The Simple Care of a Hopeful Heart: Developing a Personally Designed Self-Care Protocol

Objectives

• Assess workaholism, happiness and satisfaction in career and life.

• Explore basic stress management strategies for overall health.

• Respect self and others as foundational to managing secondary stress.

• Differentiate toxic work environments from intense work environments.

• Design a personally tailored self-care protocol.

I wanted to change the world. But I have found that the only thing one can be sure of changing is oneself.

—Aldous Huxley

After experiencing 2 years of extreme job stress in a failing healthcare organization compulsively working long hours and dealing with significant family issues, Marta took a “self-care plunge.” She made an appointment to see a therapist. “What am I doing here?” she silently wondered as she sat in the therapist’s waiting area. “I just need to pull myself together and move on.” Just as Marta was about to abandon the appointment, the door opened, and Dr. Paul welcomed her into his office. Marta sat on the couch across from Dr. Paul who opened the conversation, “Tell me what brought you here.” Marta’s mind raced to find a reply, instead she began to cry, then sob. She tried to speak, to gather her thoughts but the flood of tears washed every rational thought away. She cried for at least half an hour and was thinking to herself how wasteful this was. Afterall, these sessions were expensive, and all this crying was wasting time—a typical response from Marta who was driven to succeed—cost effectively. Dr. Paul just sat supportively, saying nothing, handing Marta a tissue from time to time. When the crying ended, Marta tried to answer Dr. Paul’s initial question. She described her extreme work and family issues and admitted needing “guidance.” She could not bring herself to say the word help. Dr. Paul listened intently and then said, “This is a good beginning. I will see you next week—same time?” And the weekly sessions continued for the next five years as Marta learned to adjust her perspective and take better care of herself.

Health care is one of the few professions where it is socially acceptable to ignore your family, your nonwork life, yourself. Workaholism and burnout are increasingly serious problems among physicians, physician assistants (PA), and nurses. For physicians it begins during residency. Shaufeli et al.¹ studied workaholism and related variables among 2,115 medical residents. Using standard assessment scales, they determined that “working excessively” combined with “working compulsively” results in workaholism and its attendant negative results. Compared to their “hard-working” colleagues, workaholic medical residents

• Exhibited higher levels of exhaustion and recovered less well,

• Showed a strong tendency to relate to patients in a more callous or cynical manner,

• Believed that they accomplished less than their counterparts, and

• By their own assessment, performed poorly delivering medical care.

As a prelude to these recent findings, Gabbard and Menninger theorized many years ago with respect to physicians as to why there might be a predisposition to workaholism and burnout:

The demands of practice are a convenient rationalization. Physicians work long hours to deny dependency, to eradicate any trace of aggression or destructiveness that they fear others may suspect; win the unconditional love and approval of colleagues, patients, and community; to maintain complete control; and to conquer the terror of death.^2p35

Whether their theory is correct or not, care must be taken not to be driven in one’s career to the extent that everything else loses value and accordingly does not receive the attention it should.

In an extensive review of studies focusing on the work life PAs by Essary et al., the existing data reveals

• Burnout among PAs is higher in specialties such as primary care, hospice and palliative care, oncology, and primary care.

• Despite reports of burnout in specific specialties, job and career satisfaction remain high.

The authors speculate that the adaptable nature of the PA role “lends itself to specialty transition which may serve as a buffer against the long-term effects of burnout.”³ They also indicate that much more research is needed on the tenor of PA work-life experiences.

In a study of 1,781 nurses, Andreassen et al.⁴ investigated the relationship between workaholism and negative work-related incidents including self-harm incidents like dozing at work or while driving, harming patients, or mishaps with equipment. They found that workaholism was the most consistent predictor of

• Working despite being ill thus increasing the inevitability of negative work events.

• Impaired mental health and accident proneness.

• Diminished recovery after long hours of work.

• Obsessiveness, which contributes to increased self-reporting of negative work-related incidents.

Andreassen et al. concluded that “workaholism is consistently and positively associated with negative work-related incidents, even after controlling for various demographic and work-related variables, and sleep duration.”^4p379

Although being a healing professional is a wonderful life commitment, unless care is taken to ensure that the rest of one’s life is fulfilling as well, one’s life becomes too narrow, limited, and eventually distorted. This can have a negative impact not only on oneself but also on family life and other interpersonal relations.

With respect to the COVID-19 pandemic, burnout and secondary stress among clinicians is now considered a parallel pandemic. Dzau et al.,⁵ of the National Academy of Medicine, Action Collaborative on Clinician Well-Being and Resilience, recommend that every health care organization have a chief wellness officer with a voice at the highest level of the organization. There should be wellness programs for staff and clinicians should be encouraged to speak out about their work conditions and risks. Health care organizations should also be supporting the self-care efforts of the clinical staff. Finally, the authors recommend a post-COVID-19 national epidemiological tracking program to measure clinician well-being.⁵ Investing in clinician well-being will go a long way to improve not only the quality of care but also the long-term health and viability of health care organizations.

In addition to workaholism and the narrowing of one’s horizon so that outside interests, family, and even self are left out, there is the added problem of denial. Most health care professionals would deal with the dangers of burnout or vicarious posttraumatic stress disorder if they were aware of them. They would also view the elements of stress management in a more respectful and serious manner. Stress management includes basic elements (Box 5.1) of which we are aware at some level but do not really “know” at the level of true commitment. When this is so, people who are in intense helping roles pay for this in terms of psychological and physical health—not to mention the havoc it wreaks in the family and on one’s necessary social outlets. If people do not pay for ignoring stress immediately, they do so eventually. The problem with “eventually” is that as in many psychophysical disorders in which psychological stress produces physical changes over time, the damage done that seems so benign or reversible initially becomes, after a period of time, more or less permanent. At that point, even when stress is reduced and personal is self-care enriched, the physical harm already incurred will have chronic implications for the rest of one’s life.

Another reality that we must deal with is that

the self is limited. It has only so much energy. If it is not renewed, then depletion will take place. Too often we do not avail ourselves of the type of activities that truly renew us. When this occurs we run a greater risk that we will unnecessarily lose perspective and burn out, which is not only sad for us but for the people we are in a position to help in our circle of family, friends, and coworkers.^6p46

Sometimes, however, a rude awakening is required for us to realize how far we have drifted from a balanced life.

Wicks vouches for this personally:

Several years ago, a very close friend of mine in his early forties was dying, from brain cancer. He was outrageous and we constantly teased one another. Even though he was dying, this did not stop.

He had been living in New York and I hadn’t seen much of him in the years since I was the best man at his wedding. When he was hospitalized in Philadelphia to undergo experimental treatment, I visited him. When I came to visit, he had already been there for almost two weeks.

When I inquired about his health, he shared a summary of his condition, which included loss of short-term memory. So, I said to him: “You mean you can’t remember what happened yesterday?” He said: “No.”

Then I smiled and said: “So, you don’t remember me coming in and sitting here with you each day for five hours for the past two weeks?” He looked at me, hesitated for a second or two, grinned widely, and said . . . well I can’t share exactly what he said . . . but we both had a good laugh over it.

One of the things he did surprise me with, though, was a question that really helped me put my activities in perspective. He asked: “What good things are you doing now?” As I started to launch into an obsessive (naturally well-organized) list of my recent academic and professional accomplishments, he interrupted me by saying: “No, not that stuff. I mean what really good things have you done? When have you gone fishing last? What museums have you visited lately? What good movies have you seen in the past month?” The “good things” he was speaking about the last time I saw him alive were different from the ones I, in my arrogant good health, thought about. Unfortunately, I have a lot of company in this regard.^6p50

Box 5.1 The Basics of Stress Management

Physical Health

1. Sleep: Without enough sleep the quality of what you do will decrease; rising early requires going to bed at a reasonable hour.

2. Food: Eating three light meals, at a reasonable pace, and being mindful of the nutritional value of what you eat is one of the best ways to keep weight down and nourishment and energy up.

3. Exercise: Taking a fairly brisk walk each day is a good minimum exercise. Doing it on a consistent basis is better than some irregular or future extensive exercise plan which we fail at and feel guilty about.

4. Leisure: Relaxing with your feet up and/or being involved in activities that provide genuine enjoyment are not niceties of physical health. Rather, they are undervalued but essential building blocks to good health. Leisure helps us “flow” with life’s joys and problems in a more accepting philosophical way.

5. Pacing: Taking a little more time to get to a place makes the trip more relaxing; stopping every hour or hour and a half to get out of the car and stretch on long trips makes the trip a lot more enjoyable and helps increase stamina. Likewise, taking breaks when you feel the need makes your productivity better. The important lesson here is to use any technique necessary to slow yourself down so you don’t rush to the grave missing the scenery in your life along the way.

Psychological Stability

1. Laughter: If laughter is good medicine, then surely laughing at yourself is healing. We all tend to take ourselves too seriously. So, doing something about this can significantly reduce unnecessary stress and help improve one’s perspective on self and life.

2. Values: Know what is important and what isn’t; by knowing what you believe to be really important you can choose easily and well between alternatives.

3. Control: Be careful to discern between what you can control and what you can’t; while worrying about something when it happens is natural, continuing to preoccupy yourself with it is not. When you catch yourself worrying endlessly, tease yourself that you must be “the world’s best worrier.” Then plan what you can do about it, and let it go. If and when it comes up again; review the process until it lessens or stops. This technique may need a good deal of practice for it to “take root” in your attitude.

4. Self-Appreciation: Reflect on what gifts . . . [have been] given you, recall them each day in detail (make a list if you have to on paper), and be grateful for them by promising to nurture and share them—not in a compulsive manner but in a generous way. By this I mean have low expectations that people will respond as you would wish or appreciate your efforts. However, simultaneously still try to maintain high hopes that you can appreciate . . . multiple measures of “success” in your work so you don’t miss the good that is occurring before you because of a narrow success-oriented viewpoint. For instance, too often we measure what we achieve at the end of a process and fail to see or value appropriately all of the good we did along the way.

5. Involvement . . . Not Over-Involvement: Be active in what you feel is meaningful (the kind of things you would be pleased to reflect on at the very end of life—not necessarily those things that others might feel are impressive or important). Assertiveness on your part both to volunteer to be involved in what you believe is good and to say no to demands that aren’t, is also an essential part of increasing your involvement in stimulating activities and curbing (wherever possible) ones that are personally draining.

6. Support Group: Have people in your life who care; contact them frequently by phone and in writing as well as in person. Ideally, among this group should be a variety of psychologically healthy friends who can challenge, support, encourage, teach, and make you laugh.

7. Escape: There are times when we should “run away” because facing things directly in all of our relationships all the time would be debilitating. To do this you can use novels, breaks during the day, movies, walks, hobbies (fishing, bicycle riding, etc.).

8. Be Spontaneous: A small creative action or change during the day or week can make life much more fun. This is a lot more practical than waiting for a yearly vacation.

9. Be Careful of Negativity: Often we hear negative comments like thunder and praise like a whisper. Use self-talk to catch your own negative tendencies (i.e., to see things in black-and-white terms, to exaggerate the negative, to let one negative event contaminate the whole day or week, or to discount other positive events). Then answer these thoughts with more accurate positive ones. For example, if you feel slightly depressed and check your thinking, you may see that because one thing went wrong today, you are saying to yourself that you are really a failure at what you do. By recognizing this exaggeration as nonsense, you can tell yourself more correctly that you made a mistake, not that you are a mistake! Following this, you can then recall successes you have had and bring to mind the faces of those who have been grateful for your presence in their lives. This will show you the face of [love] . . . in the world and help break the back of the strong seamless negative thinking you are under at the time. Remember, negative thinking takes a good deal of energy. Stop it, and a great deal of energy will be freed up for growth and enjoyment.

10. Check Your Individual Balance in the Areas of:

a. stimulation and quiet,

b. reflection and action,

c. work and leisure,

d. self-care and care of others,

e. self-improvement and patience,

f. future aspirations and present positive realities,

g. involvement and detachment.

Source: Wicks RJ, Touching the Holy: Ordinariness, Self-Esteem and Friendship. Notre Dame, IN: AMP; 1992. Used with permission.

A self-care protocol varies from person to person and differs according to one’s stage of life. As Baker notes,

there are many ways to practice self-care. No one model exists in terms of definition, meaning, significance, or application. Differences between individuals relate to personal history, gender, and personality, and within-individual differences relate to developmental stage, or changing needs. Such differences influence the substance and process of self-care. For one person at a particular stage of life, self-care might involve maintaining a very active schedule and hiring a housekeeper. For another person, or for the same person at a different stage, self-care might involve considerable amounts of quiet, uncommitted personal time and tending one’s own home.^7pp18–¹⁹

Because a self-care protocol needs to be tailored to the individual, it is helpful to have a large pool of possibilities from which to choose. The list that follows is designed to spur thinking around what could comprise a self-care protocol in your own case. Knowing which elements you might entertain as part of a self-care protocol and questions to ponder in the overall development of it are both good initial steps in engendering self-respect, rejecting the compulsive rat race of professional life and taking responsibility for yourself.

Elements of a Self-Care Protocol

Taking the time to focus on the following basic elements of self-care necessitates that we step back from our work routine to regain perspective and engage in ongoing self-renewal. As you peruse the list, think about if and when you chose to engage in any of these elements: