Well-Being in Health Carers

By Jonathan Egan

There is a problem within the caring professions. The problem being that many staff are reporting that they are feeling worn-out, burnt-out, emotionally and physically depleted, even looking to change their careers or to prioritise their remaining energies to their home-life rather than at work.

If left undiagnosed, this may lead to an increase in staff intending to quit, or worse, developing presenteeism, rather than absenteeism through stress or sick leave.  Presenteeism involves staff coming to work but not engaging with their work with any passion, having a cynical attitude and being irritable with other staff and clients alike.  Their mood will appear flat and lifeless and they will engage with all innovations with a wry scepticism which deflates new staff who arrive with enthusiasm and energy.  It appears akin to a depression, however, the opposite effect of the street-angel, house-devil occurs, these people re-engage when they leave work and their mood returns to normal.

Most people enter the caring professions with a passion for helping another, so what is happening?   Well, recent reviews of the literature addressing burnout suggest that there are a few environmental ingredients, the first being high work-load and low control. Nurses who report that their workload is too high, given their available time, and that their autonomy to choose and prioritise aspects of their work leads to burnout (Bria, Baban & Dumitrascu, 2012). Bria et al (2012) also found in their systematic review of health care workers and burnout that those whom have higher levels of burnout use more emotion focused coping, compulsive behaviours and defensive strategies such as withdrawal, denial and humour.  Personality factors related to developing burnout include high levels of Neuroticism and Introversion. Interestingly high N and low E have been found to be linked to the Type D Personality (Howard & Hughes, 2012).

JE4Christina Maslach refers to burnout as a syndrome which leads from emotional and physical exhaustion to a detached and cynical attitude to work (depersonalization) and lastly leads to reduced personal accomplishment (Maslach, Schaufeli, & Leiter, 2001).

Burnout has been linked to poorer health outcomes in staff.  Stressed staff tend to reach more for the sweet and fatty and their other areas of self-care such as physical exercise become less appealing when exhausted. The cigarette helps to relax and the glass of Chardonnay seals the deal.

The health care choices of staff is important to note- as despite the connection to burnout and poorer cardiovascular health, a recent review of bio-markers related to burnout found none (Danhof-Pont, van Even, & Zitman, 2011). Bianchi, Schonfeld, & Laurent (2015) have gone so far as to call for burnout to be removed as a diagnostic category in ICD-11 which was coded as Z73.0 in ICD-10, as a ‘state of vital exhaustion’ and is commonly used in Nordic countries as a reason why staff cannot attend work on scripts from their GPs. Therefore, our current understanding of burnout appears to need to be focused on our psychological, cognitive-emotional and health psychology models as a better way of understanding burnout.

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A study I presented at last year’s EHPS conference looked at two samples of therapists and psychologists and the psychological factors related to them developing burnout (Egan, Meehan, Carr & Heavey, 2015).  Both the emotional exhaustion and depersonalization measures of the Maslach Burnout Inventory were predicted by immature defences employed by carers.   What does this mean in practice?  When faced with clients, carers can try and manage their sense of ‘I have nothing left to give’ by withdrawing emotionally from the other and then by perceiving the client in a categorical or grossly simplified if not distorted manner.  We tend to dichotomise when stressed, it is adaptive in a war setting to quickly categorise others as with or against us.  Staff then start to treat interactions with patients or clients as a transaction rather than a relationship.  The staff member does not having anything left to give.

Heard, Lake and McCluskey (2011) developed a model which can allow staff to examine the reduction in staff’s capacity to care for others, which occurs when burnout takes up residence.  Using an attachment model they describe how many health carers own self-esteem is linked to their effective care-giving.  In a sense it would be described as defensive care-giving, it leads to the carer feeling better about themselves.  According to attachment theory, the care-giving attachment system is only activated on being elicited by a care-seeker. Unless elicited, the person receiving care from the nurse/psychologist/doctor may be received by the patient as intrusive.  On the reverse side, being ignored by a professional after asking for help will result in a protest.

An additional layer to the burnout syndrome developing is that many staff are excellent care-givers, but poor help-seekers.  They have never learned or learned at an early age that there may be no-one available to give or care-to-give them care. West (2015) in a systematic review of the relationship between a health worker’s attachment style and burnout suggested “Compelling evidence of a link between insecure adult attachment style and negative psychological outcomes associated with emotionally challenging work in health and human services occupations” (p. 585)

A key way for staff to recover from burnout then is to follow the following steps:

  • Become reflective about why you have entered the caring role. How did you care-seek as a child and now?  What type of response did you receive when you asked for help?
  • Notice in the here and now (in work) when you move from your ‘self’ to care-giving, is your response attuned to a care-seeking response from the patient or is it intrusive?
  • Calm yourself from leap-frogging over yourself into care-giving to others
  • Learn to centre yourself in an expansive posture, taking the full space of your body (recent review suggests expansive posture reduces ANS arousal and recution of inflammatory response (Carney, Duccy, & Yap, 2015)
  • Practice diaphragmatic breathing exercise and stay in the here and now
  • Become intimate with your fight-fight-freeze-flop system, calm it when it is misfiring
  • Reach out to others when sad, frustrated or overwhelmed, far more effective than food, alcohol, exercise. The rule is- if the upset happened in a relational context it will best be repaired or processed in a relational context. If the stress is due to overload, then exercise and mindfulness and other actions are entirely appropriate.
  • Lastly, my own research and some recent research in TCD has found that there is little point in distressing after the event, it is ten times more beneficial to try and process in the moment, during the therapy session, the client interaction, than come back to it later. Supervision is also an important buffer from burnout, but only if the quality of the relationship with the supervisor is rated highly by the care-seeker (Hickey & Egan, 2000)!

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