Long before COVID-19, burnout was a major concern

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From Luke’s Journal October 2023  |  Vol.28 No.3  |  Mental Health I

“If you are studying dentistry to get rich, you can leave now,” opened the lecturer on my first day at the University of Melbourne School of Dentistry.

Indeed, why did we choose to study a degree in healthcare?

Certainly, there are easier degrees to study and quicker career paths to pursue.

Definitely, there are many different ways to make money and get rich.

We all wish to be in a respected profession and to be financially secure. It is also completely human to be influenced by factors such as ego, pride, and family expectations. Ultimately though, among our mixed bags of motives pursuing a career in healthcare, there is always an altruistic aspect that differentiates healthcare from other vocations – the distinct privilege of being in the business of caring for others. To be able to witness daily our calling to serve not only God, but our fellow human beings. To be trusted by our patients in their most vulnerable moments. To be invited into the personal space of another. To show compassion during their most challenging times in life. To be able to alleviate pain and suffering, to save lives.

Sadly, many healthcare workers find it more and more difficult over time to fulfil their calling to provide health with care due to burnout. Literature shows excessive workloads, demanding time pressures, administrative burdens, organisational cultures and moral distress all contribute to clinician burnout.¹ All of this, coupled with personal traits common among health professionals such as perfectionism, high expectations and conscientiousness, results in frequently being identified as ‘professions most likely to burn out’ or ‘jobs with the highest suicide rates’. High levels of workplace stress among dedicated, selfless frontline workers was widely publicised by the media during the COVID-19 pandemic. During the height of the pandemic, 71% of healthcare workers reported experiencing moderate to severe burnout.²   Long before COVID-19 though, burnout was already a major concern among workers across the healthcare system.³

Burnout among healthcare professional can have significant negative consequences:

1. in the healthcare system as a whole: increased absenteeism, increased staff turnover and increased numbers of clinicians who are reducing their work hours, or leaving the profession. The resulting workforce shortage, in turn, increases the pressure on those remaining in the system. 
2. in the quality of care for patients: reduced patient safety, reduced patient experience, and reduced patient outcomes.⁴
3. in self care for clinicians: most notably, increased mental and physical health issues, increased workplace injuries, increased substance abuse and suicidal ideation.¹

The impacts of burnout on an individual’s life can be extensive, including physical, relational, psychological and financial consequences. The most significant of negative consequences of burnout is suicidal ideation. A recent study reported 1 in 6 Australian dentists had thoughts of suicide in the previous 12 months.⁵ Other statistical data showed doctors experienced significantly higher rates of suicide compared to the general public.⁶ 

How can we stop burnout from compromising our ability to care as a health professional?

Whilst keeping in mind the Serenity Prayer by Reinhold Niebur…

‘God, grant me the serenity

To accept the things I cannot change;

Courage to change the things I can;

And wisdom to know the difference.’ 

…what are the changes we can make? Do we have the courage to implement change?

Not all of us will be able to effectively influence the entire healthcare system. Changes of magnitude take time and collective effort, and there has been greater awareness and progress made in recent years. However, we can all control the quality of care for each patient we encounter. To effectively care for our patients, we must learn to effectively self-care. We can all make a change to one life at a time, starting with your own life.

Identify the Problem

To enable change, we must first identify the problem and reach a correct diagnosis. So how do we identify burnout?

The WHO definition for burnout is:

‘A syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed.

It is characterised by three dimensions:

• feelings of energy depletion or exhaustion;
• increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
• reduced professional efficacy.’ ⁷

Commonly observed signs and symptoms of burnout are summarised in the diagram below:

In modern best practice, we often quote the adage, ‘Prevention is better than cure.’ As dentists, when we see an early cavity, we try not to jump immediately into filling the cavity. Instead, we implement early intervention methods (like remineralisation), and instil a strong preventive regime (for example, reminding patients to brush and floss daily; reinforcing six monthly check-ups). Similarly, doctors would not usually jump straight into medicating mild cases of diabetes or high blood pressure. They would instead first try to focus on counselling the patients to adopt a healthy diet and start exercising regularly, monitor the changes, then reassess. In the case of burnout, improving our awareness and identifying mild signs and symptoms early in ourselves or in those we care about can lead to implementing immediate, conservative changes. Early intervention and proactive programs can prevent further progression of the problem and eliminate the need for drastic measures such as hospitalisation or leaving the profession.

Implement Change 

When you notice a few early signs of burnout, implement change immediately. Early intervention prevents the worsening of symptoms and can remove the negative effects of burnout from drastically affecting multiple areas of life. As someone who has battled burnout at different stages of my career, when I notice early signs of burnout creeping in, my burnout prevention action plan is to remember my namesake acronym, GRACE:  

Gratitude

Recharge

Acceptance

Compassion

Encouragement

GRACE is defined as ‘approval or kindness, especially (in the Christian religion) that is freely given by God to all humans’.⁸

As Christians, we know that God shows kindness and forgiveness towards us, even when we are undeserving. Reminding ourselves of this, helps us show grace towards our patients, our colleagues, our family, and friends, and most importantly, ourselves. I say most importantly, not because we should be selfish or self-centred, or consider ourselves above all others. As crew members on flights remind us every trip, “Put on your own oxygen mask first, before helping others.” You cannot care for others if you do not first care for yourself.

How many of us forget to eat lunch or choose unhealthy quick snacks, while working hard and counselling patients to adopt a healthy diet? How often do we choose not to go to the bathroom for hours (or even the whole day) while seeing back-to-back patients? If we do not first show grace towards ourselves and fill our emotional and physical tanks, we will find it progressively more difficult to operate from a place of overflowing grace and care. With no ‘oxygen’ remaining for yourself, how will you help others? 

Gratitude

Fostering an attitude of gratitude is one of the easiest ways to reduce stress and anxiety. Research shows that a single thought of gratitude produces a 10% increase in happiness, and a 35% reduction in depressive symptoms.⁹ 

Counting our blessings instead of our worries shifts our focus towards the positives in our circumstances and the people around us. Gratitude gives us a refreshed perspective. Some ways we can foster an attitude of gratitude include keeping a gratitude journal, sharing things we are thankful for and showing appreciation towards people in your life. The easiest way is by remembering to say thank you. If you don’t do this already, try thanking the barista who made your coffee, the bus driver who took you to work, or the cleaner in the public bathroom. See how your words of gratitude can brighten someone’s day. The Bible also reminds us of the importance of gratitude and giving thanks to God in all circumstances:

‘Rejoice always, pray continually, give thanks in all circumstances; for this is God’s will for you in Christ Jesus.’

(1 Thessalonians 5:16-18, NIV)

‘Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God.’ (Philippians 4:6, NIV)

Recharge

One of the key aspects of burnout is exhaustion.  We were not created to be ‘human doings’ but ‘human beings’. Sometimes we become so busy doing and achieving, we forget to take time to recharge our batteries. God models this to us during creation, where he rested on the seventh day. Jesus also took time away from the crowds and was recorded taking naps frequently in the New Testament.

Recharging physically can be passive, by sleeping the recommended seven or more hours a day, or by taking naps.¹⁰ We can also recharge actively by ensuring we nourish our bodies with healthy meals, take breaks throughout the workday, and go to the bathroom regularly. Other aspects of our lives also require regular recharging, such as refuelling our emotional tanks and relationships. Set apart time to do activities you love, with the people you love. And prioritise quality time with people who energise you and fill your love tank. Most importantly, we need to recharge spiritually and recharge our relationship with the God who provides rest for our souls. Jesus tells us in Matthew 11:28-30,

‘Come to me, all you who are weary and burdened, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls.’

Sometimes when we continuously forget (or disobey) God’s command to rest and recharge, we may find ourselves in situations where God forces us to take a break. When we do not take time to rest, God in his wisdom and love, may need to make us rest.

‘The Lord is my shepherd, I lack nothing. He makes me lie down in green pastures, he leads me beside quiet waters, he refreshes my soul.’ (Psalm 23: 1-3, NIV)

Acceptance

Acceptance in many forms prevents us from travelling further down the path of burnout. As health professionals, many of us are guilty of the tendency to want to be in control and strive for perfection. Failures can be hard to accept, and we can fall into the trap of comparison, alongside criticism of ourselves and those around us. The first step of acceptance may be as simple as just accepting the fact you are experiencing symptoms of burnout.

Acceptance is making peace with yourself and the reality that you are only human. Acceptance is realising that God is the one in control and God is also the only one who is always perfect. Accept your human limitations; it’s ok that you do not have all the answers. Accept help and advice from others; ask for help when you need it. Accept the things you cannot control, while praying for the wisdom and courage to change what you can control. Once you show kindness and acceptance for yourself, you can then show grace and compassion towards others.

‘Accept one another, then, just as Christ accepted you, in order to bring praise to God.’ (Romans 15:7, NIV)

Compassion

Compassion is ‘a strong feeling of sympathy for people who are suffering and a desire to help them.’¹¹

One of the defining features of burnout is cynicism, which can result in frustration and irritability towards others. We become disconnected and may experience compassion fatigue towards the sufferings of our patients. We may also start developing negative emotions towards our colleagues, friends, or family. As Christians, we serve and model after a God, who ‘is gracious and compassionate, slow to anger and rich in love.’ (Psalm 145:8, NIV) We are called to ‘be kind and compassionate to one another, forgiving each other, just as in Christ God forgave you.’ (Ephesians 4:32, NIV)

The desire to help our patients is not lacking among healthcare workers. However, before you can sympathise, you need to first listen and seek to understand. We can only diagnose correctly if we listen and correctly interpret our patient’s challenges and pains from their perspective, before we can help in the correct manner required. Listening requires time, patience and humility, things that we may lack if we are stressed at work. I find it helpful to remind myself that each patient is a precious child of God who is loved by God, and ‘we love because he first loved us.’ (1 John 4:19, NIV)

Therefore, as the image bearers of our Heavenly Father, ‘holy and dearly loved, clothe yourselves with compassion, kindness, humility, gentleness and patience.’ (Colossians 3:12, NIV)

Encouragement

We were created for community. God models this for us in the Trinity, the holy and perfect community of God the Father, the Son, and the Spirit, each unique in roles and talents, but equally important and unified. Only in community can we be encouraged, as well as to be encouraging. God calls us to ‘encourage one another and build each other up’, to ‘encourage the disheartened, help the weak, be patient with everyone.’ (1 Thessalonians 5:11,14 ; NIV)

Invest time and effort in building relationships where you feel comfortable in sharing your vulnerabilities, where you can ask for help when required. Seek to find a mentor like Paul, a friend like Barnabas, and a mentee like Timothy. None of us can walk through life alone. Along our journey of life and ministry, we need friends like Barnabas for mutual encouragement and support. To grow and be encouraged to seek out opportunities, we need to learn from those who have gone before us. Mentors like Paul, who can keep us accountable and share their experiences with us, can save us a lot of unnecessary heartache. To give and contribute to our communities, we also need to seek out mentees like Timothy, who we can guide, share our experiences with and encourage.

When we show grace towards ourselves and those around us, and remember to daily:

• foster an attitude of Gratitude
• take time to rest and Recharge
• show kindness and Acceptance towards ourselves
• show kindness and Compassion towards others
• invest in relationships where you can be an Encouragement and be encouraged,

We are taking positive steps towards fulfilling our calling to practise health with care, while practising self-care. Theodore Roosevelt famously said, ‘No one cares how much you know, until they know how much you care’. Applying this to our healthcare practice, I have similarly realised that,‘Patients don’t know how much you know, until they know how much you care.’  

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