Caring for carers of Caring for carers of

critically ill children critically ill children

Louise FrenkelDepartment of Psychiatry and Mental HealthUniversity of Cape Town

Interesting question...Interesting question...Growing awareness within medicine that

doctors at risk of burnout. (O’Keefe & Shelton, 2007).

Many will recognise yourselves in description

Will already know what contributes to your stress, and also, some of the things you could do to ameliorate it.

Interesting issue: why don’t we do what we know will help? Why don’t we listen to our own good advice?

Will come back to this question..... But first:

What is burnout?What is burnout?

Over 100 named symptoms, but central are:

emotional exhaustioncynicismperceived clinical ineffectivenesssense of depersonalisation in relation

to co-workers, patients, or both Spickard et al, 2002

Definitions (cont)Definitions (cont)

Also, dissociation from oneself (lose touch with own emotional and physical needs)

Psychology of postponement; habitually delaying attention to significant relationships and other sources of renewal until all the work is done or the next professional hurdle is achieved.

Burnout is a syndrome which spreads gradually and continuously over time, sending people into a downward spiral from which it is hard to recover.

Spickard, 2002

Measuring burnoutMeasuring burnout

• Development of Maslach Burnout Inventory to measure burnout (mid 70s)

• Measure 3 main features: 1. Emotional exhaustion 2. Depersonalisation 3. Reduced accomplishment

What does research say about What does research say about stress levels amongst stress levels amongst

paediatricianspaediatricians?? Dangers of burn out recognised amongst a wide

range of medical practitioners (O’Keefe & Shelton, 2007).

Not much research on paediatricians, and most in the area of paediatric oncology

Study of pos and neg work characteristics associated with burnout in 126 primary care paediatricians in Israel◦ found that Absence of positive job features (e.g.

Autonomy, recognition of one’s work and utilisation of skills) may be more NB in causing burn out than the presence of negative characteristic (e.g. workload, distressed parents etc).

Kushnir et al, 2008

Research (cont)Research (cont)In last 2 years Red Cross Hospital has

seen turnover of 9 of its junior paediatric drs before the end of their contracts.

Study (Stodel, 2009) using Maslach’s Burnout Inventory. ◦All 22 drs sampled experienced a high

degree of burnout on one of the 3 scales of burnout (emotional exhaustion, depersonalisation, and reduced accomplishment).

What causes What causes burnout?burnout?Complex interplay between a range of

factors:Not simply excessive stress, but complex

human reaction to stress which relates to the personal realm (a persons inner

resources, ability to deal with stress etc)

the demands of the job (type of work)

the working context, (structural and organisation issues)

Causes (cont)...Causes (cont)...Not going to focus on working

context although is very important; e.g. workload, lack of resources, administrative duties...

More interesting is the interplay between the personal internal resources, and the particular demands of the job.

Demands of the job: Demands of the job: Emotional workEmotional work• Emotional component –

sometimes hidden, but often disregarded in terms of its impact.

• Attending to sick children and parents in distress, and managing whatever this evokes for you.

• ‘Receptive’ to the child’s and the parents’ anxieties, and concerns, and containing these feelings, AS WELL AS YOUR OWN, while making the important medical decisions.

An organisational defenceAn organisational defence

When the work routinely evokes

emotional stress and anxiety, then an organisational defence can develop

Menzies Lyth (a British psychoanalyst) working with nurses in the late 50s described this process

Organisational defencesOrganisational defences“The need of members of an

organisation to deal with anxiety, leads to the development of structured defence mechanisms, which appear as elements in the organisation’s structure, culture and model of functioning” (Menzies Lyth; 1988)

This is not an individual defence, but becomes the way a profession is structured and how it operates

Example of organisation Example of organisation defences used by nursesdefences used by nurses

Splitting and task orientation◦Core of anxiety in relationship to patient,

the closer, the more anxiety.◦So, patient care split into a number of

disparate tasks (minimises patient contact)

Bureaucratisation; ◦more and more focus on completing

forms and counting tasks – provides false sense of achievement, but takes you away from engagement with patient and feelings

Paediatricians’ defences?Paediatricians’ defences?Are there organisational defences

being used to protect paediatricians?‘Culture’ of having to cope, with

stigmatising of emotional vulnerability on the part of the doctor.

Emotional work recognised, but seen as up to the individual to deal with it – left in the personal realm? (story of surgeon). Becomes a personal problem.

Disadvantage of these Disadvantage of these defencesdefencesCan deprive you of job satisfactionAdds to level of stress – defences

ensure that doctors have no help in confronting and getting help with their anxiety

Dilemma; To do the job, have to have some ‘boundary’ in terms of emotional involvement but being depersonalised is not good for you or the patients you are treating.

What is needed?What is needed?A fine balance...A fine balance...

– A balance; ability to remain empathic, respond to parents’ distress, but also think and act without feeling overwhelmed

– Need an in-between state which is protective but at the same time allows for sensitivity, compassion and importantly, the ability to function.

Beginning to find solutions Beginning to find solutions (1)(1)Acknowledgement of emotional impact of work, and recognising it as part of the job (not as personal challenge that you have to conquer quietly and on your own)

Recognition of a defensive culture amongst doctors which stigmatises the expression of emotional stress. ‘Unprofessional’.

Solutions (2) Self-Solutions (2) Self-knowledgeknowledge

Have to begin with thinking about what the work evokes for you (personally)◦ All of us, particularly in the helping professions

have our reasons for choosing this work – some desire to make reparation, and/or some anxiety about being able to make things better.

Why NB? If you can be clearer about your own feelings/desires/anxieties, and where they originate you will be less likely to feel overwhelmed.

Solutions (3); Self-Solutions (3); Self-knowledgeknowledge

Having a degree of self knowledge, knowing strengths and vulnerabilities is very NB in recognising your own potential for burnout

How do you recognise early signs of stress in yourself? (lists, overeating, not sleeping etc)

Solutions (4); Knowing Solutions (4); Knowing yourselfyourselfAre you the sort of person who may be

vulnerable to burnout? Are you:

◦ Very committed to your job◦ inclined to suppress emotions◦ Routinely self critical

Do you:◦ accept responsibility readily◦ See work as important part of your identity◦ Struggle to say ‘no’ to demands◦ Find it difficult to discuss problems and feelings◦ Struggle to be assertive and/or have strong

needs for approval

Solutions (5)Solutions (5)

Obvious ways of looking after yourself (eating healthily, having regular exercise) – why is it so difficult to do?

In terms of your own expectations of yourself, you may feel guilty about not coping (your fault)

Dovetail with external ‘culture’: if you do make some boundaries - worry that colleagues/family will think you are selfish, a bit lazy, letting others down?

Solutions (6)Solutions (6)

So pressure externally from medical culture (stigma), and pressure internally (in terms of high expectations of self)

Both the external and the internal pressures can be thought about, and so mediated

If a more accepting and gentler approach to the emotional stress of the job can be allowed, then job satisfaction may increase, and you may find more energy to tackle some of the important bureaucratic issues around resources etc

Solutions (5)Solutions (5)

Personal ‘supervision’ for paediatricians (O’Keefe and Shelton, 2007).

◦System of regular meetings with one or two colleagues to mentor, give peer supervision, discuss emotional demands of job etc

Implications of Kushnir’s study: focus and capitalise on the positive features of the job that help make the stress more tolerable rather than to attempt to reduce the negative features

Solutions (cont)Solutions (cont)

Leave you with the question;

What are you as a group of paediatricians doing to challenge the external and internalised stigma, and to make collegial support possible?