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BURNOUT IN HELPING PROFESSIONS...and what we can do about it



As we embark on year three of Covid, the teaching and nursing crises seem to be approaching “evermore” status, and not in the enchanting Taylor Swift way, but in a critically dangerous way.



So, here’s my question... what are we doing about it? I took this week’s podcast episode and blog to explore just that.


Like most arguments I make, I like to start with data. Is this an effective strategy when debating another person, not always. But be sure, I leave you with actionable solutions for you and your managers.


I’ll speak mostly about nursing, as it’s what I’ve experienced and have researched more heavily, but will periodically make connections to the other, largely woman-dominated helping profession: teaching. Last week we discussed the invisible work of women and asking for help in an ultra-independent western society. Throughout that episode we talked about the unpaid work of women at home through domestic labor and childcare. And women in the workplace, largely in the form of office housework, emotional support and Diversity, Education, and Inclusion (DEI) work.


This led to curiosity about my former field: Nursing and Healthcare, and its sister field: Teaching and Education. It’s unsurprising to me that these fields that are mostly operated by women, involve bottomless emotional and physical labor, are systemically understaffed, while being simultaneously and sneeringly undervalued. Does it shock anyone that the roles of mother, nurse, and teacher are flooded with woman, and are belittled. While their impact on the larger ecosystem is unparalleled and conveniently ignored. There’s enormous entitlement from society that although these areas of work are imperative to the health and growth of our communities, since they are historically deemed “women’s work” they’re devalued and therefore under-budgeted.



The United States is the only high-income country to not offer paid parental leave on a federal level; she-faulting the responsibilities for caregiving and domestic engineering to women…for free… Nurses and teachers, around 3/4 of which are women, are historically overworked and underpaid. It’s crystal clear that society runs on the unpaid labor of women. And frankly, I’m at a point with all of it where I’ve become increasingly comfortable with burning it all down.







Health insurance companies raking in billions of dollars a year… "see ya bitch."




I’m done.




That may be too dramatic and excessive, but is it? Is it really? Ya’ll medical insurance companies, like United HealthGroup, profited $28.4 billion last year (2022).


Although, before we burn and build, we need to understand the current foundation. Think of this portion of the post as land surveying. We’re taking stock of the current ground, the potholes, and slippery slopes before constructing something beautiful on top.


Since I can’t resist a top news story moment: Let’s start with a commonality between teachers and nurses, since over the past couple of weeks they’ve shared a community: Florida, our fun, crazy, racist, rich, good times friend... that we use for vacation...but morally disagree with on a lot of fundamental issues. Over the last week we’ve heard Ron DeSantis, Florida’s governor, reject African American Studies. And Markenzy Lapointe, U.S. Attorney in Florida, charge 25 people with participating in a wire scheme fraud; that allowed untrained persons to obtain nursing degrees. Permitting them to sit for boards, of which 37% passed, and afterwards helped them find employment. Again, here's my question… what are we doing about it?




Well, for these specific situations, Floridian high schoolers have threatened to sue DeSantis, gaining the support of civil rights attorney Ben Crump as well as politicians and persons of power across the educational and political spectrums. As for the 7600 fraudulent degrees, totaling $114 million between 2016-2021, more than two dozen people have been charged, each facing up to 20 years in prison. I’m not a lawyer and have little desire in pretending to be one by reading the charge documents. But if that kinda stuff tickles your pickle – see the "charged" link above. You can knock yourself out.


This nursing scheme furthers the already weakened and fragile trust people have in the American Healthcare system. But let’s be clear, that’s distrust in the system, not the nurses themselves, as a 2022 Gallup Poll reports that 79% of Americans rate the honesty and ethical standards of nurses as “very high” or “high”, the highest of a diverse set of professions, but does highlight a 10-point drop since the 2020 ratings. The 20-80% distrust in the for-profit American Healthcare system is strongly associated with the avoidance of care, unlikelihood of continuing care and a higher need to monitor and confirm their health care decisions. Those who distrust the system are more likely to have infrequent visits, resulting in higher overall costs (i.e., preventative medicine is generally less expensive than curative treatment). If one lacks trust in a system, they won’t participate in it until they have to.


The nursing profession has seen its fair share of stagnation, but as the pandemic waged on it’s gotten significantly worse. In 2021 alone, we lost more than 100K nurses, a larger drop than ever in the past four decades. Most notably from those under the age of 35, which underwhelmed expectations by 80,000. It’s estimated that 17-30% of nurses leave within the first year, and 30-57% by their second. Since historically since nurses have stayed throughout their career, this poses huge implications for the ability to provide safe and adequate healthcare. This is where we see an interesting crossover with teaching, where young teachers and those early in their careers are most likely to leave. So, what gives?




Like any job, it takes time to get your feet wet, learning how to organize and prioritize the work. However, they also report bering woefully underprepared, resulting in feeling overwhelmed and incompetent. I’ll address this towards the end when we get to action items.


The national teaching attrition rate usually hovers around 16 % but could jump to 25-54%. Nursing, historically around the same, 17% between 2017-2020, but in 2021 jumped to 27.1%.

“Doesn’t anyone want to work anymore”

has become the new Boomer executive chant, channeling a “Kim K undertone” that screams “get your f@*king ass up and work.” While continuing to ignore the call coming from inside the hous-pital.




Nurses at Mount Sinai in Manhattan and Montefiore Hospital in the Bronx just ended a three-day strike over poor staffing and pay, both of which they received in negotiations. Should it have come to a ½ a week strike, putting patients and other medical professionals at risk. No. No it shouldn’t have. The message – if you want it, you gonna have to fight for it. Okay, then we’ll do just that.




Both teachers and nurses note significant reasons for leaving are poor leadership support and burnout amongst a stressful work environment, inadequate staffing and better pay and benefits elsewhere. As an Executive Leadership Coach and Organizational Learning and Development Facilitator, I’ll cover: 1) Burnout and 2) Leadership. As I make my way through my master’s in organizational change, I may possibly do a follow-up post to tackle staffing, pay and benefits.


Burnout is a technical term that was first coined by Herbert Freudenberger in 1975, after observing patterns in his “helping profession” patients. He defined burnout as

“progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the condition of their work.”

In the 80s, Christina Maslach, an American Social Psychologist, began to study the phenomenon. Eventually becoming the expert in occupational burnout with her creation of the Maslach Burnout Inventory, which has become the standard tool for assessing burnout. I’ll detail the assessment shortly. Freudenberger, Maslach and the World Health Organization agree on the following three criteria:


1. Emotional Exhaustion: which is caring too much for too long. This is most strongly linked to negative outcomes in our health, relationships, and work – especially for women since they tend to shoulder the majority of emotional labor across the board.



2. Depersonalization: a decrease of empathy and compassion. This is the medical professional with bad bedside manner. Now this person could just be an asshole, but another possibility is burnout.



3. Decreased Sense of Accomplishment: which is a sense of futility; like nothing you do is going to make a difference, so why try?




Burnout was added to the 10th edition of the International Classification of Diseases (ICD-10), and last year with its 11th edition included the following definition:


“a syndrome conceptualized as resulting from chronic workplace stress that has not be successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job and 3) reduced professional efficacy.”

All this to say is that burnout is: I’ve cared for too long, I don’t care anymore, and it doesn’t fucking matter. Our healthcare professionals and educators are feeling this way daily. It’s unfair and dangerous to them and the population they serve. Leadership must be addressing it head-on and empathetically; I’ll share my recommendations shortly


In the Journal of Patient Safety, they evaluated status quo units compared to ones with a “burnout reduction program” and decreased nurse burnout. The status quo hospitals spend on average $16,736 per nurse, per year employed on nurse-burnout attributed turnover costs. With a burnout reduction program, such costs were reduced to $11,592 per nurse, per year employed. That’s a difference of $5,144 per nurse, per year employed. At the time I left the hospital, I had 4 years under my belt. Theoretically, my hospital would’ve saved $20,576 if they had addressed burnout head on.


According to a 2018 Press Ganey Nursing Special Report: Optimizing the Nursing Workforce: Key Drivers of Intent to Stay for Newly Licensed and Experienced Nurses the average hospital can lose $4.4 million- $7 million annually, due to nursing turnover. This estimate includes overtime, closed beds and diversion, and paying for agency nurses, who make between 151%-237% more than staff RNs. Not to mention the time, energy, and cost to advertise & recruit, which can take 66-126 days. Then orient, and train new RNs which is usually around 3-4 months. And of course, decreased productivity. The report estimates, each 1% percent change in nurse turnover is worth $337,500 in either direction.


The thing is, it’s been noted that removing the stressor (i.e., having a day off or leaving early) is not enough. We have to move that stress through, and out of our bodies, to feel differently. I want to differentiate stress from clinical depression or anxiety, that may require medical treatment. Burnout is an organizational phenomenon, that may result in serious psychological disorders, but that’s not what I’m speaking about here. For our purposes we’re discussing the number #1 reason nurses are leaving in droves, which is a stress. I’ll talk more about stress management shortly, but first allow me to paint a picture of what the life of a hospital staff nurse is like.


To begin, she usually works 12-hour shifts – either 7a-7p or in the reverse, overnight while you’re sawing logs. Most of the time, she’s walking into an absolute clusterfuck of an over-crowded unit with dangerous nurse to patient ratios. She’s hounded about charting, policies, and procedures to a point where her clinical autonomy is stripped away, resulting in a very cookie-cutter, robotic approach to care. She tolerates verbal abuse from other staff and physicians and unacceptable physical abuse from patients. In addition to microscopic amount of time, they have to sit, eat or even use the bathroom. This may explain why 6:10 Americans believe nurses are underpaid, while about 7:10 believe hospitals and insurance executives are overpaid.


Y’all can keep spouting off projected career growth numbers and the promise of job security but you won’t keep us until you address the concerns nurses have been speaking about for decades. First of all, there will be job security in any position that has an obscene amount of vacant, unfilled positions. This is not a flex. Second, you can keep your nurse’s week, cheap-ass, water tumbler blasted with the hospital logo, mkay? Pass.




It’s becoming progressively difficult for nurses to provide the care they wish to deliver and foster a connection with their patients, with the ridiculous amount of defensive charting that’s required. I can’t begin to tell you how much of Labor and Delivery nursing is excessive, detailed, and cumbersome charting while trying to not only, assist in keeping parent and baby safe during delivery, but bond with someone during one of the most vulnerable moments of their lives. I had to wonder, was it more about quality care and patient experience, or ensuring that care was charted litigiously. Are we more focused on defending ourselves in court or delivering excellent healthcare? Most days, I couldn’t be sure.




We see the negative impact of burnout through absenteeism, decreased productivity, high attrition rates, communication breakdowns, nursing errors, poor patient outcomes and physical symptoms like headaches, insomnia, cardio, and immune diseases… to name a few.


Those at risk are those that work overtime, have a lack of autonomy in how they perform their job functions, receive insufficient reward, lack work community, and experience a deficiency in fairness.


Other risk factors include a conflict in values, unclear job expectations, and extremes of activity. Personality traits like low self-esteem, a lack of awareness or boundaries, drive to overachieve, and need for approval are also burnout contributors. For nurses and teachers who are usually over-giving and empathetic people, they are highly susceptible to burnout and have been taken advantage of for too long.




Though, through self-development, increased self-awareness, and clear boundaries one can improve some of these traits; that have formed out of habit or survival. As we’ve discussed, women hold most teaching and nursing positions, so let’s connect a few dots here. Ameila and Emily Nagoski discuss Kate Manne’s “Human Giver Syndrome” in their aptly named book Burnout: The Secret to Unlocking the Stress Cycle. The concept of the “human giver” is when one, usually a feminine presenting person, is morally obligated to give away their humanity - their time, energy, love, attention, and bodies to others; without expecting anything in return. As opposed to “human beings” who are morally obligated to be their whole humanity. If you’re hungry for more, I discussed this concept in relationship to the unpaid work of women and ultra-independence in the first episode..


In a 20 min read, we’re not going to rewrite “dawn of time” societal programming, but we can review stress management, leadership training and organizational support. You can then demonstrate the stellar leadership you crave by presenting these options to your hospitals, clinics, and schools. You know I have the data to back it up too so, if you want it, just let me know. It can help beef up the request…cough cough…demand.




Let’s start with stress management. If you’ve been following me or have taken my 2021 courses, this will be a review. If you’re new to emotional regulation and stress management, I hope the next 5 mins or so makes your stress a tad more tolerable. I’ll review the most popular and effective ways of completing the stress cycle but let’s take a moment to define success. It’s important to recognize that if we’re backlogged in stress, one workout or crying session may not make you feel 100% better. Our goal here, doesn’t consistent of all or nothing. Our target is to monitor any change. To overuse obnoxious organizational jargon - we just need to move the needle a little. You’ll know you’re completing the cycle if you feel even incrementally better. You may need to run through more of your personal self-care menu to continue making a positive impact. To help you construct that menu, I created a worksheet for you.


Okay, let’s review 8 of the most effective techniques for stress management. You may want to grab a pen and paper:


1. Movement: is the #1 scientifically proven way to complete the cycle. But movement means different things for different people, so move the way you feel best for 20-60 mins per day. The important thing is finding the ways you like to move your body the most, so you continue doing it. Sedentary lifestyles are a pain. Literally, and linked to a host of physical and mental complications. There are movement options for everyone that don’t include gym bros and marathon training schedules. Taking a walk, stretching, dancing in your kitchen are wonderful options. If you don’t know where to start, see this free app full of home workouts ranging from gentle yoga to HIIT (High Intensity Interval Training)

2. Being Social: According to research, people with more acquaintances are happier. And as a tried-and-true introvert who had little qualms about pandemic social isolation, I was bummed to hear this. So, my brain actually needs other people... Fuck. Being social in a simple conversation with the cashier at the grocery store is enough to reassure our brains that we and the world are safe, and that not all people suck!

3. Breathing: Slow, deep breaths switch our nervous systems from the sympathetic, flight/fight/freeze, to the parasympathetic, rest and relaxation. The “5-5-7 Breath” is a great place to start with this. You inhale for a count of 5, hold for 5 and exhale for a count of 7. Repeat this cycle 10 or more times until your body feels calm. The number of seconds is not as important as the process of hold your breath at the top and exhaling longer than inhaling. Whatever count feels good to you, do that! This is good practice for bodily self-awareness, otherwise known as somatic awareness. When coaching behavior change, bodily awareness is huge in noticing triggers so we can interrupt the spiral.

4. Meditation: Neuroscience research has shown that mindfulness practices decrease activity in our amygdala, our emotion center, and increase connections between the amygdala and prefrontal cortex, our logic center. This helps us be less reactive to stressors, recover better when we experience them and access planning and logic skills during. Don’t get me started on the patriarchal narrative that women are more emotional. No boo, you just believe anger is not an emotion or at least an acceptable one. There’s no gender difference in the brain.

5. Laughter: According to neuroscientist Sophie Scott, it is an “ancient evolutionary system that mammals have evolved to make and maintain social bonds and regulate emotions.” If you’ve laughed while reading this post, you’re welcome. We’re regulating emotions right now. “We are so on the right track, you know? We are working. We are clicking.” Quick, where’s that from?...


I’ll give you a couple more seconds…


F.R.I.E.N.D.S - Rachel Green and "Josh-u-a"





6. Affection: Affection focuses on a deeper connection with another person. This does not automatically mean physical affection, as we can be emotionally connective. But, a warm, 20-second hug, has been shown to have value. This is co-regulation where we assist each other in regulating our nervous systems. Its why babies want to be held, it calms them down. We’re all just bigger babies running around pretending we’ve got it all figured out. We don’t.

7. Creativity: Of course, creativity includes things like painting and sculpting. But it could also be interior design, creating a photo album, constructing a bulletin board in hallway at work, or reading a book and using your imagination to picture the scenes. I mean, grab some colored pencils and a coloring book, and call it a day. We don’t need to reinvent the wheel here.

8. Crying: I’ve saved my favorite for last! If you know me at all, you know that this is true. Crying is a great example of dealing with the stress not dealing with the stressor. Listen, crying doesn’t eliminate our problems. But like, no one claimed it did. That’s not the point. So, let’s break this crying stigma down. Crying doesn’t make your boss a kinder human. It doesn’t magically increase staffing or give you the support you deserve. But it does physically release the hormones associated with the stress, which completes the stress cycle. I mean… it sounds super rational to me. Continuous tears which lubricate our eyes, contain 98% water. Emotional tears, however, contain stress hormones and other toxins. The research suggests that when we cry, we release these hormones from our body. So, grab a tissue and let ‘er rip. I hope no one walking by and only read that line. That would be unfortunate and super embarrassing.


You’re probably thinking, that’s all well and good Linds. But like... work is still a shitshow regardless of what I do. Leadership support is still significantly lacking. Don’t worry, I got you. Let’s gather some background.


A lack of good management or leadership is consistently reported as a top reason for nursing turnover. Gallup has reported that managers account for at least 70% of the variance for employee engagement.


So, what can our managers and organizations do to address these concerns…


We can begin by assessing the current level of burnout on our units through interviews and assessments with our staff. We can do this through tools like the Maslach Burnout Inventory that I mentioned earlier, that yields threes score for each respondent:

1) Exhaustion

2) Cynicism

3) Professional efficacy.


While it’s important to highlight those in need of more individualized support, this is not the time for that. Here, we’re assessing where we are as a team so we can begin constructing systems for change. I’ll discuss personalized support shortly.


The three categories are brought together to generate five profiles: Burnout is on one end and engagement is on the other, with the other 3 falling in between:


  1. Burnout: negative scores on exhaustion, cynicism, and professional efficacy

  2. Overextended: strong negative score on exhaustion only

  3. Ineffective: strong negative score on professional efficacy only

  4. Disengaged: strong negative score on cynicism only

  5. Engagement: strong positive scores on exhaustion, cynicism, and professional efficacy


From here we can focus which areas and what specifically needs our most focused attention so we can actually address them.


To manage individual needs, managers can prioritize 1:1 touch bases, coaching sessions, and check-ins, especially with 1st and 2nd year nurses, since they’re at such a high risk for leaving. Within these conversations we can discuss desired career trajectory, professional and personal development, ideas and needs to improve the unit. These are regular, standing sessions that are prioritized for the health and safety of staff and patients. No one can pour from an empty cup, even nurses and teachers. We must take care of them so they can take care of others.


I vividly remember my former manager telling me that I should be picking up overtime shifts, without expecting an incentive because it’s the “right thing to do”. Ughhh… I respectfully disagree, mam. The right thing to do is pay your nurses an provide adequate staffing so I don’t have to work overtime.



These 1:1 session will only be as impactful as the caliber of emotional intelligence and communication skills the involved leader. Which is why, professional development leadership coaching and management training focused on relationship building, effective communication, boundaries, and stress management is imperative for success, should be prioritized to their schedules and budgeted for.


Other focuses include:


  • Strong, holistic, person and skill centered orientation programs

  • PTO for CEUs (paid time off for continuing education)

  • Decreased mandatory overtime: a no tolerance for guilting into extra shifts.

“No.”


It’s a complete sentence. If you have to guilt or bully people into staffing your unit, you’re the problem.


🎵 It’s you. You’re. You’re the problem, it’s you.

Really bringing that Taylor Swift reference in the intro full circle.


We can also evaluate our alignment with our organization through a Values-Based Assessment. This can highlight what’s important to us, highlighting how certain situations are extra triggering and provide a foundation for further discussions with nurse leaders and hospital executives.


We can provide emotional and coaching support to staff during their shift. This would be built into your burnout reduction problem. Where a trained coach, with a nursing background, is available for conflict management, stress reduction, and coaching support in real time. This alleviates the burden on other staff and managers to provide this support, while also delivering a 3rd party, objective perspective for conflict resolution.


It’s the prioritization of assessment and reflection that goes undervalued and incomplete; in most arenas, not just healthcare and education. Building it into our schedules is essential to solving our most pressing problems, increasing the well-being of the staff, and providing an excellent experience for our patient population. To address the root cause, we must be willing to dig beneath the surface.


RESOURCES



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