Clinician wellbeing, and, prevention of burnout is recognised as important throughout the healthcare system. Issues such as the complexity of patient treatment, and, uncertainty in final outcomes can be particularly demanding in fields such as oncology. Being in a caring role can produce a sole focus on the “other” without the same attention to the self. Although health care professionals advocate self-care and wellbeing to patients, should clinicians apply such advice to themselves? Is there a need? How can clinicians address this effectively? Does self-compassion have a place in the welfare and resilience of health professionals?
What is burnout?
The World Health Organisation (WHO) describes burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed. Across the various research and clinical definitions of burnout, emotional exhaustion is the most consistent core feature, (Kristensen et al., 2016; Lee et al., 2013). Meanwhile, the other components of burnout as defined in the commonly used Maslach Burnout Inventory (MBI)—depersonalisation and low personal accomplishment—are less consistently found in the varying definitions of burnout, and, actually can be considered consequences rather than causes of burnout (Kaschka 2011).
Is there are need to address burnout in health staff?
Unfortunately, the answer is yes. Increasing demands upon the health care system, and, limitations in resources may make the clinician feel that they need to do more with less. Furthermore, being in a caring role, by necessity, there is a focus on the client. However, this can also mean that clinicians may have less awareness, and, give less importance to their own wellbeing. The statistics can be sobering when looking at rates of burnout, and, distress amongst health care professionals.
Work related burnout has been reported in 69% of Australian junior doctors
Data from the medical profession can be used to illustrate the situation. Work related burnout has been reported in 69% of Australian junior doctors (AMA Survey Report on Junior Doctor Health and Wellbeing. Canberra: AMA 2008; Markwell & Wainer 2009), and in 75% of Australian medical graduates (Willcock et al., 2004).
Burnout can be associated with a number of personal difficulties for the health professional, including depression, marital dysfunction, substance abuse, lower job satisfaction, and, intention to quit work (Kristensen et al., 2005; Kumar, 2016)
In addition to the situation being personally difficult for the health professional, depression and burnout can contribute to adverse impacts for the recipients of the intended care, such as:
- Increased medication errors (Fahrenkopf et al., 2008)
- Self-reported suboptimal patient care (Shanafelt 2002)
- Longer recovery period for patients after hospital discharge (Halbesleben & Rathert, 2008)
- Self-medication with prescription drugs such as benzodiazepines (Elliot et al., 2010, Hughes et al., 1992), which can further impair patient care.
Young doctors (aged < 30 years) have a higher rate of psychological distress and attempted suicide than other Australian young professionals
Ultimately, longer term unaddressed clinician burnout can lead to very high levels of distress, and, suicidal ideation. A report compiled by Beyond Blue states that:
- Suicidal ideation in Australian doctors is higher than the general population
- Young doctors (aged < 30 years) have a higher rate of psychological distress, and, attempted suicide than older doctors, the general community, and, other Australian young professionals
Stressors upon medical professionals are recognised to be multifactorial; and include elements such as staffing for patient numbers, high levels of responsibility, professional culture, and availability of support / mentoring for junior colleagues. Such a situation is concerning, and, has been receiving attention in the media.
Recommendations for staff wellbeing
As a result, Beyond Blue has made the following recommendations for improving the mental health of medical students and junior doctors:
- Promote the importance of maintaining good mental health and wellbeing
- Address the stressful and demanding nature of the work environment
- Systemic intervention to address negative attitudes towards those with mental health symptoms
- Target support for vulnerable subgroups
- Ongoing monitoring of the mental health status of doctors and students
All of the topics highlighted by the Beyond Blue report are important areas for investigation and intervention. However, a meta-analysis comparing person-directed interventions (such as teaching coping skills), versus, organisation directed interventions (such as modifying workloads, staff cohesion and resources), found that “person-directed interventions were more effective than organisation-directed interventions at reducing emotional exhaustion” (Dreison et al., 2016). The remainder of this piece focuses on discussing person-directed interventions that might be useful for the individual health professional to adopt as they carry out their role within the organisation.
Are there effective interventions for burnout in health care professionals?
Despite growing recognition of burnout within medical, nursing and allied health fields, effective interventions appear to be lacking. A 2015 Cochrane review examining 58 studies on interventions to reduce work related stress and burnout, found the quality of evidence for relaxation strategies to be moderate, while other interventions (such as cognitive-behavioural therapies and organisational strategies) were low (Ruotsalainen et al., 2015). Other reviews have concluded that overall, limited progress has been made in amelioration of health provider burnout (Dreison et al., 2016).
More recently, mindfulness based approaches have become an area of investigation for health professional wellbeing and stress prevention. Mindfulness approaches work by training attention towards one’s present experiences in an objective, accepting and open way. Mindfulness based interventions have been found to be beneficial for both general populations and specific patient groups, but the impact upon professional burnout is an area of growing interest. Mindfulness training appears to enhance health professional resilience over time (Foureur et al., 2013, Pidgeon et al., 2014). A systematic review of mindfulness based interventions for health care providers found associated improvements in stress, anxiety, depression and burnout, however there is limited understanding as to the specific mechanisms by which such benefits occur (Lamothe et al., 2016). Another review points out that there are weaknesses in mindfulness research with regard to theoretical frameworks, sample sizes, and, long terms follow up within the area of health professional stress (Burton et al., 2017). Clearly, more work needs to be done in understanding the active ingredients, and, interventions which can be used to assist with clinician distress.
Self-compassion in clinician welfare
Self-compassion is a related concept which incorporates mindfulness, but also includes self-kindness and a sense of common humanity with others (Neff, 2003). As such, self-compassion is not just a way of focussing one’s attention, but also incorporates a sense of care and understanding to the individual who is experiencing the difficult events. It is not the same as self-pity, self-esteem or self-indulgence. Like mindfulness, self-compassion is also a teachable skill which can be enhanced with practice.
Self-compassion is a relatively new approach within the field of psychology, but promising results are being obtained within different populations. However, it is acknowledged that within areas such as medicine “direct assessment of self-care and self-compassion have been limited to date” (Mills & Chapman, 2016). This is an identified gap within the literature regarding health professional resilience and burnout prevention, which potentially has long term implications.
“That there has been scant research into these areas limits clinical practice, medical education, and potentially compromises the preparedness of future doctors” (Mills & Chapman, 2016).
The evidence base for self-compassion in clinician welfare is growing. Recent research studied the associations between resilience, mindfulness, self-compassion, and, emotional wellbeing of doctors in Pakistan. Regression analysis showed that self-compassion was the only significant predictor of emotional wellbeing (Sabir et al., 2018), and thus may hold more promise than mindfulness.
Burnout vs. Compassion Fatigue vs. Empathy Fatigue
There appears to be some confusion between burnout, and, a related term in the literature known as “compassion fatigue”. These terms are not interchangeable. Burnout can be considered a direct consequence of exposure to various work-related stresses, and, can affect a person’s ability to display compassion (Durkin et al., 2016). Compassion fatigue is a more specific term describing the effect of listening / seeing / exposure to traumatising events that others have experienced, and, has been considered a secondary form of traumatic stress (Figley, 1995; Figley, 2002). Put in another way, all workers have the potential to develop burnout, but the demands of clinical practice also puts health care professionals at risk of compassion fatigue. Research indicates that more than a quarter of health care professionals working in cancer care are at high risk of compassion fatigue (Hunt et al., 2019).
Some experts believe that the term compassion fatigue is a misnomer, because it is not fatiguing to extend compassion to others or to oneself. “Empathy fatigue” is the new term used to describe the emotional exhaustion which caregivers may experience. One of the reasons for this shift in terminology is recent neurobiological research that shows the cerebral networks activated by acts of empathy are very different than the areas of the brain that are activated by acts of compassion. Compassion lights up areas of the brain that release positive neurotransmitters such as oxytocin and vasopressin, making one feel revitalised. On the other hand, extending empathy activates brain areas that sense and perceive pain and feelings of stress, resulting in a depletion of feel-good neurotransmitters (Dowling, 2018). In other words, empathy involves the sharing of emotions, and, feeling another’s pain. In distressing situations – such as cancer related anxiety, depression or grief – we may take on the emotional distress of the other person as our own distress. However, compassion goes beyond feeling with the other, to feeling for the other, hence reducing the clinician’s empathic distress (Dowling, 2018).
The research in this area is relatively small but suggests that self-compassion training helps with reducing distress within the self, while also improving resilience and wellbeing. This in turn can help the health professional to increase compassion for others (Durkin et al., 2016).
Compassion in health care – future directions
You may not have heard about “Compassionomics”, which is a branch of knowledge and scientific study regarding the effects of compassionate healthcare. Given the challenges faced by the health care system, including the burnout and mental welfare of clinical staff, several investigations are occurring into this field. It is proposed that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout) (Trzeciak et al., 2017). Watch this space!
The take home message:
Burnout and professional distress is a growing issue which requires attention as it can affect the clinician, patient, the organisation and the broader functions of the healthcare field.
- Health professional distress and burnout can potentially cause serious consequences if left unaddressed.
- Building one’s personal resources can be an effective avenue to address burnout
- Relaxation techniques and mindfulness are evidence based skills to assist with burnout
- Self-compassion cultivation is an approach which should be considered by health professionals
- Test your level of professional burnout and distress by the Professional Quality of Life Scale (PROQOL) proqol.org
- More information on self-compassion self-compassion.org
- Book “Effective Self-Care and Resilience in Clinical Practice” by Dr. Sarah Parry
- Compassionomics http://dx.doi.org/10.1016/j.mehy.2017.08.015, https://www.compassionomics.com/
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Dowling, T., (2018). “Compassion does not fatigue!” The Canadian veterinary journal= La revue veterinaire canadienne 59: 749-750. https://europep,mc.org/articles/pmc6005077
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