and we have patients who were by themselves for a long time, and now they're able to maybe start bringing in one of their caregivers, you know, we have a lot of different competing factors when it comes to the patient care aspect. And the interesting part about this is that the biggest complaint that I've heard from both sides of the fence is that what is one of our most basic instincts? We connect with people (and) we connect through our facial expressions, maybe by touching them on the arm, or patients who need or want us to give them a hug. All of these things are off limits, they can't even see our facial expressions, they can't have us give them a quick pat on the arm of reassurance. So, a lot of that direct patient care has been impacted. And it does sort of hit the core of what we're used to, as we connect with our patients. And now we're connecting by phone, which is a little difficult, maybe a little bit easier by Zoom or other technology. But as you can see, there are things that happen. We lose connectivity. We've heard that a lot of our patients are just not that good with technology. So, we're having to become IT support people to be able to make sure that our patients know how to use the technology effectively. There's also this decreased of autonomy where we feel like we're sort of being watched more or supervised more. I know that many of the work from home people feel that they have to be logged into their computer, their employers tracking that there is a whole lot of feeling like there is less independence in our day to day role. And that can be very frustrating and a little bit demoralizing. We don't have as much time then for pleasurable or meaningful activities. We can't see a lot of our friends and family. Many of us as I mentioned, in the earlier session, my last travel was at the end of February to Miami Breast. So, thank goodness it was for something obviously, it was fabulous. The conference was great, but it just shows you that we are used to kind of being a mobile society and we've been locked down and that's really challenging, because that activity of getting out, of seeing our friends and family is so important to us. And then obviously the ongoing stressful situations that we deal with in our day-to day-work. There's chronic conditions of patients living with, and through, their cancer, we're dealing with death, we're dealing with health inequities to begin with. And now COVID is brought up even more health inequities. So those day-to-day stressors, which we had a lovely session where we just talked with Dr. Newman and Dr. Fairley about a lot of the health inequities that we are dealing with. And we know that these stressors are not just temporary, these are ongoing. And so how do we put those into context? So, there's some kind of risk that we should look for, right? We had the risk factors. So now what are the symptoms, and here's sort of a list of symptoms. Maybe we're doing more unhealthy behaviors. We're not eating those fruits and vegetables, like we were told in an earlier session. We're hyper aroused, we have shorter fuses. We avoid things, we just don't want to deal. So, we're checking out, we're re-experiencing sort of negative thoughts. We're forgetting things, we're indecisive. And our motivation is waning. These are all sort of symptoms of compassion fatigue, and things that we should be inventorying. Now you can inventory these, there's some nice quality of life tools out there. And in particular, there's one that many of us use that we can share if you're interested. But I think you know, just reviewing yourself, just like we do with our patients, what sort of their need’s assessment or their distress screener, that's sort of what we need to do for ourselves. And then once you hit into that category of burnout, you're really seeing things sort of elevate to a different level of impatience, hyper arousal is there but now we're super impatient. We're emotionally exhausted. We have sort of clouded judgment. We're super cynical. We feel ineffective, we don't have that value of being able to what I like to call sort of you feel good about yourself, you can self soothe all those things that make us an independent, successful person. We just don't feel that way. And people get withdrawn. So, I think that as you look at these symptoms, once again, there's some standardized tools to use if your organization is interested, but just thinking through, you know, am I on this spectrum? Where am I falling? And how do I start checking and balancing myself, so I don't tip over the edge. So, I love this, right? Why can't we just have an FDA approved drug to help us treat burnout and compassion fatigue? I'm not going to read the term off because actually, you could say it in a way that probably isn't PG-13. But I think the fun part about this, which was out last fall, as we started really realizing the importance of compassion fatigue is that we don't have, you know, this, this magic pill or this quick fix. This is a systematic, you know, sort of social issue. This is an organizational issue. This is an individual issue. And so, we need to start sort of taking that from all those different levels. And hopefully, you know, realizing and supporting each other as we prevent, and hopefully mitigate compassion fatigue and burnout. So, what are some of these strategies? Of course, we hear this all the time, you got to fit your own mask before you start putting on other people's masks. And that's for sure, you know, we cannot really extend ourselves if we're not taking care of ourselves. So, we need to be self-aware. We need to do that sort of personal needs assessment. We need to talk to colleagues. And that I think is one thing that's happened as a result of COVID. My colleagues and I check in on each other, we definitely will text each other and say "Hey, how you doing?" We do Zoom happy hours and that's been fun. But once again, sort of more time on the screen, but definitely a way to connect. And so I think that when we think about COVID, and we think about how we, we need to find some positives in the negative, I do feel like we've connected more with our peers and our colleagues, and check in a little bit more than we used to. And I think that is one of those positives that I hope we can take through COVID not just during or with COVID.

I think there are some providers who are obviously more burnt out than others. When you look at COVID, and what that pandemic did, you have a lot of non-essential care that was sort of put on hold, right. So, whether that be different types of screening or imaging, elective surgeries, maybe it was your dermatologist, you couldn't go in and get a skin screen, but other providers were very busy. Those were hospitalists, oncologists were very busy, (as were) pulmonologists and emergency room providers. So, when you start looking at the disciplines that were sort of thriving during COVID, there was a difference in level of intensity and burnout. But you also had those who weren't as busy. And I think they had a different type of intensity. They also felt, you know, maybe it was financial, maybe it was the fact that they weren't contributing in their day-to-day like they are used to doing, you know, so there is balance on each side of that, but I definitely think those that were still on the front lines, or whose practice, whether it was in oncology, whether it was in ICUs and things like that, they definitely had a harder go and still do in the day-to-day and dealing with COVID and compassion fatigue. Work-life balance is always a challenge. What are those triggers that kind of set us off? Is it getting the alert that you have a Zoom meeting in 15 minutes? And does that just make you have a little bit of anger? So, what do we do? Do we take a deep breath, and we saw from Nancy earlier, she had us hold our breath for 20 seconds to show the patient experience? But maybe we need to do a little bit more mindfulness and reset, so that we can take that breath, we give ourselves permission to take that breath, we push a reset button. My little cat here who's been my coworker all day today has been very good. But periodically just reach over and give them a little pet. And that does allow me to sort of reset, (it) takes my mind off of whatever it is I'm thinking that could be negative. So, our animals, our family, or friends, breathing, mindfulness, all very important things to think about. Are we eating healthy? Are we drinking too much? I did see and read an article that alcohol sales are up 48% over COVID. That's kind of a crazy number. So, how are we balancing that with our healthy behaviors, we do see a lot more people walking and walking with their families, having family dinners with their circle of contamination, as we call it, sort of your circle of trust? So, there's some positives that we've seen, but also the stressors. So, we need to build our tools and think about self-care. What's in our toolbox? What did we used to do that made us feel good? What were some of those things that, you know, we used to practice healthy behaviors? How do we get back to those, and I think this is a really important time to do that. We have a toolkit on our website at the University of Kansas Health System that has to do with resilience. We are all hard wired to be resilient. And if we work in cancer care, if we work in direct patient care, if we work in organizations that support patient care, we are definitely feeling the need to kind of hone our skills and really focus on those key components and facets of resilience. We have the hard wiring, but sometimes we just need to reset. So, I think this is a really important sort of toolkit that you can access. It talks through these different facets. It gives you some at-home skills you can utilize. It gives you some workplace skills, you can empower your teams or your colleagues to utilize. So really important to think about. I think that you know, as we kind of summarize, and we just wanted to give you a quick snapshot, as Nick highlighted about the importance of compassion fatigue and burnout it is real, it's common, we have had a much higher chance of developing some of those signs and symptoms because of COVID. And so, I think that as navigators, as community health workers, as nurses, as administrators, whatever role you are playing, you have felt that additional stress, and so how are you doing dealing with that risk. How are you empowering yourself and using your tools? We know we need to intervene early. But that means we have to be self-aware and scan. We need to be talking to our colleagues. And hopefully they're saying to us, hey, you're a little wiry today. I got a text on a Zoom meeting the other day. And my colleague literally said, you need to simmer down. And I knew what that meant I was getting a little revved up more than I normally would. And we don't have the same way to connect with some of our colleagues like we usually do. So, I think the important part is we do need checks and balances both for ourselves, and we need our friends and our colleagues to help us with those checks and balances. We need our organizations to support the strategies that we would want to deploy. And we heard from Karen in an earlier session, how they are concerned about their employees and their staff. And they're concerned about their kids and their families. So, the important part is that we need to pay that forward (and) we need to practice those behaviors ourselves. And we need to deploy those across our circles of care to our patients, to our colleagues, and to our staff. And there's significant, you know, cost to burnout. So how can we start addressing those early, address them often, and really support the need to intervene with self-care on a daily basis. So, we want to thank you and see if there are any other questions out there. Or obviously, we've hopefully given you some good tools, with the navigation toolkit with the Academy of Medicine toolkit, and the resources for resilience, to help you empower yourselves and your teams to really think about prevention of compassion fatigue and burnout. And, Nick, did you have any kind of final comments you want to make as we sort of finished this session?

Nicholas Bove: Yeah, thank you, Jennifer. I mean, I really appreciate your talk here and just the mere fact of you acknowledging this and helping people to define it, I think is very helpful. Like, sometimes people need to hear it. Although sometimes it seems very intuitive to validate what people are going through, to give it a name. I think it's very helpful. So thank you. It's real. And I think you've walked us through that and helped give us some tips. The only comment I would have, and I'm curious if there's anything from the chat box is, you know, you mentioned a couple practical tips. Any other sort of specific guidance or specific things that people are doing that you think on a day to day basis, while these health care workers or navigators are doing their job that that might help lessen some of that burnout.

Dr. Jennifer Klemp: I think that, you know, sometimes especially as people are working from home, maybe they do feel a little less valued or undervalued. I think as navigators, many have been working from home early on, because they're using obviously telehealth with phone or video as their main source of connection now. So if you're feeling sort of underappreciated or undervalued, then we do need to share that with our administrators, we need to somehow figure out how we acknowledge that the value of the team, and we don't function without our team, right? There is no one who functions well, really in a silo. So how do we support each other? How do we make sure we feel valued? How do we make sure we're communicating effectively? And I think that is one thing that we've seen. So, we did hear earlier in one of the sessions of maybe it's an opportunity for us to do a needs assessment for our teams. Are you getting what you need? Is your home office sufficient? Do we need to enhance that with any additional tools, so probably doing some sort of survey or engagement with those that are still working from home would be helpful, and then also those who've gone back to work. They're probably feeling a little kind of cautious. They're going home to their families that makes them feel concerned. So how are we addressing those ongoing concerns, and making sure that we're being transparent, that we have good communication, that we're doing alerts, whether it's been emails or texts with our teams and our staff? But transparency really is the best way to avoid frustration, and I think sometimes that's hard for organizations, because that's not always inherent in the structure that we live in. And we'll see if there's any other questions that have come in. So, beyond COVID, do we see any specific segments of providers that may be kind of more at risk? Absolutely. I think that you know, as we think about living through COVID, we will continue to have a lot of these, especially responsibility and time stressors. So when I think about community health workers and navigators, one of the most common questions I get, and it's nothing super clear in the even in the metric toolkit is what should my census be, you know how many patients should be on my caseload. These are very individual because your patients each have individual needs. Every patient doesn't need the same level of care. So, we're having to risk stratify and triage, so that ongoing stressor will continue to be there. And so, I want case, you know, our case managers, our patient navigators or nurse navigators to really think about how we're using our time and the highest risk patients need our time. And sometimes that doesn't feel as good because we want to give to every single person. But at the same time, we need to be able to identify those at highest risk. So, we can give those individuals the care and support that they need.


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