Healing the caregiver

Efficacy of burnout interventions in the medical education pipeline

OBJECTIVE

Little is known about the efficacy of current interventions to mitigate burnout among medical students and residents, despite its association with mood disorders, absenteeism, low job satisfaction, and medical errors. This review summarizes the efficacy data of burnout interventions and how each modality is used.

METHOD

OVID-SP Medline, Google Scholar and PsychINFO were searched for combinations of medical subject headings (MeSH) terms: premedical students, medical students, internships, intern, medical graduate, clinical clerkship, and residents in combination with a keyword group of burnout, professional burnout, suicide, attempted suicide, and prevention. Studies with data on the efficacy from burnout prevention programs were included for review.

RESULTS

Nineteen studies were selected for inclusion in this review. Eleven different types of interventions and combinations of interventions were used. There were six studies on the impact of the 2003 duty-hour restrictions by the Accreditation Council for Graduate Medical Education on burnout. Other approaches included self-development groups, conversion to a pass-fail grading system and training in mindfulness, communication, and stress management. Half of the intervention approaches had at least one study demonstrating benefit in reducing burnout. Self-development groups, the Respiratory One Method for relaxation, and conversion to a pass-fail grading system appear to reduce burnout. The burnout data on mindfulness training and the 2003 resident duty-hour restrictions are mixed. There were no studies available on burnout among premedical students or suicide prevention among medical students or residents.

CONCLUSIONS

There is a growing body of evidence-based interventions to mitigate burnout which can be used in the development of future programs. More research is needed to identify and intervene against burnout earlier in the medical education pipeline, including at the undergraduate level.

Home health nurses coping with practice care errors

The Institute of Medicine report from 2000 ( To Err Is Human: Building a Safer Health System, National Academy Press, Washington, DC) highlighted the magnitude of practice care errors in the US healthcare system as well as the potentially life-threatening consequences they create. Nurses who make care errors experience a devastating mental and emotional impact and do not know how to deal with the experience. This study assessed how nurses cope with care errors and what strategies they use. A survey design was used for this study and 192 home health nurses completed the survey in a southeastern state. Packets containing sealed surveys, a flier, and a description of the study were mailed to the nurses. Results of the study with home health nurses indicate that nurses felt angry at themselves for making the care errors. Planful problem-solving was the most frequently used coping technique followed by accepting responsibility. The most commonly reported change in practice following a care error experience was paying more attention to detail, followed by personally confirming patient data and changing the organisation of data. Intervention research is needed to help nurses better deal and cope with care errors and to better assess the need for providing such nurses with professional support and counselling after becoming involved in a care error experience.

Burnout assessment in house officers: evaluation of an intervention to reduce stress

BACKGROUND

Medical house officers are at increased risk for stress related symptoms leading to professional burnout.

AIMS

Measure burnout in house officers and establish whether utilization of a psychotherapeutic tool individually by physicians reduces symptoms characteristic of burnout.

METHOD

Two groups of pediatric house officers at the University of California Davis Health System completed a Maslach Burnout Survey (MBS) at the beginning and end of a three-month period in 2003. An Intervention group (7 of 15 enrolled) was trained in the use of a self-administered psychotherapeutic tool. Outcome Measures were MBS scores and a qualitative interview of intervention group members.

RESULTS

There were no significant differences between the two groups, prior to the study or over time. Qualitative interviews revealed that subjects experience stressors in relation to their professional activities, but already utilize some elements of the tool and were too busy to implement the entire tool systematically.

CONCLUSIONS

Pediatric trainees did not seem to manifest burnout symptoms based upon the MBS; interviews suggested that some do experience significant stress, although manifestations and responses were varied, some may be at risk. Methods identifying individuals at risk for burnout, and interventions to cope with stress may be valuable to their training.

Regaining our humanity through story

In this issue of Innovations in Integrative Healthcare Education, we are departing from our usual format of spotlighting specific projects or programs in lieu of presenting a more extended piece by MacKenzie on relationship-centered care and narrative medicine. The importance of these topics cannot be overestimated in their role of humanizing the healthcare encounter, improving self-awareness of the practitioner, and creating a space in which the patient feels deeply listened to. A commentary by Dr Michelle Sierpina is also included in this special section to put into context the power of narrative in medicine and in patients' lives. Her recent PhD focused on the power of life stories told by seniors; that research and training enables her to provide a broad and scholarly review of the power of story in relation to MacKenzie's article. In the medical school at University of Texas Medical Branch, we send out first-year medical students in the first couple of months of the first semester to patients' homes to just get their story, not a medical history, as part of a required course on the practice of medicine. Many students find this immensely anxiety provoking, due to the lack of structure and familiar context. However, ultimately they find an opportunity to encounter a real person in a nonclinical setting. A scoring rubric based on the construction and quality of a short story allows us to grade the students objectively. However, a most interesting finding, which we expect to present at the Ottawa Conference in Australia next spring, is the process of personal transformation that such story writing has for students. This is also reported by MacKenzie in her article and in Sierpina's accompanying commentary. The importance of capturing and understanding the patient's story is also a major focus in nurse practitioner programs across the United States, where the art of listening and the importance of patient narratives have long been emphasized. In an integrative assessment of patients, we "make a history" rather than "take a history." This means that we coconstruct with the patient the reality of the medical encounter and the tone and timbre of the healing relationship. By bringing our own culture, beliefs, and values to the exam room and then allowing the patient to share theirs with us, we create a new kind of relationship-centered, patient-centered care model. This allows the strength of the linear standard medical history, chief complaint, history of present illness, past history, social/family history, review of systems, etc, to be informed and enriched by the nonlinear, perhaps circular, patient story. This story making further allows deeper exploration of the patient's life goals as well as their medical goals.(1) It creates increased personalization of the provider-patient relationship and moves from the "I-them" to Buber's "I-thou." Enjoy the article and the accompanying commentary and consider how to implement this kind of care and mindfulness into the education of health professional students and your practice.

A paradigm of integrative care: healing with curing throughout life, "being with" and "doing to"

We are presenting an integrative paradigm of care. We will review the basis for its evolution from prior series and parallel models. In this paradigm, healing and palliation (when indicated) are introduced in parallel with curative measures as soon as any diagnosis, especially a critical one, is made. Frequently palliative measures address patient symptoms, such as pain, anxiety, delirium, or depression, and are geared towards comfort care at the end of life. Our view of healing care is that it actively addresses the cognitive, emotional and spiritual needs of the patient and family, and includes the elements of palliative care as a complement. Because a loss is often experienced in many conditions, even in the absence of death, bereavement is represented in our model as an ongoing, continual process throughout a disease process. While we will be drawing mainly from experiences with children, the proposed model is applicable to all ages. In order to implement this model most effectively, it will be important to shift from our mindset of "doing to" to one that includes "being with" our patients and their families. The uniqueness of this paradigm, in contrast to other models, is its comprehensiveness and universality. It is appropriate for patients of any age, at any stage of their disease or illness, regardless of the severity or duration of their condition.

Síndrome de desgaste profesional en el personal asistencial pediátrico

BACKGROUND

Burnout syndrome (BS) is a chronic adaptation disorder that provokes serious problems in occupational behavior.

OBJECTIVE

In the present study we assessed the prevalence of burnout syndrome in pediatric healthcare workers.

DESIGN

Cross-sectional, descriptive study.

MATERIAL AND METHODS

In November 2002, the Maslach Burnout Inventory was given to 127 staff members (doctors, nurses and nurse assistants) working in a pediatrics department. The questionnaire includes 22 items that explore three aspects of BS: a) emotional exhaustion; b) depersonalization, and c) personal achievement.

RESULTS

The questionnaire was completed by 93 staff members (73.2 % of the whole sample; 83 % women and 17 % men). The mean age was 38.6 +/- 10.2 years and the median number of years worked was 10 (range: 1-37 years). Twenty-nine percent were pediatricians, 50.5 % were nurses and 20.5 % were nurse assistants. A total of 20.8 % had a high level of BS, 19.8 % had a moderate level and 59.4 % showed a low level. When sub-scales were applied, the results showed that 67.7 % of respondents presented a low level of personal achievement, 14.5 % had high scores of emotional exhaustion and 23.9 % obtained high scores in the depersonalization scale.

CONCLUSIONS

BS is present in a significant percentage of hospital workers attending pediatric patients. In our sample, the most notable component of BS was the lack of personal achievement. This finding alerted us to the eventual presence of negative attitudes toward self and professional activity, as well as to the loss of interest in pediatric care, low productivity and diminished self-esteem. We believe that specific strategies should be implemented to attenuate the factors influencing the development of BS in pediatric health staff.