Caring for carers of critically ill children

1. Caring for carers of critically ill children Louise Frenkel Department of Psychiatry and Mental Health University of Cape Town

2. 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:

3. What is burnout? Over 100 named symptoms, but central are: • emotional exhaustion • cynicism • perceived clinical ineffectiveness • sense of depersonalisation in relation to co-workers, patients, or both Spickard et al, 2002

4. 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

5. Measuring burnout • Development of Maslach Burnout Inventory to measure burnout (mid 70s) • Measure 3 main features: • 1. Emotional exhaustion • 2. Depersonalisation • 3. Reduced accomplishment

6. What does research say about stress levels amongst paediatricians? • 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

7. 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).

8. What causes 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 todeal with stress etc) • the demands of the job (type of work) • the working context, (structural and organisation issues)

9. 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.

10. Demands of the job: Emotional 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.

11. An 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

12. Organisational 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

13. Example of organisation defences 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

14. 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.

15. Disadvantage of these defences • Can deprive you of job satisfaction • Adds 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.

16. What is needed?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.

17. Beginning to find solutions (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’.

18. Solutions (2) Self-knowledge • 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.

19. Solutions (3); Self-knowledge • 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)

20. Solutions (4); Knowing yourself Are 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

21. 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?

22. 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

23. 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

24. 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?