Healthcare workers: diminishing burnout symptoms through self-care

1.   Healthcare workers: diminishing burnout symptoms through self-care

Burnout. Healthcare work, especially now during the post COVID-19 period, is quite stressful and burnout as a result of chronic work-related stress, emotional exhaustion and loneliness may result (see [1]). It is known that clinicians are an especially vulnerable group of professionals. Luther [1] examined work experiences of 182 clinicians and pointed out their tendency to overextend themselves with work. survey of 474 psychotherapists provides another example, which found that 61% of clinicians meet the criteria for clinical depression [2] (see also [3]). In addition to various positive aspects to being mental health workers, one can note aspects that can be frustrating for clinicians while they accommodate and adjust to the post COVID-19 era given its especially spirited demands. Woo [4] aimed to investigate rates of burnout in nurses worldwide. They conducted a systematic review on 113 studies and meta-analysis on 61 studies. All in all, their analyses were based on 45,539 nurses worldwide in 49 countries across multiple specialties. Their results suggested that one-tenth of the nurses worldwide suffered high burnout symptoms. This finding may have been expected given the job nature of nursing—physically, cognitively, and emotionally demanding. Analysis has revealed that nurses' burnout can be explained by the essence of nursing, the caring for patients and many times for physicians as well. The authors found that high burnout levels were noted in Southeast Asia, followed by Latin America and the Caribbean.

Salyers [5] conducted a meta-analysis which examined relationships between provider's emotional exhaustion, depersonalization and reduced personal accomplishment and the perceived quality, patient satisfaction and safety of healthcare. A variety of healthcare providers were included, such as physicians and nurses in outpatients and inpatient settings. The researchers found small to medium-sized relationships between burnout and both decreased quality of care and decreased safety. They observed that given the increasing rates of burnout, particularly among physicians, these findings could have important ramifications. Addressing burnout, they noted that emotional exhaustion had the strongest relationship with quality, followed by depersonalization and reduced personal accomplishment. Emotional exhaustion, it was suggested, may be the most critical element of burnout to address.

In addition, satisfaction is important for retaining patients in competitive markets and moreover, for being able to influence patients to engage in good self-care strategies, both of which could impact patient outcomes over the long term. For example, working alliance and placing the patient at the center of the healthcare provided, are associated with improved patient outcomes. In an era of increasing attention to collaborative care, burnout may interfere or even prevent provision of optimal care. The relationship between burnout and safety risk is particularly troublesome. Similar to quality, the relationships were stronger for self-reported perceptions of safety (all provider-reported), yet a significant negative correlation (−0.18) was still found for safety events (i.e., errors and adverse events). Although the effect size translates into about 3% of the variance, these findings indicate that even small statistical effects need to be taken into consideration. They asserted that “provider burnout may contribute in part to real-world outcomes for patients, putting them at higher risk of an error or adverse event. In addition to the obvious implications for patient health and well-being, a greater number of errors also leads to greater liability for healthcare organizations” (p. 480).

Self-care. Self-care was defined as the planned and self-initiated effort to take care of oneself, and is now presumed to be an essential tool for enhancing clinician wellbeing and overall efficacy of treatment [6]. The initial conceptualization of self-care, which occurred around the 1970s, stirred a debate amongst health care workers and signaled—at that time- a de-professionalization of health care workers [7]. Self-care was perceived as narcissistic, self-indulgent and unacceptable, despite an understanding that neglect of self-care may usher harm associated with occupational stress related to caring for patients [8].

Kushnir [9] observed that occupational stress can negatively affect one's well-being, both psychological, as well as emotional. Research indicated that for clinicians, such stress was found to be associated with anxiety, depression and anger, which in turn contributed to absenteeism and job-related interpersonal conflicts. Generally, stress is known to be associated with cardiovascular illness, lowered immune functioning and gastrointestinal problems, which may lead to exhaustion and depletion of personal resources, which will negatively affect patient care [10],[11]. It is observed that if clinicians will not be aware of the damaging effects of stress, and will not actively control the amount of stress they feel, they will eventually experience burnout. CPMA [12] noted that the very nature of medical practice can contribute to physicians' stress. Their workdays are, often, emotionally draining as they witness suffering, fear, pain, tragedy and death. In addition, they face additional stress from increasing patient care demands, limited resources, demanding work hours and schedules, difficulties that they may have with work-life balance and frustration in trying to meet the conflicting needs of patients and healthcare organizations.

Aside from high levels of stress and a tendency for burnout, if self-care is not practiced, the clinician may experience loneliness which may be enhanced when decisions about clients are being made, and by the clinician alone [13]. That stress experienced by healthcare professionals may be the result of their attempts to remain loyal to their clients, service their organization, adhere to their commitment to their family. As a result, professionals' loneliness and self-doubt may be enhanced [14],[15].

Karaoglu [16] explored the causes of burnout of Turkish medical students. The stressors which the students reported included professional demands and conflicts which were grounded in their loyalty to their patients on the one hand, their responsibility towards their employer, and their wish to be with their own families. They found that both men and women experienced loneliness, similarly. Like everyone else, clinicians may experience disappointments, losses and illnesses, which focuses the clinician's effort to address those stress causing events, in addition to the service they offer to their clients. It is suggested that for clinicians, personal lives cannot be separated from their professional one, and it is incumbent upon them to address it before it gets too much for them to bear.

Norcross and VandenBos [8] saw this issue as a major one and stated that “we must make self-care a priority. Self-care is not a narcissistic luxury to be fulfilled as time permits; it is a human requisite, a clinical necessity and an ethical imperative. If not us, then who will value our self-care? ... Certainly not insurance carriers, who greedily demand more of us while doling out less reimbursement and less autonomy. Hopefully our loved ones, but they understandably have their own needs and agendas, which only partially match ours. No, if anyone is to advocate for and prioritize our replenishment, it must be us” (p. 15).

Mosolova [17] assessed the range of symptoms of psychopathology, which include anxiety, stress, depression and burnout, as well as the risk factors in frontline healthcare workers in the Russian Federation. The authors conducted two independent, cross-sectional online surveys which covered responses of 2195 healthcare workers in May and in October of 2020. Stress, anxiety, depression, burnout and perceived stress were assessed. Although they conducted their study in the Russian Federation, the authors noted that despite differences of organizations and cultures, many risk factors can be found worldwide. The study, which was conducted during the recent COPVID pandemic, revealed that a significant proportion of healthcare workers displayed mental health problems that have exacerbated since the onset of the pandemic. They found that the level of anxiety in Russia was higher when compared with other countries using research that was conducted around the world. Most of the participants reported fear, anxiety and high stress levels. Similarly, it was reported by the American Nurses Foundation that during the same period feelings of exhaustion, being overwhelmed, anxious and irritable all intensified (Cipriano et al., 2020). In their second survey, Mosolova [17] found that 74% of the participants reported burnout. Almost half had moderate depression, feeling tired and having less energy. Two thirds of their sample pool reported moderate or high perceived stress, including feeling nervous and stressed, experiencing anger due to things outside of their control, or being upset at what happened unexpectedly. Regarding possible risk factors of psychological problems, women had higher levels of stress and anxiety according to both surveys. Based on reviewing the literature, it was observed that anxiety disorders, depression, and burnout occur mainly in women. Similarly, studies from other countries found that younger age was positively correlated with higher levels of psychopathological symptoms.

In the following pages we will highlight the consequences and negative effects of not exercising self-care.

2.   The occupational hazards of working the healthcare profession

2.1.   Physical isolation for those working on their own

Practicing medicine and patient care requires privacy. There is a price to be paid for such an isolation. While clinicians may feel “together” in a hospital setting, the actual practice of caring for patients can be a solitary task. While inpatient treatment teams do involve others, most clinicians and particularly those who attend to outpatients go it alone. Treatment, especially by those practicing independently, affords restricted contact with people of the “outside world” and clinicians may only have some breaks in between seeing clients. Those working in hospital or clinic environments may be more fortunate in that respect, as group meetings, grand rounds and in-service workshops provide interruptions and movement [17].

Environmental deprivation may result from a consulting room, which offers minimal physical movement. It is not unusual for clinicians to feel sleepy or bored after hours of working on their own. Seeing multiple patients per day, clinicians may experience a numbing similarity, which may lower their sharpness and the treatment they provide to their clients, which ends up affecting their ability to be authentic while properly attending to their patients [18].

2.2.   Emotional isolation

Despite the intense contact of practicing medicine, emotional isolation is experienced by many healthcare providers. Focusing exclusively on patients and their health struggles often precludes attending to the healthcare worker's emotions and needs, which relate to their life. Once attending to their patients, clinicians are expected to set aside their personal concerns, and focus on the patient, their conditions and needs. Personal feelings are restrained in the name of competent treatment. Pope and Tabachnick [2] found that up to 80% of clinicians experienced anxiety, anger and sexual attractions as part of their work, feelings which they cannot share and must contain. Preti [19] echoed those statistics, which they based on a large-scale review of the literature.

Patients, naturally, react to their treatment providers. For example, patients may idolize their physician which may result in the clinician feeling burdened with unrealistic expectations. Alternatively, the clinician may adopt that idealization and develop feelings of grandiosity, which is clearly not health for one to develop. When patients verbally (and rarely physically) attack their therapist, the clinician may end up feeling demoralized, humiliated or rejected, feelings that the physician commonly addresses alone [20]. The ethical as well as the legal requirements of confidentiality causes healthcare workers to actively split off the emotional impact of their work from their personal life [21]. In fact, Simpson et al. [22], conducted a study on a sample of 443 clinical and counselling psychologists. They found it most distressing to balance their work demands with their personal lives.

2.3.   Patient behaviors

Patients are rarely seen when they are at their “best” [23]. Being susceptible to patients' emotions may be contagious and even result in vicarious traumatization, thus making it very difficult for healthcare workers to express empathy and caring [24]. Most distressing behaviors of patients include those related to patient safety (e.g., the possibility of self-harm), severely distressed clients or clients displaying chronic and complex mental health issues [25].

A known stressful behavior that patients may display is aggression. Aggression may be expressed verbally, physically, through stalking or even an attempt to kill the healthcare provider with a knife or a gun. Unfortunately, that behavior increased, especially during COVID, where increasing complaints of verbal and physical violence against health care providers have been reported [26]. Garcia-Zamora et al. [26] Conducted an electronic survey during the months of January and February 2020, at the height of COVID. Their survey was conducted in Latin America, but they suggested that results were similar in other countries, as suggested by the literature. They surveyed physicians, nurses and other health team members. A whopping 55% reported that they were subjected to acts of abuse, wherein 96% faced verbal abuse, and 11% were physically attacked. As a result, nearly half of experienced psychosomatic symptoms after the event, and 33% of them considered quitting their profession.

Healthcare workers are commonly unequipped when it comes to dealing with cliental anger [27]. Thus, client anger may elicit in the attending worker submissive behavior or passive aggressiveness, which may result in harm to the therapeutic relationship [28]. Patients' aggression was found to be associated with clinicians' long lasting psychological damage, such as intense anxiety, depression, PTSD, anger and a fear of returning to work [29],[30]. Vicarious traumatization which follows may result in feeling compassion fatigue [31]. Patients suffering from various personality disorders will express their self-destructive patterns, comorbid disorders and intense anger towards the clinician or healthcare workers and that obviously may increase the clinician's stress [8]. Trumello et al. [32] surveyed Italian healthcare workers, including physicians and nurses, and found that, particularly during the recent pandemic, healthcare workers experienced increased levels of stress, secondary trauma, anxiety and depression as well as lower levels of compassion.

Research indicates that about 10–15% of mental health practitioners will face a licensing complaint during their professional careers, especially if they are male, and the number in the medical and healthcare professions (including psychologists, social workers, providers of complementary treatments) are similar. Only two to three percent of practitioners will actually end up facing a malpractice suit. It was found that up to one quarter of clinicians are constantly concerned about malpractice, either committing them or being sued by their clients about them [33]. In extreme cases clinicians were found to develop litigaphobia which is an unreasonable fear of litigation by a client, and that concern is not unrealistic. While the majority of complaints to the licensing board may be without merit, the investigation process is rough, demanding, and anxiety arousing for the clinician [33].

2.4.   The clinician's life

Some life events may result in significant distress, and those were accentuated during COVID. To wit, it appears that between 75 and 82% of clinicians reported experiencing significant distressing event in the past three years, which may include such events as dysfunctional marriages, divorce, serious illnesses or interpersonal losses or death of a spouse [24],[34]. Lai et al. [35] reported that a considerable proportion of healthcare workers reported symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%) and distress (71.5%).

Female clinicians may communicate what happens in their private lives; for instance when they are noticeably pregnant which may hamper their anonymity and lower patient-clinician boundaries [36]. That may result in them feeling guilty for becoming pregnant and, later, not providing their newborn with optimum parental attention, and fatigue may impair their professional effectiveness [37]. Locker-Forman [38] wrote about the stressful period that she went through during her pregnancy when working as a clinician with children: “I had been working with the 11-year-old and his family for approximately two years before I became pregnant. At times, he played in an extremely destructive way, throwing objects in the room, climbing on file cabinets and trying to destroy toys. On several occasions, I had to physically restrain him in order to prevent him from running away or hurting himself. While I never worried that he would intentionally hurt me, I was always aware of the possibility that he could lose control and harm me inadvertently” (p. 34–35).

The family may also cause disruptions in the clinician's work, caused by family emergencies, ill children, elderly parents who need help or other unexpected events. That highlights the complexities of the clinician's professional role and in order to succeed in it, one has to balance personal and professional needs [39]. Personal losses, such as divorce, may raise the healthcare worker's concerns that patients may find out that their marriage failed [23],[40]. Some clinicians and healthcare workers were found to engage in sexual misconduct with a patient when their personal lives were non nurturing. Loneliness, enduring a spouse's or a parent's death, personal illnesses and financial concerns are amongst the main causes of sexual misconduct with patients, for those who may commit such a grave ethical transgression [41],[42]. Myran et al. [43] conducted their study on the mental health of physicians in Ontario Canada, and found that between 2017 and 2021, i.e. before and during COVID, all-cause outpatient visits between March 1, 2017, and March 9, 2021. On average, 23% of outpatient visits healthcare workers, by physicians, were due to mental health and substance use before the COVID-19 pandemic. During the first five months of the pandemic, the number increased to 28%. They reported that before and during the pandemic, over 65% of mental health and substance use visits were found to have been caused by anxiety, while mood disorder accounted for 15%. In their Discussion, they concluded that increases in mental health and substance use visits during the COVID-19 pandemic were precipitated by increased levels of anxiety, depression, and stress in healthcare providers, which may signify worsening physician mental health.

3.   How to go about self-care

Self-care is within us. We are our own therapeutic tools. Lasky [44] stated that our tools for self-care never get dull, chipped or broken. Since medicine is a demanding profession, including various occupational hazards, our self-care must begin by having realistic expectations, realizing that sometimes we may feel overwhelmed, and even drained. It is important to recognize the stresses, but also to understand that they are shared by most healthcare workers. That recognition, by itself, could be therapeutic [8]. Research indicated that seasoned clinicians experience many of the same doubts, confusion and strong emotions [35],[45]. Freud, in his early writing [46] commented on the effects of treating people and wrote that “no one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human breast, and seeks to wrestle with them, can expect to come through the struggle unscathed (p. 100).” Accepting that reality will sharpen in us the understanding that self-care is required. The Buddhist nun Chodron [47] wrote a book entitled “Start Where You Are”, which advocates exercising empathy to patients and ourselves alike, with the understanding that we need support, nurturance and recharging.

Difficulties are challenges but are also an opportunity to grow, an ancient Chinese proverb assert. Resiliency means that the practitioner responds to challenges with actions aimed to correct the situation, and, moreover, prevent it from recurring [6]. Not only our patients, but we too may be broken emotionally, and need to embark on a journey to heal ourselves and function better. At times, we may not be able to overcome the challenge by ourselves, and teamwork may be in order. For example, survivors of abuse or extreme trauma, such as abuse, aggression or sexual attack, requires that a team of professions be responsible for their treatment, where they can share insight and lighten the burden of every member involved [48].

Self-care needs to be individually tailored, which can be enhanced by adhering to a proper diet, ample sleep, exercise and meaningful interactions with people, which physicians and healthcare workers are known to ignore due to heavy professional responsibilities [49]. The Canadian Medical Protective Association [CMPA] [12] asserted that the first step for physicians and healthcare workers to practice self-care is to put themselves first. They observed that, while physicians have the knowledge and skills to be healthy, they attend wholly to their patients at the price of neglecting their own physical and mental well-being may suffer... Physicians must allow themselves to reach out for help. They may do so by speaking with a trusted colleague, with their life partners, a religious advisor or a professional mental health worker. Florio Pipas [50] eloquently stated that “Want to see change in your team, your organization, or beyond? Start by filling your own tank... Physicians should consider a critical shift in thinking—one that prioritizes caring for oneself as an effective means of caring for others”.

Self-reflection and mindfulness. Fjorback et al. [51] highlighted the importance of self-reflection and regularly practiced mindfulness in centering the practicing clinician, directing their attention to themselves as well, enhancing their ability to monitor their own feelings and wellbeing, and introduce corrective practices if needed. Fessell and Golman [52] asserted that what physicians and other healthcare workers need to develop and enhance is their emotional intelligence, which includes: self-awareness, self-management of our emotions and how we express them, social awareness through empathy and listening to others, and relationship management, meaning attending to ourselves and to our social support system.

The importance of sleep. Much was written about the importance of nutrition and exercise, and less about that of sleep, which was—for many years—regarded as unimportant and disposable. Many were taught that sleep is, mostly, a wasted idle time. Research, however, indicates the importance of sleep, since brain waste is being carted away, and muscle and neurological renewal take place, while we are asleep [53].

Massage therapy. During practicing patient care, clinicians experience many moments, if not hours, of stress which stresses their body [54]. Over time this may lead upper back and neck region to spasms. Massage may be very helpful in alleviating pain and boosting the immune system, as well as providing touch which is known to be healing by itself [55],[56].

Nutrition, hydration and exercise. Research has repeatedly demonstrated the importance of exercise in improving mood and building mental stamina [57]. Neuhaus et al. [58] suggested that activity-permissive work stations (e.g., a stepping device that is fitted under the desk) could allow the clinician to exercise in some manner and significantly help reduce sedentary time.

Research has shown that ergonomic components to the office may increase effectiveness. Office softness and orderliness, often results in improved quality of services [59].

Many clinicians report that they consume much less than the recommended amount of fluids, and instead eat unhealthy junk food. A healthy, balanced diet while also having ideal amounts of fluid intake before, are a must [60]. Additionally, engaging in active sports like walking, playing tennis, or bicycling are highly recommended, and is reported by 71–89% of clinicians to be their preferred physical activity [61].

Receiving support from our social support network. People in general, including clinicians, all need social support. It may be offered by colleagues, if we welcome it, from friends or family or from supervisors [50],[62],[63].

Clinicians, like all people, could greatly profit from personal therapy. Norcross et al. [64] found that of those service providers who received therapy, 96% believe that it is important and positively affects their personal and professional growth. Personal psychotherapy may help the practitioner improve his or her emotional functioning, and that may have far reaching positive consequences, personally and professionally (see also [65]). Personal therapy may strengthen the practitioner's conviction that it has the ability to positively impact people's lives. Research indicated that, as a result of personal psychotherapy, there were several positive effects, including increased empathy and reduced negative perceptions of patients [3],[66].

Retreats. Going on vacations, and especially to retreats which may cater to one's physical as well as emotional needs, may allow the clinician to experience pleasure, something that promises excitement, relaxation and personally gratifying experiences [67].

4.   Competence constellations can help deal with stress

Competence constellations, the termed coined by Johnson et al. [68], refers to a clinicians' “network or consortium of individual colleagues, consultation groups, supervisors and professional association involvements that is deliberately constructed to ensure ongoing multisource enhancement and assessment of competence” (p. 566). This notion has recently gained traction in the literature, and some researchers believe that in the near future it will be integrated into training and licensing regulations, just as the ethical code of conduct was [8]. Below is a summary of the numerous benefits of these peer networks, and how they can help improve the clinician's and the patient's wellbeing.

4.1.   Addressing ethical dilemmas

Competence constellations aids clinicians who face challenging dilemmas. While there is an established code of conduct, real-life situations often blur the line between what the professional wishes to do, and what the ethical code may recommend. It was observed that codes of ethics cannot suggest ways od resolving all ethical issues, while the avoidance of violations does not necessarily equate with ideal ethical practice. Codes of ethics essentially represent the best judgment of one's peers about common problems and highlight professional values [69].

Consequently, a constellation network allows the healthcare professional to provide feedback regarding unethical or questionable practices by colleagues without fear of potential repercussions. These peer networks would allow clinicians to exchange information and allow for constructive criticism to be taken non-judgmentally.

4.2.   Benefits to the patient

When clinicians are faced with situations that require a judgement call, professional dialogue is an important part of the resolution process. This is particularly important in high-risk issues, since the clinician experiences then intense emotional reactions which may hamper one's capacity to focus on potential resolutions [70]. Conversely, when healthcare workers themselves are going through stressful events, they may not pay full attention to their client's problems, confusion and struggles. Support from their peers may end up allowing the patient to be attended to by a calmer and more attentive clinician [70]. Patients from different cultural backgrounds than that of the healthcare worker can complicate matters, as the clinician may fail to attend to their sociopolitical context, and (inadvertently) cause them harm [68],[71]. Thus, speaking with clinicians from other cultures may increase the clinician's ability to attend to those patients.

5.   Conclusions

In this article, I aimed to draw attention to the dangers of stress, burnout and professional misjudgment inherent in working in the healthcare field, the toll it may take on the clinician and the price of neglecting to take care of oneself. We reviewed the various demands, stress and negative impact that healthcare workers are subject to, what contributes to the emotional load that they carry and which internal and external factors may hasten their progression towards burnout. Healthcare workers know what is necessary to maintain a healthy body and mind. However, they rarely make that a priority when it comes to themselves. In this brief review, I attempted to raise the flag, so to speak, and highlight the ramifications of neglecting one's physical and mental health, emphasizing the importance of self-care, and of addressing needs which most people have to various degrees, though in healthcare workers they may be more urgent. Self-care, which includes various strategies that the individual can practice, as well as reaching out to support groups, changing one's social ecological landscape, cannot only heal burnout or even prevent it from occurring, but more importantly, bring personal and professional growth that healthcare workers deserve. As Welch [72] so poignantly observed “Pray to God, but continue to swim toward shore”. Whether one reads this proverb literally or metaphorically, its message reminds us that we need to take care of ourselves. Taking care of ourselves does not mean giving up hope that others will care about us. It means, however, that we cannot be totally dependent, even minimally, on others. This, of course, is not so for children. For adults, the test of maturity is the willingness and ability to take responsibility for ourselves (p. 151).