When you come to the end of your rope, tie a knot and hang on.
—Franklin Delano Roosevelt
Kylie was accepted into a Physician Assistant Program after earning a biomedical engineering degree and working 5 years in the health IT industry. She had experienced a serious health problem and was inspired by a physician assistant (PA) who was especially instrumental in her care and recovery. Emergency medicine was her first love, and 1 year after graduation, she secured a position in an inner-city emergency department (ED) where she has practiced for the last 5 years. Weeks of 12-hour shifts caring for critically ill COVID-19 patients had pushed Kylie to the brink. “I am exhausted, depressed and I do not feel safe. I can’t even visit my Mom who has dementia for fear of infecting her. I tried to talk to the ED director who is usually so understanding, but she brushed me off, ‘This is what we signed on for so stop complaining and go with the flow!”—difficult to do when the flow is a tsunami. Like many health professionals working in modern health care, Kylie is reconsidering her career choice.
Secondary stress represents the stress caused by the pressures placed on professionals who care for others in need. To understand the causes, symptoms, and prevention/mitigation interventions, it is helpful to break down secondary stress into three components:
One of the earliest researchers of the human stress response, Hans Selye, described the general adaptation syndrome in which the body responds to stress of any kind with a unified defense mechanism. This reaction to stress can raise the body’s resistance to stressful agents both physical and psychological and can also be used to protect against illness. However, when the reaction is faulty or overly prolonged, it can also produce disease and even death.1 An exploration of the components of stress highlights the many systemic stressors in medicine and nursing that must be faced as well as the inner resources and personal growing edges that will emerge in the process of meeting them.
Facing stressful obstacles is like tacking through rough waters. In his book First You Have to Row a Little Boat, Richard Bode describes this approach quite well:
To tack a boat, to sail a zigzag course, is not to deny our destination or our destiny—despite how it may appear to those who never dare to take the tiller in their hand. Just the opposite: It’s to recognize the obstacles that stand between ourselves and where we want to go, and then to maneuver with patience and fortitude, making the most of each leg of our journey, until we reach our landfall.2p49
“Tacking” is an ideal metaphor for the way medical and nursing professionals must face pressures in general and chronic secondary stress in particular. To ignore what must be faced or to simply seek to take everything head on may be disastrous both personally and professionally. On the other hand, knowledge about the mechanisms of secondary stress and our unique responses to stressors may help us to psychologically tack the stressful waters so we can make the most of all that we face as caregivers.
Chronic Secondary Stress
Russian playwright Anton Chekhov once proclaimed, “Any idiot can face a crisis—it’s this day-to-day living that wears you out.” A 2006 study of Minnesota medical students reported a 45 percent rate of burnout including emotional exhaustion, depersonalization, and a low sense of personal accomplishment. The study results also revealed that in addition to work related events, negative personal life events also correlated highly with the risk of burnout.3
Eiser4 asserts that physician depersonalization is associated with worse patient outcomes. “Burnout begets lower patient satisfaction as the physician also experiences dissatisfaction” (Eiser AR, Ibid., p. 135). He attributes this phenomenon to the decline of physician status in society, where physicians “were expected to make great personal sacrifice, but also . . . occupied a position that was honored and rewarded both financially and emotionally” (Eiser AR, Op.Cit., p. 135). In concert with Eiser’s4 views, Clever, also a physician, aptly notes, “We cannot relieve the suffering of others if we, ourselves, are suffering.”5,6p393 Such unfortunate suffering can occur slowly, quietly, almost imperceptibly.
Burnout is also reported in studies of PAs and nurses. In a study of PAs, Coplan et al.7 reported that PAs’ experience modest levels of burnout. Study participants reported spending too many hours at work and more female PAs than male PAs (32.2 percent vs. 25.6 percent) have left a position because of stress.
The American Nurses Association conducted a health risk appraisal of 13,500 registered nurses between 2013 and 2016.8 This study, which has served as the impetus for the American Nurses Association’s Healthy Work Environment initiative, revealed that 82 percent of responding nurses cited workplace stress as a health risk. The culture of health care has evolved into a crucible of stress for all health professionals who are committed to caring for others but who need also to care for themselves.
In the novel The Case of Lucy Bending, the psychiatrist laments in a way that rings all too true for medical and nursing professionals in real life:
Most laymen, he supposed, believed psychiatrists fell apart under the weight of other people’s problems. Dr. Theodore Levin had another theory. He feared that a psychiatrist’s life force gradually leaked out. It was expended on sympathy, understanding, and the obsessive need to heal and help create whole lives. Other people’s lives. But always from the outside. Always the observer. Then one day he would wake up and discover that he himself was empty, drained.9p42
An Insidious Unnecessarily Unhealthy Culture
Communications theorist Marshall McLuhan once posed the following question: “If the temperature of the bath rises one degree every ten minutes, how will the bather know when to scream?” In no setting is this question a more apt one to consider than in health care settings that contribute to the unhealthy lifestyles of their staffs—oft times under the guise of requirements for good patient care. Summers and Summers’s recent book Saving Lives: Why the Media’s Portrayal of Nursing Puts Us All at Risk is a stark reminder of how the media reinforces myths and stereotypes of nurses. They point to the international nursing shortage as a symptom of how the nursing profession is generally portrayed as
a critical factor underlying the shortage is the huge gap between the actual nature and value of nursing, on the one hand, and what policy makers, career seekers, and the public at large believe about nursing on the other. Nursing has not received adequate resources because it continues to be seen as a peripheral, menial job for women with few other options. Legislative reforms and better funding will not be enough, vital as those steps are. All the numbers measuring the shortage reflect what starts in our minds. The shortage cannot be resolved until public understanding improves. We must change how the world thinks about nursing.10p20
The news media’s portrayal of nurses during the recent COVID-19 pandemic may generate a more realistic image of nurses, their extensive knowledge base, and their deep practice skills, given the media’s characterization of “nurses as heroes.” This positive portrayal also extends to all other medical practitioners, particularly first responders and those who staff emergency departments and intensive care units. On the other hand, the recent pandemic has created unprecedented stress for medical and nursing professionals who risked their health to care for others in environments ill prepared for the task with respect to the availability of personal protective equipment, testing, treatments, and hospital capacity. It is a historical fact that societies learn from pandemics, improving infrastructure and intervention as a function of lessons learned. Will the lessons of COVID-19 extend to improving clinical environments and ameliorating the stress of medical and nursing professionals, the health care system’s most precious commodities? Or will the pandemic experiences of medical and nursing professionals discourage others from seeking health professional careers?
During a grand rounds on the topic of medical practice and secondary stress, we discussed the important balance that needs to be met. On the one hand, contemporary medicine is intense—long hours, poor staffing, life and death decisions, lengthy documentation requirements, and relationships with staff and patients all take their toll. On the other hand, there are elements in health care that have crept quietly into the culture that can be applied individually or systemically in ways that lessen unnecessary stress. For example, policies can be enacted to prevent workaholism, sleep deprivation, and other stressors of training instead of viewing them as part and parcel of the practice scene. If this is not done, the problem just perpetuates itself. As one practicing physician, who was interviewed for a study on residents in family medicine, said about the carryover of the time pressures he experienced in training, “You may be able to get out of the residency, but it’s real hard to get the residency out of you.” Careful examination of this situation though can lead to other, more hopeful conclusions. These points and a myriad of other factors make it imperative that we have a greater understanding of chronic secondary stress (burnout, compassion fatigue) if self-understanding and care are to be based on sound awareness of the challenges and dangers present in health care.
Definition and Causes of Burnout
Edelwich and Brodsky, in one of the first academic book-length treatments of the topic of burnout, defined it as a “progressive loss of idealism, energy, and purpose experienced by people in the helping professions.”11p14 Freudenberger, who coined the term burnout, described it as “a depletion or exhaustion of a person’s mental and physical resources attributed to his or her prolonged, yet unsuccessful striving toward unrealistic expectations, internally or externally derived.”12p223 Since Freudenberger introduced this term, the concept of burnout has been questioned as to its necessity because the same symptoms and signs are seen in other disorders (depression, anxiety). However, many in the field, believe that the term is still quite helpful in highlighting and validating the extremes of stress that can be experienced by medical and nursing professionals. Moreover, the term burnout represents a comprehensive way to look at the emotional stress that health care workers uniquely experience in their work. The United Nations Policy Brief on COVID-19 and the Need for Action on Mental Health each point to the immediate need for services for frontline clinical workers in the COVID-19 pandemic.
First responders and frontline workers, particularly workers in health and long-term care play a crucial role in fighting the outbreak and saving lives. However, they are under exceptional stress, being faced with extreme workloads, difficult decisions, risks of becoming infected and spreading infection to families and communities and witnessing deaths of patients. Stigmatization of these workers is common in too many communities. There have been reports of suicide attempts and suicide death by health-care workers.13p11
The causes for burnout are legion. As Pfifferling helps us to appreciate, trying to pin down one source of impairment that health care professionals need to be aware of is futile: “As with diseases or conditions that do not have a single cause, there are multiple suggestions, as to the origin, contributing factors, and types of susceptible hosts.”14p3
In an article on the topic of burnout, psychiatrist James Gill wryly notes that “helping people can be extremely hazardous to your physical and mental health.”15p21 His timeless description of who might be good candidates for burnout follows:
Judging from the research done in recent years, along with clinical experience, it appears that those who fall into the following categories are generally the most vulnerable: (1) those who work exclusively with distressed persons; (2) those who work intensively with demanding people who feel entitled to assistance in solving their . . . problems; (3) those who are charged with the responsibility for too many individuals; (4) those who feel strongly motivated to work with people but who are prevented from doing so by too many administrative paperwork tasks; (5) those who have an inordinate need to save people from their undesirable situations but find the task impossible; (6) those who are very perfectionistic and thereby invite failure; (7) those who feel guilty about their own human needs (which, if met, would enable them to serve others with stamina, endurance and emotional equanimity); (8) those who are too idealistic in their aims; (9) those whose personality is such that they need to champion underdogs; (10) those who cannot tolerate variety, novelty, or diversion in their work life; and (11) those who lack criteria for measuring the success of their undertakings but who experience an intense need to know that they are doing a good job.15p21
Most researchers and authors on the topic of burnout have developed their own tailored list of the causes of burnout (Box 1.1), but
there is much overlap, and all seem to point to the problem as being a lack that produces frustration. It can be a deficiency—the lack of education, opportunity, free time, ability, chance to ventilate, institutional power, variety, meaningful tasks, criteria to measure impact, coping mechanisms, staff harmony, professional and personal recognition, insight into one’s motivations, balance in one’s schedule, and emotional distance from the client population. . . . And because these factors are present to some degree in every human service setting, the potential for burnout is always present.”16p336
Consequently, every healing professional is in danger of impairment in some way to some extent. Yet, care is provided in most settings only to those professionals who are so seriously impaired as to be required by their state boards to seek out help. Although programs for impaired medical and nursing professionals are essential, as in the case of physical problems or addictions, prevention or early treatment is obviously a preferable step to later intervention. However, as reported in the Annals of Internal Medicine,
Self-care is not a part of the physician’s professional training and typically is low on a physician’s list of priorities. “Physicians deal with [other people’s] problems all day, but they’re the least likely to raise their own personal problems. They don’t easily admit that they’re under stress,” remarked [neurologist T. Jock] Murray. Approximately one third of physicians do not have a doctor according to a study that examined graduates of the Johns Hopkins School of Medicine.17p145
This lack of attention by physicians to self-care can effect patient outcomes according to Halbesleben and Rothert’s18 study of 178 matched pairs of patients and the physicians who cared for them. The depersonalization dimension of physician burnout correlated with patients’ lower satisfaction with their care and longer post discharge recovery times. Self-care should be a significant component of all health professional curricula.
Box 1.1 Causes of Burnout
16. Extreme change during times in life when maturational crises and adjustments are also occurring (e.g., a 48-year-old physician who is being asked to work with patients diagnosed with cancer at a time when she has just been diagnosed with cancer herself)
In an earlier work on effective emotional management for physicians and their medical organizations, Sotile and Sotile cluster some of the research on physician stress under the theme of “betrayal.”19 To use their wording, “Remember: Stress that is highly demanding but also meaningful and controllable is healthy stress, not the sort that promotes burnout. Our counseling and consulting experience suggest that what really stresses physicians is feeling betrayed, or double-crossed.”19p336 What is meant by this “betrayal” is illustrated in a quote by a physician from a Canadian survey by Sullivan and Burke:
I believe that most physicians unconsciously contracted with society to pursue their profession to the utmost of their ability and energy, to keep up their skills and do whatever was needed to promote patient care. In return, we expected respect, the equipment to do the job and freedom from financial anxieties. All 3 of these expectations have been abrogated, yet we continue to fulfill our side of the contract in confusion, disbelief and a sense of betrayal.20p525
Eiser resonates with this point of view asserting that
physician morale globally is one of mutual distress. . . . The loss of status of the health professional reverberates through the clinical encounter and adversely affects patients as well as the physicians themselves. The social forces that wrought these changes include the extensive media coverage of medicine’s fault, electronic communication, loss of community, moral relativism, consumerist ideology, corporate control of medical practice.4p135
Loss of autonomy and status engenders conflict within work relationships and at home. Loss of autonomy occurs you realize that you are no longer making decisions and choices based on what you value and identify as important and that your decisions are having less impact to the degree that you seem to have no control at all. Thus, work becomes less satisfying and meaningful. The advent of corporate health care and large, impersonal health systems, practice by protocol, and new insurer norms has resulted in physicians, PAs, and nurse practitioners experiencing a dramatic decrease in a sense of control. When the impact of this starts to psychologically “infect” a health care organization, it can set the stage for group burnout, because negativity is so emotionally contagious.
Changes in patient–physician relationships and conflicts with peers, staff, and administration are the other two areas on which Sotile and Sotile focus.19 In relationships with patients, it is easy for health care professionals to identify with the stress that can arise from interactions with persons who relate in a difficult manner. There are classic styles that fit into this category (e.g., passive aggressive, overtly hostile, demanding especially with respect to time, etc.). One colleague recently quipped: “I really think there are only five difficult patients in the world and they just move from hospital to hospital.” Eiser cites the postmodern organization, characterized by ambiguity, a flattening of traditional hierarchies and shifting power relationships, as a tsunami of stressors effecting medical and nursing professionals as well as hospital administrators.4p139
Sometimes a patient becomes difficult to deal with for a myriad of reasons (e.g., the health care professional is exhausted from being on call all night or completing a 12-hour shift), and this inadvertently exacerbates the situation. In one observation of interactions in a pediatric emergency department, the observer noted the different styles of workers and their effect on one patient. A 30-year-old woman brought in her youngest child, a 1½-year-old, who was having respiratory problems and a rising fever. When she first brought the child in at midnight, both the physician (who was struggling with English) and the nurse listened carefully to the problem, explained possible causes, and suggested several approaches. Once there was agreement on the approach, treatment was careful, kind, and swift. The mother of the patient reported great satisfaction with the treatment provided for her child and the information given to her.
When the woman had to revisit the same emergency department the next morning to clarify one of the forms of treatment and to request assistance with it, she encountered three physicians and a nurse when she entered the unit. She noted that not one of them stood to greet her or made eye contact. Instead, they remained focused on their tasks, writing notes and talking on the phone. As the mother explained her needs, they seemed confused and impervious as to how to meet them. As the woman became more fearful about whether her needs would be met, one of the physicians became more strident as to what she should do. When the woman expressed anger, rather than letting her vent and express understanding as to how she felt, the physician kept repeating to the child’s mother, “You are not listening. You are not listening!” The physician in question did not seem to realize that the patient was not the only one having a problem listening. The physician was not perceiving the emotions masking the fear this mother was experiencing concerning her child. The situation could have been managed much differently before it became a stressful situation for both the patient and the physician. The overall lesson is that there is enough unavoidable stress in the health care setting without communicating to both patients and colleagues in a way that unnecessarily increases stress. When patients, particularly pediatric and geriatric patients, and their families, have increased stress due to poor physician/nurse-patient communications, it is the caregiver who ultimately is the recipient of the patient’s ire. However, it is difficult for some medical and nursing professionals to develop a sufficiently sound level of self-awareness to discern the nuances of patient communication on every occasion. However, increasing self-awareness is a self-care goal that should be seriously pursued. Self-awareness leads to more effective self-regulation, the conscious planning or responses instead of automatic reactivity. (See the discussion in Chapter 3 on approaches to self-awareness.)
In terms of conflict with peers, staff, and administrators, Sotile and Sotile rely on a 1999 survey conducted for the American Academy of Physician Executives, which elicited types of conflicts experienced in health care environments.19 Eiser also identifies types of conflict experienced by physicians in contemporary health care environments.4 These sources and types of conflict are represented in Table 1.1.
Table 1.1 Sources and Types of Physician Conflict with Peers, Staff, and Administrators
Source: Sotile MW, Sotile MO, The Resilient Physician (Chicago: American Medical Association; 2002)—summarized from Aschenbrener CA, Siders CT, Managing low to -mid intensity conflict in the health care setting, The Physician Executive. 1999;25:44–50, and Eiser AR, The Ethos of Medicine in Postmodern America (Lanham MD: Lexington Books; 2014).
The list in Table 1.1 is only part of the story. The danger of burnout, particularly in the context of the recent pandemic, remains a serious threat to the psychological welfare of health care professionals and those they serve. Therefore, a greater awareness of the form, causes, and manifestations of compassion fatigue or burnout is necessary. It should be noted that compassion fatigue is a type of burnout but with more rapid onset and resolution. The following statements by medical and nursing health professionals should be viewed as less a part of the territory of working in health care settings and more as symptoms of impending burnout that require vigilance.
• Workaholism: “I need to constantly check my email and phone mail even when I am not working on the weekend.” “My husband and I need to earn a down payment for a house, so I have to work more shifts than I’d like.”
• Isolation: “I really don’t feel part of things on the unit. The other nurses (physicians, emergency medical services personnel, X-ray technicians, respiratory therapists, etc.) are nice people, but I feel so different and removed from them. I never discuss my work or personal life with any of them.”
• Boredom: “I am so tired of doing the same thing every day. When I’m not killing myself, I’m bored to tears. If I hadn’t invested so much in this field already, I would get out. I can’t wait until the end of a shift.”
• Depletion: “I feel it is taking me longer and longer to do less and less. I no longer feel the passion about the job as I did in the past. I am tired before I begin. I don’t quite dread going into work, but it certainly is getting to that point. All I think about is the job.”
• Conflict: “Everything seems to get on my nerves now. I argue with the patients, am irritable with the staff, and am no fun to be with at home. I also resent having to deal with patients’ families and feel that everyone is asking too much of me.”
• Arrogance: “I wish I didn’t have to deal with such incompetent co-workers. Also, I wish the patients would just do what I tell them and not ask so many questions. One even had the nerve to ask for a second opinion when I told her my diagnosis and treatment plan.”
• Helplessness: “I am not sure I really can do anything to change my situation. This is the workload I must deal with, plain and simple. I know if I complain, I might be fired. Also, my sleeping is often disturbed, I have no time for family and friends, my sinuses are always bothering me, and I know I drink too much coffee in the morning and wine in the evening.”