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Persis Mary Hamilton has a rich background in nursing, nursing education, and writing. She has written fourteen nursing textbooks for two major publishers. Her doctoral dissertation investigated the relationship of learning to behavioral objectives and visual design in a textbook. Persis Hamilton works with Wild Iris Medical Education to ensure compliance with American Nurses Credentialing Center accreditation guidelines. She is involved with assessing needs, planning, implementing, and evaluating all nursing continuing education activities offered by the company. Over the years Hamilton has worked in most areas of nursing. She taught for more than 40 years in vocational, associate degree, baccalaureate degree, and graduate nursing programs, served as item writer for the League for Nursing, and was the principle speaker at numerous continuing education workshops. In addition, she has conducted research in Micronesia as well as Guam. Currently, Persis maintains a private practice in psychotherapy. Recently she completed a historical novel about the care of psychiatric patients in the 1930's, entitled Deportation Train.
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CASE
Carol is a team leader in a locked unit at the state psychiatric hospital. Because of recent staff shortages, she has been required to work double shifts with dangerously low staff/patient ratios. She used to feel good about her job and confident that, even though her patients were severely impaired, she was making a difference in their lives. Lately, however, she has been emotionally and physically exhausted and can't seem to relax. She complains of "nervous headaches" and stomach pains and has mood swings, exploding in rage one moment and bursting into tears another.
To survive, Carol has become distant and detached from her team members and patients. Most of her co-workers are immigrants who do not share her values or understand her approach to problems. They openly deride Carol, talk about her in their native language, and complain to the supervisor about her attitude. She knows she is not managing the situation well, but the stress of the environment and lack of support from the administration are wearing her down. She feels angry, trapped, ashamed, and a bit fearful she will lose her job.
Carol is suffering from what Maslach and Jackson call burnout, a maladaptive response to stress. The disorder is characterized by emotional exhaustion, depersonalization (detachment), and a reduced sense of personal accomplishment (1986). Caregivers, like Carol are especially vulnerable to burnout. They work in demanding situations and hold high expectations for themselves, believing they should be able to handle anything, no matter what the challenge. Fortunately, the condition is treatable and preventable. Caregivers like Carol can learn to cope with stress by gaining an understanding of stress and stressors, recognizing the signs and symptoms of overload, and acquiring skills to manage and prevent burnout.
The idea of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence. Han Selye carried on the work of Cannon, defining stress as the "rate of wear and tear on the body" and stressors as the "causative agents of stress" (1956). Selye found that stressors may be physical, such as infection, injury, and pain, or may be psychological, such as fear, anger, and sadness. He identified what he called a general adaptation syndrome (GAS), whereby the body seeks to maintain homeostasis, or balance (see box).
GENERAL ADAPTATION SYNDROME
Alarm Reaction
Resistance
Exhaustion sets in as the individual fails to adapt to stressors and becomes exhausted.
Source: Adapted from Selye, 1956.
Lazarus enlarged our understanding of stress and the ways people deal with it when he observed that, when individuals view a new or evolving situation, they first decide whether it is a threat. He called this primary appraisal. Then, as folks further monitor a threat, they evaluate their ability to cope with it by what Lazarus called secondary appraisal (1966). In this second step of appraisal, individuals may judge themselves unable to handle the situation and withdraw. Others, especially caregivers, are apt to believe they "should" be able to handle anything and attempt to do so no matter how great the cost. These individuals are at high risk of developing burnout.
Instead of persisting until they burn out, caregivers can learn more effective coping strategies, become self-aware, acknowledge their own limitations, and acquire emotion-focused and problem-solving skills. Likewise, managers can provide physical and emotional support for staff members because they value them and understand the stressful nature of their work. Likewise, caregivers can do much to prevent burnout in patients by supporting and nurturing them through what may be a long and stressful illness.
Carol, our caregiver, felt over-worked and under-appreciated. At some point she realized (primary appraisal) she was over-powered by an entrenched bureaucracy and out-numbered by an unsympathetic staff. She realized she was not performing at the level she expected of herself, she felt guilty and ashamed and feared she might lose her job.
To cope, Carol began using a strategy she had seen others employ: depersonalization (detachment and dissociation). After a while she realized (secondary appraisal) her method of coping was not solving the problem and the situation was getting worse. She was becoming emotionally and physically exhausted and began to experience the three cardinal symptoms of burnout: detachment from others, emotional exhaustion, and reduced sense of personal accomplishment.
Burnout is a gradual process by which people detach from meaningful relationships in response to prolonged stress and physical, mental, and emotional strain. The result is a feeling of being drained, unproductive, and having nothing more to give. Gorkin (2008) says that when "results, rewards, recognition, and relief are not forthcoming the groundwork is being laid for burnout." He suggests that although there are differences among people, burnout occurs in four stages: (1) physical and emotional exhaustion, (2) shame and doubt, (3) cynicism and callousness, and (4) vulnerability, collapse, and crisis.
Burnout doesn't happen overnight. It is the result of unrelenting pressure over an extended period of time, often from multiple stressors. For example, Jerry has worked more than fifty hours a week for seven years in an Internet company he started with a fellow healthcare provider. Of late, their relationship has been severely strained as their goals for the company and strategies to achieve them have grown further and further apart. Adding to the tension, the company's license to operate is about to expire and the reapplication process is time-consuming and costly.
Though Jerry works at home, he is finding it increasingly difficult to care for his wife, who is exhibiting signs of dementia; he must keep a constant eye on her lest she wander off, become lost, or suffer injury. His aged mother lives alone in a nearby cottage and also needs increasing care and attention. Jerry is not in especially good health himself, having undergone two rounds of chemotherapy in the recent past. Without question, Jerry is suffering both emotional and physical exhaustion. If this level of stress continues, he is ripe for the second stage of burnout: shame and doubt.
As individuals become more and more overwhelmed, their sense of competence decreases and their feeling of shame increases. They discount past accomplishments, even in the face of objective evidence. Gorkin suggests that although these people project an image of competence to others, a voice inside them shouts "'Imposter! You may fool others, but you can't fool yourself. You are a fraud!' Indeed, the process is not logical; it is emotional." (2008). At this stage of burnout, individuals may sigh heavily, breathe deeply, and experience a profound sense of loss, uncertainty, and vulnerability.
Normally, Jerry takes pride in doing high-quality work, but as his exhaustion progresses he begins looking for shortcuts. This gives him pangs of guilt and further undermines his self-esteem. Jerry cannot admit to himself that he is near the end of his rope and, certainly, he cannot admit this to his business partner. It is no surprise that Jerry is about to enter the third stage of burnout: cynicism and callousness.
As a defense against feelings of vulnerability and inadequacy, many individuals decide there is only one thing to do: protect themselves. Like Carol in our first vignette, they develop an "attitude," saying to themselves, "I can't let them get to me. I've got to take care of myself!" At first, the strategy works because people tend to avoid unpleasant or brusque individuals. Predictably, the strategy does not work for caregivers because they are not comfortable being "bad guys." They have always thought of themselves as gracious and accommodating and now they feel angry and rejected. As they seek to protect themselves, their hostility turns to suspicion and mistrust and they become cynical and callous.
For a while, Jerry went along with decisions his partner was making because he wanted to avoid conflict. He was not comfortable with anger and didn't want to rock the boat. Besides, he had trouble establishing boundaries. He wanted to avoid hurting anyone's feelings, much less his former friend's. Furthermore, his thought of himself as obliging and a "nice guy." At the same time, Jerry felt frustrated, rejected, and angry. He had difficulty expressing his displeasure in an objective, focused way. The conflict was taking a huge physical and emotional toll. Jerry began losing sleep, felt his blood pressure rise, his stomach churn, and his heart pound. Gorkin said it well: "Burnout does not just harden the attitude; it begins to harden the arteries" (2008).
At the fourth stage of burnout, coping skills are at their lowest level. These individuals are worn down, vulnerable, and exhausted. Their defenses have begun to fail. Old hurts and upsetting memories of past failures and poor choices have begun to seep through their protective shield. Every area of life is affected. The smallest of slights and least important omission makes them respond intensely. When someone else is recognized instead of them, the smoldering coals of sibling rivalry reignite. Nothing is going well. Everything seems to be going against them.
People in this stage of burnout are in crisis. They have been pillars of strength, dedication, and responsibility. They have provided a shoulder for others to cry on, the will to do the impossible, and the know-how to get things done. Ordinary folk would have crumbled under the load they have carried. They cannot go on. They have run out of steam and are at the bottom of a dark and lonely pit. There is no place to go but up.
To understand burnout, we need to have a better understanding of crisis. Crises are experienced by people of all ages, cultures, and socioeconomic conditions and may not be related to specific mental disorders. Generally speaking, crises begin with a precipitating event and intensify into severe emotional and physical disequilibrium. What is unique about a burnout crisis is the length of time individuals suffer high levels of stress before they reach their limit of endurance. This unique feature speaks to the perseverance and commitment of caregivers who suffer burnout.
Maturational crises have to do with predictable transitions people experience as they move from one stage of human development to another. Erik Erickson identified these stages in terms of the developmental tasks of infancy, early childhood, preschool, school-age, adolescence, young adulthood, mature adulthood, and late adulthood (1963).
Situational crises are events or circumstances that threaten the physical, social, or psychological integrity of individuals. These threats may originate in the physical body as a result of disease and injury or in the psyche of people as a result of emotional stress.
Burnout crises are primarily situational crises, although maturational issues may also be present. These crises occur after a period of unrelenting stress and result in emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. In the crises of burnout, individuals have reached the end of their reserves; anxiety overwhelms them and they become disorganized, confused, depressed, and may even become homicidal or suicidal.
When individuals reach the crisis stage of burnout, they cannot go on—they must stop. They need to:
Although these actions require determination, effort, and courage, they lead to emotional and physical health.
When people acknowledge they are burned out and in crisis, they need to take a break and get help. Preferably, they will find a therapist who is skilled in crisis intervention, one who will give them the nonpossessive warmth, accurate empathy, and genuineness described by Rogers (1961). Burned-out individuals have used up their emotional and physical reserves. During initial counseling sessions, they need to be heard, to pour out their story to someone who respects them and will give them unconditional positive regard (Carkhoff, 1977). Often their story consists of a collection of mixed-up, disconnected, jigsaw puzzle–like fragment of frustration, loss, and fear. In future sessions, they and their counselor will sort through the pieces, examine each one, and gradually put the puzzle of their lives back together again.
As burned-out individuals scrutinize each part of their story, it is not unusual to find that one or more of the pieces is a jagged, unhealed, unresolved grief of loss. The loss may be a cherished loved one, prized possession, reputation, health, opportunity, or other valued object. When unresolved bereavement is a factor in burnout, individuals need to engage in what is called grief work. This is an emotional process by which bereaved individuals re-experience their loss, loosen their ties, and gradually adjust to life without the cherished person or thing. To facilitate the process, counselors recommend people repeatedly set aside a time to grieve during which they allow themselves to experience the emotions of loss. At the end of the allotted time, they close the book, dry their tears, and return to activities of daily living. Over time, this repeated exercise facilitates the grieving process.
Though there are many conceptual frameworks to explain bereavement, the complementary schemes of Worden and Attig offer a broad view of the tasks of grieving and the coping strategies to help a person accomplish the tasks.
| Tasks* | Coping Strategies** |
|---|---|
| *Source: Worden, 1991.** Source: Attig, 1996. | |
| Acknowledge the reality of the loss. | Struggle to take in the reality of the loss. |
| Work through the emotional turmoil. | Acknowledge feelings and express them or otherwise process them. |
| Adjust to an environment in which the deceased is absent. | Adopt life pattern changes required by the loss. |
| Loosen ties to the deceased. | Find new ways to relate to the lost one and accommodate the loss in relationships with fellow survivors. |
When individuals are in positions of high stress and overwhelming anxiety, they may not realize just how stressed they have become. They may insist they can "handle it," whatever "it" may be. Over time, they become distraught, distrustful, and skeptical of the goodwill of others. They may attempt to protect themselves with a defense of cynicism and denial. However, this does not work because denial is a lie they tell themselves. However, when people confront the truth and admit their exhaustion, cynicism, and vulnerability, they open the door to health and healing. Indeed, the truth does set folks free. As soon as people accept themselves just as they are, honestly admitting their frailty, failures, and fatigue, they are relieved of the burden of being perfect and can replace denial, cynicism, and fear with acceptance, joy, and hope.
Often, individuals who are burned-out have been trying to be super people. They have been strong and accommodating, worked diligently, and persevered no matter what was asked of them. Things are different now. When folks reach a burnout crisis, they must admit they are not super beings, they are human beings and they have limits. These limits may be different from other persons, but they are real and they are theirs. As with denial, when individuals admit their less-than-perfectness, they are wonderfully liberated. In the future, they will be better equipped to heed the signs and symptoms of emotional and physical exhaustion.
Setting personal boundaries means knowing who you are, where you begin and where you end, and when to say "This is my responsibility and that is yours." Typically, caregivers are empathetic, understanding, and nurturing. All too often, they have weak boundaries and easily merge their identities with others. Such mergers are not healthy. They burden caregivers, contribute to burnout, and deprive the people with whom they merge of autonomy and self-respect. When individuals fail to maintain personal boundaries between themselves and others they may exercise inappropriate control over others and become unwitting codependents. For this reason, caregivers must take care to establish and maintain personal boundaries, freeing both themselves and the ones whom they serve.
Self-nurturance means caring for oneself. When people who are burned out and in crisis finally stop what they are doing and get help, they are beginning to nurture themselves. Good for them! Self-nurturance is not the immature selfishness of children. It is a conscious awareness of personal needs, a taking responsibility for oneself so that others do not have to do it for you. Ultimately, self-nurturance is a measure of maturity whereby folks take care of their own basic needs for survival, safety and security, belonging and affection, respect and self-respect, and self-actualization (Maslow, 1968). Practically speaking, self-nurturance means providing yourself with adequate sleep, a balanced diet, physical and mental exercise, human companionship, and self-actualizing activities.
People who are burned out may have experienced high levels of stress for such a long time they no longer know how to relax. Their home and work environment may have been so demanding that they could not take time for themselves, or they may have felt guilty when they took a moment to relax. Now they must learn to reduce their stress. Domrose (2008) suggests the following stress-reducing tips:
To recover from burnout or prevent burnout, many individuals find the regular practice of a relaxation exercise of great value.
RELAXATION EXERCISE
Problem-solving is especially difficult for individuals who are burned out because they are emotionally and physically exhausted. Nonetheless, as burned-out individuals take a break from a stressful situation, get help, grieve for losses, confront denial and cynicism, acknowledge limitations, establish personal boundaries, nurture themselves, and use stress-reducing strategies, they are ready to begin solving problems, recovering from burnout, and preventing its recurrence. The four steps of problem-solving, (1) define the problem, (2) formulate goals and objectives, (3) take action, and (4) track progress are discussed in the next section as part of burnout prevention (Leiter & Maslach, 2005).
All of the same actions that help people recover from burnout can be used to prevent it. For example, if you are beginning to feel overwhelmed by stress in the workplace, take some sick days, vacation time, or, if need be, a leave of absence. Somehow, the business will go on, your clients will receive care, and the organization will manage. Mental and physical health must come first. Find a therapist who can help you with stress and unresolved grief. Confront your cynicism and denial.
Acknowledge that you have limits and are not a super-being. Nurture and care for yourself, physically and emotionally. Find a friend who will listen and care for you just as you listen and care for them. Practice stress-reducing activities such as long walks, exercise, and relaxation exercises such as the one in the box above. Finally, do some serious problem-solving by evaluating your relationship with various areas of work that cause anxiety and increase your stress.
Whether you are an employer, employee, independent entrepreneur, or family caregiver, researchers have found six work-related areas that cause conflict and stress. These are: workload, control, rewards, social community, fairness, and values (Leiter & Maslach, 2005).
When relationship conflicts occur in the six work-related areas, stress levels rise and burnout looms. Individuals are faced with a choice of actions. They can "grin and bear" the situation or they can quit and look for job that is a better fit for them. Another option is to stay on and try to change their relationship to the work. When individuals choose to change their relationship to work, they need to take the four steps to problem-solving identified earlier, namely to: (1) define the problem, (2) set objectives, (3) take action, and (4) track progress.
The first step involves a careful self-appraisal of the situation. Ask: "Which of the six work-related areas are causing me stress?" If there are several problem-areas, prioritize the list and address the one you consider most amenable to solution.
Once you have identified a problem, make sure it is a manageable issue; be specific, positive, and practical. Set attainable objectives, preferably ones that are shared by others in the community, such as reducing time-consuming busy-work.
Take the initiative and do what you can by yourself without the approval or participation of others—such as gaining a new skill or knowledge. Some actions will need the support of others. If so, use your influence to gain their cooperation. Exercise leverage with those who have power to make changes. Give ultimatums only when you have exhausted milder approaches and when you can afford to lose.
When you achieve some change, even a small change, keep track of your progress. This will encourage you and others to continue your effort. Expect resistance to change and make adjustments as you go along, keeping your objectives in mind.
While it is true that caregivers can work to identify and solve stress-producing problems as individuals, it is important for organizations to recognize the need to reduce workplace stress and prevent burnout. When they do, these organizations become magnets, attracting and keeping staff members of the highest quality.
Attig A. (1996). How We Grieve: Relearning the World. New York: Oxford University Press.
Brigham D. (1994). Imagery for Getting Well: Clinical Applications of Behavioral Medicine. New York: Norton.
Domrose C. (2008). "Patients and RNs Face Unprecedented Stress," Nurseweek California.
Erickson EH. (1963). Childhood and Society. New York: Norton.
Gorkin M. (2008). The Four Stages of Burnout. Retrieved November 11, 2008 from http://www.stressdoc.com/four_stages_burnout.htm.
Lazarus RS. (1966). Psychological Stress and Coping Process. New York: McGraw-Hill.
Leiter MP, Maslach C. (2005). Banishing Burnout: Six Strategies for Improving Your Relationship with Work. San Francisco: Jossey-Bass (Wiley imprint).
Maslach C, Jackson SE. (1986). Maslach Burnout Inventory, 2nd ed. Palo Alto, CA: Consulting Psychologists Press.
Maslow A. (1968). Toward a Psychology of Being, 2nd ed. New York: D. van Nostrand.
Selye H. (1956). The Stress of Life, rev. ed. New York: McGraw-Hill.
Worden W. (1996). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, 2nd ed. New York: Springer.
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