10:14 PM. I am just getting ready to lock the clinic and go home after my last session for today. My phone rings. It’s an unknown number. “Good evening, my name is G.” says the voice at the other end of the line. “I’ve got your number from a friend that worked with you. I think I need some help. Can we please meet?”
I’ve met G. in person two days later. He was a team leader for a team of paramedics working for a university hospital. He talked passionately and proud about his job and his team, but it was something about the way he was talking that evoked sadness, emptiness. “I work anywhere in between 80 and 100 hours a week and I constantly have the feeling that I have to be there, that everyone else depends on me, that is never enough.” He talked about the burden of being in close and continuous relationship with very misfortune clients and having to provide comfort to their families. I often have people dying in my hands, wondering if I could have done anything more to save them.” About feeling always stretched and exhausted and barely being able to see his family due to the ungodly working shift patterns. “I still want to help but I simply don’t feel I can do it anymore. I started to withdraw, to try to get less involved to not spend time with my colleagues after work as I used to. It was my dream as child to become a paramedic, and I loved every bit of it for years but now it starts to feel like a nightmare.”
Everything that he was talking about indicated that this could be burnout. There are many different ways to define burnout, but in essence burnout is a prolonged emotional and physical response to chronic stressor at work. I already knew that the impact of burnout could be profound not only into the lives of health practitioners who will directly experience its effects, but also into the lives of their patients, users and members of team. All in all it has a tremendous negative impact on the quality of care services.
It must be horrible to go through this, I thought. Little did I know that only a few years later I would have find out on my own skin how it feels. We had two sessions together. Towards the end of the second session whilst talking about how difficult is for him to tell his colleagues how he feels because he does not want to worry them, he suddenly stopped talking and his eyes filled with tears. “I just realized that almost everyone in my team probably feels the same. Going through the same struggles. Should I ask them to come and see you or your colleagues here at the clinic?”
“Why don’t we all work together?” I said. “In a group. Individual work can be really useful, but you are going through similar experiences. Working as a team. Being there for each other on the field. I think you can help each other here as well. I think if we work on this as a team it can be so much more effective.”
I filed a request to use the board room in our clinic, once a week for 2 hours. We had our first meeting exactly two weeks later. I brought my colleague Dan with me. G. brought 11 of his colleagues. Their stories were ever so similar to G’s story. Together, we started a journey that lasted 4 and half months. 20 weeks. 18 sessions in total. 90 minutes each session.
During the first session we took time to know each other, to understand what are the main issues that we can address in our time together and what would be the best way to do that. We used mind-mapping and brain-storming to explore what might cause burnout, basically to find out what hurts, and where, and how, to find commons goals that the group wanted to achieve and identify paths and links to bridge the gaps between the issues and the goals. All the contributions were written down and arranged on a white board and used as a menu from which to choose themes of discussion in the following sessions. We wanted to create an experience in which we fully involved the group members rather than impose a prescribed set of interventions.
We constructed our intervention method roughly on the Balint approach of group therapy. Developed by a physician called Michael Balint in the late 50’s it was one of the first structured interventions designed to address burnout in the medical field. It remains until today the most used burnout group intervention and its emphasis is largely on helping the group members to improve their understanding of their relationship with their job and their relationship as a team, enabling them to find common solutions to the issues they struggle with. Respecting the uniqueness of this method, we as facilitators tried to have little involvement in the group discussions and merely focused on facilitating the process and keeping the participants focused on the goal of self-reflection of shared similar experiences, thus empowering them to engage into a creative and bespoke problem-solving process rather than just feed pre-designed generic answers and solutions.
Also, in order for us to be able to measure to extent of everyone’s burnout level and to track the progress of this journey that we were about to embark on, at the end of the first session we assessed the 12 members of the group by using a combination of Maslach’s Burnout Inventory and Leiter’s Areas of Work Survey. Both of the measures have a demonstrated reliability and validity across a variety of occupational settings and are widely regarded as the best tools to measure burnout. Maslach’s Inventory assesses the three main dimensions of burnout: exhaustion, depersonalization and self-efficiency. The AWS looks the at 6 work areas mostly associated with burnout: workload, reward, sense of community, fairness, values and control. We looked at levels of frequency and intensity for all measures. The assessment also gave us a really good insight into further discussion topics.
In the weeks that followed participants focused on topics on a wide range of topics such as: risk factors, triggers and warning signs of burnout; effects and consequences of burnout; stages of burnout and stages of recovery; dimensions of burnout and organizational influence; self-care at the workplace; awareness of own resources and limits; personal boundaries; time management and goal setting; role, identity and self-image; changing attitudes and reactions; building stress resilience; developing preventive strategies and job crafting.
In addition to the group discussions, over the course of the 18 sessions our approach also included a highly integrative range of interventions such as cognitive restructuring exercises for exploring perceptions of inequity, stress management for developing coping skills, mindfulness strategies for learning relaxation techniques, rational emotive therapy for enhancing assertiveness and interpersonal skills, drama therapy and role play for learning to recognize emotional responses , existential therapy exercises for defining and strengthening values and beliefs – all coming as an answer to particular needs brought up by participants in the sessions and introduced at the end of each group session. All of our sessions started with a short (10 minutes) seated and guided meditation. All these exercises and methods alongside with a description of the aim and background of the intervention were compiled into a manual and workbook by myself and Dan given to each participant.
We used our last session to reflect at the work that we have done together. We asked everyone what was it like was to participate in this group and what impact, if any, has participation had for them. We looked at ways in which they can make the changes they have achieved permanent and looked at various sources of support they can access in the future.
All initial 12 participants were still there, which was a good sign in itself. From an individual perspective they all talked about finding balance, growing self-confidence, energy and vitality, better personal boundaries, better at finding solutions to daily stressors. From an organizational perspective they talked about development of opportunities at work, increasing participation at work, feeling more supported at work and also feeling better at offering support to other colleagues, better job satisfaction, and better communication skills. The levels of absenteeism (especially sick calls) have reduced significantly over the course of thee 4 and half months.
We compiled our participants’ suggestions on organizational changes needed to prevent stress and burnout in a document that we have presented to the directorate of the hospital and into a presentation for emotional wellbeing at work conference.
It also help us, the facilitators, to understand how such an intervention can provide an opportunity for discussion and reflection within colleagues, focusing on work-related stress and burnout, with one’s own unique situation and experience as starting point. It can provide an opportunity for mutual support between colleagues, to share and compare experiences with colleagues, and also learn from each other.
From a technical perspective when we measured the burnout scores again at the end of the last session we observed that overall burnout decreased from 54% to 37%, emotional exhaustion scores decreased from 23.82 points to 18.17 points, and depersonalisation score decreased from 9.05 to 7.41. High emotional exhaustion decreased from 38% to 21% and high depersonalisation decreased from 38% to 29%. We asked everyone to complete a short version of the questionnaires at 3 months and then 6 months after the end of our group and the reduction into burnout symptoms have remained constant at both times. We also encouraged all participants to meet at least once a month in the form of a support group and continue the work that they have started in our group.
As soon as we started this process we wondered how much of this is going on out there? A few weeks into our group work we went to enquire further, to ask around and do some research. We send a short form of our questionnaires to all public and private emergency care departments in the city. The results were striking. The problem was epidemic and its prevalence amongst emergency care staff was really worrying. More than 80% of respondents displayed signs of burnout.
We put our findings together in a grant proposal. We took the best out of our initial experience and narrow it down to a module of 12 sessions. We wanted to have the resources to help as many people as possible. The proposal was successful. We had the chance to expand our intervention into an 18 months programme. 122 doctors, nurses, paramedics, ambulance drivers, fire fighters and health care assistants from emergency care units around the city. Both the process and the results were mirrored in all of the subsequent groups. This was the beginning of Twelve.
On this fantastic initial journey I learned a few things that I would like to share with you:
There is no specific therapy for burnout. It is a unique condition that is created by such a mixture of individual, organizational and societal factors that calls for a highly integrative and bespoke approach. Creating a group approach and strongly promoting a sense of community and support that will be maintain in the organizations after the interventions have the strongest positive impact on reducing and preventing burnout levels. The ravaging damage that this can cause to people’s wellbeing definitely calls for development and use of robust assessment tools and preventive measures in every single organization. Such preventive measures will come at a so much reduced cost compared with the pharmacological and psychological interventions meant to tackle the consequences of burnout.
Prevention can come at two levels, primary and secondary prevention.
The prevention mechanism can be either primary or secondary. Primary prevention takes place in the phase of human resources selection and is aimed at identifying those employees at risk of burnout. Once identified these employees, it is possible to proceed building an individual project of prevention for each of them.
Secondary prevention implies to follow precise techniques of prevention in which employees are given the chance to explore the causes and effects of burnout and enable changes required to overcome burnout, such as: 1) targeted educational workshops and trainings focusing on raising knowledge and techniques to reduce occupational stress; 2) creation of support groups for the solution of the problems experienced by employees; 3) discussion of problem cases with a consultant to develop bespoke therapeutic planning; 4) learning new educational techniques, both during targeted exercises and during the discussion of problematic cases; 5) supervision and monitoring of the employees’ level of wellbeing.
People who are most passionate about their work and are most committed and devoted to the cause, whatever the cause might be are at the highest risk of burnout due to high expectations of themselves. During the last decades, the incidence of stress and burnout and the amount of research focused on these issues have been increasing: the studies carried out concern, especially, employees in the sector of services, including social workers, nurses, teachers, lawyers, medical doctors and police officers.
And finally, 8 years later I can observe that the phenomenon of burnout is constantly increasing. More than 75 per cent of people in the workforce are believed to be affected by burnout in UK (Deloitte Burnout Survey 2019) . It seems that the problem is no longer limited to those ones who work with disadvantaged people, who constantly need help and assistance, but concerns all individuals who fail to carve out moments of relax; in this way, they nullify any difference between work and private life.
But the good news is that there are solutions, there are ways to wake up from the nightmare, to enjoy your life again and to rekindle the passion for your jobs. And it lies in your power. And in your organization’s power. Sit down. Talk about it. And talk about it some more. And in the end you will overcome it. Together. Maybe in groups of TWELVE.