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Clinician Self-Care 

Clinician Self-Care
Chapter:
Clinician Self-Care
Author(s):

Emily Chai

, Diane Meier

, Jane Morris

, and Suzanne Goldhirsch

DOI:
10.1093/med/9780195389319.003.0018
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date: 10 July 2020

Introduction

All health care professionals can experience the substantial personal and professional pressures that come with taking care of patients in today’s U.S. health care system. Palliative care professionals face the added challenges of providing care to seriously ill patients and their families who are navigating a very emotional and stressful time in their lives.1

Given the physical, emotional, and spiritual demands of offering compassionate care for seriously ill patients and their families, combined with the organizational and administrative challenges of the health care work environment, palliative care clinicians must develop a strategy for self-care. Whether it is a structured formal practice or an informal collection of self-awareness techniques, all palliative care professionals should integrate practical and effective self-care strategies into the fabric of their personal and professional lives.

Consequences of Neglecting Self-Care

  • Many commentators have pointed to the paradox of health care professionals dispensing advice to others yet personally ignoring advice about leading a balanced life. This is not a new problem for medical practitioners.2 Some providers are just not familiar with the early warning signs and symptoms of unhealthy personal and professional pressures that may be overwhelming them. Or they may know that they are profoundly stressed, but may not be familiar with self-care strategies that can help restore the balance in their lives and help manage the pressures they are coping with in their job.

  • Lack of awareness and/or inability to establish an effective self-care practice can eventually progress to the deep physical and emotional exhaustion of burnout or compassion fatigue.

Burnout and Compassion Fatigue

  • Burnout and compassion fatigue are related conditions. But although they are frequently used interchangeably in the literature, they are not equivalent concepts.

  • Burnout is defined by Maslach as “a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do people-work of some kind.”3 Emotional exhaustion has been identified as the first stage of burnout, followed by depersonalization employed as a coping strategy, and eventually resulting in feelings of reduced personal accomplishment.4

  • Compassion fatigue (CF) is a more recent construct, first used in 1992, and defined as a “deep, physical, emotional, and spiritual exhaustion accompanied by acute emotional pain.”5 Because CF is associated with helping or wanting to help a traumatized or suffering person, it is also referred to as secondary or vicarious traumatization. One theory explains compassion fatigue in the health care professional as the result of extended exposure to the suffering and trauma of others while simultaneously receiving little or no emotional support for oneself in the workplace, and with no self-care practices in place.6

Prevalence

  • Extensive research has confirmed that nurses are particularly susceptible to burnout.7 One study found that 40% of hospital nurses have burnout levels that exceed the norms for health care workers, and that their job dissatisfaction is four times greater than the average for all U.S. workers.8

  • In a large national sample of physicians from several specialties, 46% of responders reported at least one symptom of burnout. Rates of burnout differed according to specialty, with the highest prevalence occurring in “front line” physicians (family medicine, general internal medicine, and emergency medicine).9

  • In a study of students at seven U.S. medical schools, burnout was reported by 49.6% of students, with 11% reporting suicidal ideation within the past year.10

  • Palliative care practitioners have a number of personal and job-related stressors, and the prevalence of burnout is significant. The literature is conflicting, however, as to whether palliative care clinicians have higher or lower rates of burnout than other health professionals.11

Causes, Risk Factors, and Symptoms

Table 18.1 compares the causes, risk factors, signs, and symptoms of burnout and compassion fatigue.

Table 18.1: Burnout vs. Compassion Fatigue: Causes and Risk Factors

Burnout

Compassion Fatigue

Definition

  • State of mental and/or physical exhaustion caused by excessive and prolonged stress

  • Mental distress manifested in individuals who experience decreased work performance resulting from negative attitudes and behaviors

  • “Cost of caring” for others in emotional pain

  • Sometimes known as secondary or vicarious traumatization

Cause

  • Stress arising from interaction with work environment

  • Result of:

  • Frustration

  • Powerlessness

  • Inability to achieve work goals

Stress arising from clinician/patient relationship

Risk Factors

  • Individual risk factors:

    • Early in career

    • Being single

    • Lack of openness to change

    • Triad of doubt, guilt, and exaggerated sense of responsibility

  • Job risk factors:

    • Time pressure

    • Solo practice

    • Inadequate resources

    • Lack of social and supervisor support

    • Lack of information and control

  • Organizational risk factors:

    • Lack of reciprocity/loyalty not rewarded

    • Human services job

    • Must display or suppress emotion on the job

    • Must be emotionally empathic on the job

  • Other risk factors:

    • Previous mental health problems (especially

    • depression)

    • Low “hardiness” or resilience

    • External locus of control

    • Avoidant or passive/defensive coping style

    • Type A personality

  • Individual risk factors:

    • High expectations/idealism

    • Perfectionism

    • Lack of self-awareness

  • Job risk factors:

    • Short intervals between caring for

    • patients

    • No debriefing process

  • Other risk factors:

    • Personality traits of compassion

    • and empathy

    • Personal history of trauma or

    • victimization

    • Working with traumatized and/or

    • victimized people

Signs and Symptoms

  • Overwhelming exhaustion

  • Feelings of cynicism and detachment from the job

  • Sense of ineffectiveness or lack of personal accomplishment

  • Similar to PTSD

  • Hyperarousal

  • Disturbed sleep

  • Irritability or outbursts of anger

  • Hypervigilance

  • Avoidance

  • Desire to avoid thoughts, feelings, conversations associated with patient’s pain and suffering

  • Re-experiencing

  • Intrusive thoughts or dreams

  • Psychological or physiological distress in response to reminders of work

Consequences of Unaddressed Burnout and Compassion Fatigue

Many studies on the impact of burnout on the health care system have suggested that physician burnout may erode professionalism, influence quality of care, increase the risk for medical errors, and promote early retirement.9

Diagnosis

The standard assessment tool for burnout is the Maslach Burnout Inventory (MBI), available from Consulting Psychologists Press, http://www.cpp.com. The MBI is a validated instrument consisting of 22 questions that measures the three classic signs and symptoms of burnout:

  1. 1. Emotional exhaustion: measures feelings of being emotionally overextended and exhausted by one’s work

  2. 2. Depersonalization: measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction

  3. 3. Reduced accomplishment: measures feelings of competence and successful achievement in one’s work

  • The length of the MBI can limit its utility in surveys of health care professionals. Responses to just two questions from the MBI (“I feel burned out from my work” and “I have become more callous toward people since I took this job”) have been shown to help assess burnout in medical professionals when the MBI cannot be used.12

  • Assessment tools for compassion fatigue include the Professional Quality of Life Scale (http://proqol.org/ProQol_Test.html) and the compassion fatigue self-test (http://www.compassionfatigue.org/pages/selftest.html).

Preventive Strategies

  • All health care professionals must attend to self-care and renewal for the sake of themselves, their family, friends, colleagues, and their patients and families. The following recommendations for preventing burnout are based on suggestions from palliative care experts.1,11,13

  • Self-awareness, self-reflection, and self-monitoring: Pay attention to stress level and understand what the triggers are; be aware of personal limits; be clear about reasons for working in the field of palliative care.

  • Techniques for developing self-awareness include journaling, regular conversations with a trusted colleague, and setting time aside for personal reflection.

  • Take advantage of supportive colleagues on the interdisciplinary team to discuss complex cases and explore difficult emotions. Find peers who understand the work and can serve as a sounding board.

  • Utilize regularly scheduled support mechanisms, e.g., formal supervision for practicing therapists or social workers.

  • For new palliative care practitioners, mentoring from a more experienced practitioner can be especially helpful. Experienced palliative care professionals frequently have achieved enhanced appreciation of the existential and spiritual domains of their own life as a result of caring for patients who are nearing the end of life. Rewarding and deeply satisfying benefits include a reciprocal healing process; inner self-reflection; closer connection with colleagues, family, and friends; and a heightened sense of spirituality.

  • Developing a personal support system (family, friends, a supportive primary relationship) helps to maintain the balance between work and other aspects of one’s life.

  • Develop a personal self-care practice as a source of serenity and balance, possibly with a spiritual element such as meditation, yoga, or tai chi.

  • Physical release is just as important as mental activity. Be sure to find time to include exercise in the daily routine.

Table 18.2: Consequences of Unaddressed Burn-Out or Compassion Fatigue

Domain

Consequence

Physical

  • Fatigue

  • Sleeping problems

  • Somatic complaints

Emotional

  • Irritability

  • Anxiety

  • Depression

  • Guilt

  • Helplessness

Personal

  • Depletion of emotional and physical resources

  • Negative self-image

  • Self-neglect

  • Mental illness (anxiety, depression, substance abuse, suicide)

Behavioral

  • Aggression

  • Callousness

  • Pessimism

  • Defensiveness

  • Cynicism

  • Avoidance of patients

  • Acting out (verbally or physically)

  • Poor concentration

Interpersonal

  • Poor communication

  • Social withdrawal

  • Lack of sense of humor

  • Feelings of anger and frustration toward patients, families, colleagues

  • Neglect of family and social obligations

  • Poor patient interactions

Job-Related

  • Quitting

  • Poor work performance

  • Absenteeism

  • Lateness

  • Compromised patient care (increased use of technology, goals of care not discussed, increased length of stay)

  • Loss of boundaries

Importance of Team Support1,12,14

A core function of the interdisciplinary palliative team is to provide meaningful support to team members. Results from studies showing that palliative care clinicians do not experience a higher level of stress and burnout than other health care professionals have been attributed to the support that palliative care team members offer to each other.11

  • Team leaders should facilitate excellent team communication and consistently reinforce the importance of team building, support, and renewal. Specific strategies include:

    • Continual monitoring for sustainable workload

    • Promotion of choice and control for team members

    • Recognition and reward for job well done

    • Facilitating a supportive work community

    • Promotion of fairness and justice in workplace

  • Regular times should be set aside for the team to address difficult situations (patient-related, team-related, system-related) and to engage in problem-solving together.

  • Support groups for medical professionals should be available for team members.

  • Schwartz Center rounds are multidisciplinary rounds where health care professionals discuss difficult emotional and social issues that arise during patient care (http://www.theschwartzcenter.org/programs/rounds.html).

  • Team processes and rituals acknowledge losses and help mourn patients who have died (e.g., memorial services, patient recognition rounds, staff debriefings).

  • Teams should also celebrate their achievements, even in the context of difficult or unsuccessful cases, and find satisfaction in having tried to do the right thing.

When to Seek Treatment

  • The self-help strategies described above, combined with discussion with colleagues and mentors, can help address common stressors encountered by palliative care professionals.

  • For more complex or troublesome symptoms, it is essential to seek professional counseling. Symptoms indicating need for follow-up with a mental health professional include:

    • Continued feelings of sadness, exhaustion, anger, worthlessness, hopelessness, suicidal ideation, or anxiety that interferes with work and relationships

    • Self-prescribing of medications (particularly sedative-hypnotics)

    • Substance abuse (alcohol, prescription drugs, illegal drugs)

    • Excessive or addictive behaviors (gambling, exercise, eating, shopping)

    • Continued sleep disturbance (nightmares, insomnia)

    • Loss of professional boundaries

Take-Home Points

  • All health care professionals experience substantial personal and professional pressures and stresses. Palliative care professionals face the added challenges of providing care to seriously ill patients and their families at a very emotional and stressful time in their lives.

  • Lack of awareness or inability to practice self-care can eventually put palliative care clinicians at risk for the deep physical and emotional exhaustion of burnout or compassion fatigue.

  • Palliative care practitioners have a number of personal and job-related stressors, and the prevalence of burnout is significant. The literature is conflicting, however, as to whether palliative care clinicians have higher or lower rates of burnout than other health professionals.

  • Whether it is a structured formal practice or an informal collection of self-awareness techniques, all palliative care professionals should integrate practical and effective self-care strategies into the fabric of their personal and professional lives.

  • Self-help strategies described above, combined with discussion with colleagues and mentors, can most likely address the common symptoms of burnout. For more complex or troublesome symptoms, it is essential to seek professional counseling.

References

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