Advocating for the Advocates

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Mental health providers advocate for others—but what about for themselves?

COMMENTARY

Health care professionals are taught to care for the sick—plain and simple. Sickness can come in a variety of forms, not the least of which is mental health. Mental health symptoms can occur for a vast variety of reasons (genetics, trauma, other environmental stressors, etc). If you look at the last sentence of the Florence Nightingale Pledge that nurses take, it states “...devote myself to the welfare of those committed to my care.”1 This sentence can be interpreted in many ways. One could say that this refers to partnering with others in the care of patients, while another interpretation may be that we need to focus on the care we receive as caregivers, or “my care.”

Physicians take the Hippocratic Oath, which states “... and to live an exemplary personal and professional life.”2 Many professionals take similar oaths. Living up to these oaths is now more important than ever, especially with the mass resignation we are facing as a country. There is already a huge deficit in mental health care. In fact, over one-third of Americans live in a mental health care shortage area.3 The workforce shortages for nurses are expected to continue for many reasons.4 Some of these reasons include limited capacity of nursing programs for enrollment, shortage of nursing school faculty, an aging workforce, changing demographics, insufficient staffing contributing to burnout, and high turnover rates.4

We frequently speak with students eager to work in the mental health field, and with such shortages come amazing financial opportunities, which can certainly grab the attention of new graduates. However, many overlook the potential for burnout. Why would they even consider burnout just starting their careers? They are just ready to learn and to help others. For those of us with more experience, why would we consider burnout? Burnout is often loosely defined, but 1 definition we find to be helpful and comprehensive is “a condition marked by irritability, fatigue, problems with sleep, weight gain, feelings of helplessness or hopelessness, and social isolation.”5 A great metaphor for managing burnout is when flying on an airplane, put on your own oxygen mask before helping others.

Identifying Burnout

How do you know if you are burned out? For both of us (the authors), many signs are not only self-evident, but clear to friends, family members, and other supports. When you are working in a caring profession and spend your time attending to the needs of others, it can take some time to process and recognize your own needs. The signs and symptoms can vary. One now glaringly obvious sign, looking back, is that one of us purchased a book about burnout while combatting burnout—but felt too burned out to read it.

What does it mean to help yourself? How does one even begin to address this issue? We all know the strategies of breathing techniques, reframing, mindfulness, getting appropriate sleep, and eating well (among a variety of other things) in terms of self-care. We can teach and educate our patients about those things without a problem, and almost via muscle memory. However, there is more to the story. Let us divide this into 2 categories: 1) What kind of job do I have/need?, and 2) Completing your “stress cycles.” The emerging concept of stress cycles is starting to become more widely recognized. Stress cycles are biological processes that have a beginning, a middle, and an end.6 We are not meant to live in 1 part of this cycle.7

What Kind of Job Do I Have/Need?

Category 1 applies to new graduates and experienced providers alike. I once had a supervisor who told me (Jonathan) that “the thanks you get from an employer is your paycheck.” So, stop and ask yourself, “Do I feel valued or “thanked” enough for the work I do, as evidenced by my paycheck (or potential paycheck)?” However, money is certainly not everything. Next, we would urge any provider to look at how long are they able (or allowed) to spend with their clients. We have had countless conversations—many with psychiatrists—who see 4 to 6 clients per hour for 10 hours at a time tell us that they feel so “lonely” and “isolated” throughout their days.

So, does your current or prospective job treat clients as a paycheck or as human beings? How do you view your clients? Connection with clients can be very rewarding, and it is a therapeutic intervention in itself that cannot be underestimated. Seeing fewer patients may seem counterintuitive, as most providers want to help as many individuals as possible. However, seeing fewer patients can be protective of your own mental health and enhance the quality of the care you provide to the patients you are seeing.

There are other things to consider, of course, regarding employment, such as health insurance, CME allowances, paid time off, retirement contributions, support staff, call responsibilities, patient coverage, and various other items. Some of those may be a higher priority to you than others, and it may be helpful to take inventory and identify your high-priority, nonnegotiable items, and the items that are not as important for you in a role. You can protect yourself against burnout by ensuring you feel prioritized when you evaluate your current or future position.

If you are already in a role, and it does not align with your inventory, perhaps you should leave that role. We have worked for and have spoken with colleagues across the country who have worked for institutions that value productivity over their providers’ mental health. We both have made decisions to prioritize our own well-being and leave those positions, and those decisions were not taken lightly. We first had to identify the symptoms we were experiencing of burnout (as outlined above), and then evaluate our needs, and then evaluate the “thanks” we were receiving. This was an arduous process for both of us, to say the least, and it is certainly much easier said than done.

Stress Cycles

Category 2 is “completing stress cycles.” As providers, we tend to absorb a variety of stressors throughout our day, but how does one complete this cycle? The first step is identifying the stressor(s); the second step is completing the stress cycle.7 “The most efficient way to complete the cycle is any kind of physical movement; other effective strategies include deep slow breathing, positive social interaction, laughter, affection, cathartic crying, and creative self-expression.”7 Completing these stress cycles is protective against burnout. Not completing these stress cycles ultimately leads to burnout. So, now more than ever, let us advocate effectively not only for our patients, but for ourselves, as well.

Moving Forward

There are opportunities at the individual, leadership, and organizational levels to shift these problematic health care workplace culture dynamics.8 Top-down, hierarchical leadership constructs do not facilitate empowerment of individual providers.8 Leadership impacts workplace culture, and workplace culture can either promote or prevent burnout in providers.

In a review by Tawfik et al9 examining the relationship between health care provider burnout and the associated quality of patient care, the authors reviewed 123 publications that featured participation of 241,553 health care providers. The overall findings were that health care professional burnout was often associated with poorer quality of care.9 It would be interesting to further investigate how health care organizations assess and monitor the burnout of their providers—if they monitor it at all. There is limited literature evaluating provider satisfaction in nurse practitioners. Resources directed at burnout largely place the onus of responsibility on the individual, rather than providing a call for accountability at the organizational level.

There are a variety of organizations that claim to put people first, and some tout recognition as being for companies that put people first. However, no matter what claim a company makes or what recognition it says it has to offer, trust your own experiences. Choose to end your own burnout first before deciding which actions to take next. Remember that, as advocates, we need to advocate for ourselves to “put on our oxygen mask first” so we can continue our important work on behalf of others.

Mr Hickman is a psychiatric mental-health nurse practitioner on the Seacoast of New Hampshire. Mrs Robinson is a psychiatric-mental health nurse practitioner on the Seacoast of New Hampshire; and clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

References

1. The Florence Nightingale pledge. Pedagogy. Accessed January 11, 2022.

2. The Editors of Encyclopaedia Britannica. Hippocratic oath. Encyclopaedia Britannica. Accessed January 11, 2022.

3. Over one-third of Americans live in areas lacking mental health professionals. USAFacts. June 9, 2021. Accessed January 11, 2022.

4. Fact sheet: nursing shortage. American Association of Colleges of Nursing. 2020. Accessed January 11, 2022.

5. Wei M. Self-care for the caregiver. Harvard Health Publishing. October 17, 2018. Accessed January 12, 2022.

6. Rodquist-Kodet A. Completing our body’s stress response code. University of Kentucky Human Resources. Accessed January 12, 2022.

7. Nagoski E, Nagoski A. Burnout: The Secret to Unlocking the Stress Cycle. Balantine Books; 2020.

8. Schein EH, Schein PA. Humble Leadership: The Power of Relationships, Openness, and Trust. Barrett-Koehler Publishers; 2018.

9. Tawfik DS, Scheid A, Profit J, et al. Evidence relating health care provider burnout and quality of care: a systematic review and meta-analysisAnn Intern Med. 2019;171(8):555-567.