Caring for the caregiver to avoid moral distress, burnout
Caring for the caregiver to avoid moral distress, burnout
While the concept is not new, discussion of it is gaining traction
Due to the altruistic nature of most health care providers, members of the giving professions often put their own needs last, often to the detriment of themselves, their colleagues and their personal lives — and sometimes their patients.
The American Nurses Association code of ethics "clearly states in the fifth provision that nurses have the same obligation to self as to others, including their own personal renewal, well-being and integrity," according to Cynda Hylton Rushton, RN, PhD, FAAN, clinical nurse specialist in ethics, Johns Hopkins Children's Center in Baltimore.
"I think it is actually an ethical imperative that nurses care as well for themselves as they do for others," Rushton tells Medical Ethics Advisor. "And that quality of care can't be achieved without a healthy workforce, which includes self-respect and care for one's own well-being."
Although the ANA code of ethics clearly spells out the need for self-care, there is no similar provision in the code of ethics for physicians. However, one physician who has written about self-care for physicians says he thinks that "in terms of just clinical practice and ethical practice, I think there is an imperative to prevent [burnout] from happening — and not just for the personal reasons of avoiding burnout on the individual level, but because of the implications it has for patient care," according to Michael K. Kearney, MD, who practices in palliative care service at Santa Barbara Cottage Hospital in Santa Barbara, CA, as well as Visiting Nurse and Hospice Care of Santa Barbara.
The two typical results of the lack of self-care and renewal in physicians — particularly those caring for patients at the end of life — are burnout and compassion fatigue, according to an article Kearney's published in the Journal of the American Medical Association (JAMA) on this topic.1
Some of the symptoms of burnout, according to the JAMA article, citing Maslach et al and Vachon, are overwhelming physical and emotional exhaustion, feelings of cynicism and detachment from the job, a sense of ineffectiveness and lack of accomplishment, and overidentification and lack of accomplishment.1
From a health care team perspective, burnout can lead to low morale, high job turnover and staff conflicts, among other things, according to the article.1
Both Rushton and Kearney say that lack of self-care can lead to the kind of "disruptive behavior" on the part of health care providers cited in a July 2008 Sentinel Alert issued by The Joint Commission as behaviors that can threaten the quality of patient care — not to mention the provider team dynamics.
Disruptive behavior is a "symptom" of lack of self-care, Rushton notes.
"People who are not doing a good job of taking care of themselves are at higher risk of having behaviors that are not respectful or are maybe [manifesting] as lateral or horizontal violence in the workplace. To me, that's a symptom of this very issue — often," she says.
Providers reluctant to discuss feelings
For those caring for seriously ill patients or those at the end of life, burnout and compassion fatigue pose a threat, primarily because some health care providers are reluctant to admit to such emotions before it's too late, Rushton and Kearney say.
"Our focus has been on caring for others — caring for patients and families," Rushton says. "And I think the culture within most of medicine and nursing has been one of not really acknowledging those needs and sort of suppressing them, or denying them. And I think it makes it very difficult for people to stay connected to the meaning of their work, and to the more fundamental commitments that they have for their professions."
Rushton says nurses, in particular are "always — always — privileging everybody else before our own self-care. And some people interpret [self-care] as we're being too self-focused, and yet at the same time, we see everyday consequences of lack of self-care on our team, on our individuals — and quite honestly — on patient care."
The lack of self-care has reached a point in recent years where, according to Rushton, providers say, "Oh, my gosh, it's gotten so bad, maybe we ought to look at this and see if there is something we could do."
Kearney echoes the fact that physicians are often so busy caring for others, they forget to care for themselves.
"You know, I think a lot of people who are drawn to the caring professions in health care are genuinely altruistic and see their role as being primarily there for others, so it's not that we don't realize that as physicians we have our own limits and have our own needs," Kearney says. "It's just that it's very much a sense of, 'We'll get round to those later; first things first.'"
Therefore, Kearney says there "may be a certain reluctance to focus on oneself and one's feelings," because within the "hierarchy of priorities within health care, this has been seen as not the first thing we need to attend to."
Kearney et al's paper weaves in the story of "Dr. C," who, for example, notes that "The stuff that burns me out has nothing to do with loss . . . It's fighting insurance companies . . . " 1
However, in published papers on initiatives to address and support self-care in pediatrics at Johns Hopkins and in articles like Kearney's focused on strategies for physician self-care, there is growing attention and discussion of the issue.
Reference
- Kearney, Michael K.; Weininger, Radhule B.; Vachon, Mary L.S, et al. "Self-care of Physicians Caring for Patients at the End of Life: 'Being Connected . . . A Key to My Survival'" JAMA, 2009;301(11):1155-1164.
Sources
- Michael K. Kearney, MD, Santa Barbara Cottage Hospital, Santa Barbara, CA. E-mail: [email protected].
- Cynda Hylton Rushton, PhD, RN, FAAN, Associate Professor, Nursing and Pediatrics; Faculty, Berman Institute of Bioethics; Program Director, Harriet Lane Compassionate Care, Johns Hopkins University, Baltimore. E-mail: [email protected].
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