Burnout in Brain Injury Rehabilitation & How Community Support Helps

By Terrie Price, PhD, ABPP

Burnout is a serious concern in the healthcare field. It is described as related to chronic stress at work with physical, occupational and psychological consequences including insomnia, impaired attention, decreased work performance and diminished motivation_3. Chambers-Baltz et al. 2022 describe burnout at work is related to prolonged exposure to chronic workplace stress and includes 3 specific elements: 1) Exhaustion or low energy, 2) cynicism about the job or mental distance from the job and 3) reduction in work efficiency. Burnout is attributed to a) a perceived lack of control or autonomy b) feeling of insufficient reward or recognition c) a perceived lack of social support / community and d) feeling a shortage of meaning and purpose_5.

Wang et al.,2020 report that “Burnout syndrome is characterized by mental and emotional exhaustion, depersonalization, and a low sense of personal accomplishment.” Burnout syndrome is more prevalent in healthcare professions. Murray et al., 2019 conducted a unique study on the burnout among professionals in brain injury medical rehabilitation across a rehabilitation team. Extensive interview identified six themes: 1) special challenges of brain injury rehabilitation, 2) emotional experiences associated with treatment, 3) the impact of limited funding and resources, 4) organizational factors contributing to stress, 5) effects of work related stress and strategies used to cope and 6) support provide in the work environment.

Among special challenges in brain injury rehabilitation is coping with the reality that treatment does not “fix” or cure the brain injury. Some study participants expressed feelings of helplessness in that treatment could not heal the root cause of deficits, with interventions focused on teaching compensation strategies and management of the effects of brain injury. Some participants discussed the challenge of the slow progress seen in rehabilitation and the need for a high degree of repetition of interventions. Subsequently, the professional might feel uncertain of their skill and interventions when weighed against what may be a limited scale of improvement. The unpredictable component is the uniqueness of each injury and each injured person which requires a high degree of creativity in formulating treatment, establishing rapport with the patient, and being constantly in tune with the patient’s progress and treatment needs. Unique challenges arise in managing the patient’s behavioral response coupled with the severity of injury impacting the patient’s awareness and coping mechanisms. Families may present challenges with a lack of understanding of the injury and effects, in not following through with care or possibly enabling maladaptive behaviors.

Anosognosia (lack of awareness) presents a unique challenge in rehabilitation outcomes as awareness is highly critical to an individual’s engagement in treatment. Poor awareness can lead to conflicts and resistance to interventions as the client may not see the need or purpose of an intervention. Alternatively, educating the person to improve awareness of deficits can be emotionally challenging and discouraging for the professional. Professionals noted being emotionally impacted by the histories of their patient’s injuries, especially when injuries were caused by violence.

Funding for rehabilitation was cited as a source of significant frustration as it may lead to higher caseloads, shorter treatment periods for clients or lack of access to beneficial treatment. Participants noted that lack of funding seemed related to barriers in understanding of the insurance industry of the care needed after brain injury. Organizational factors contributing to burnout included demands related to scheduling and documentation interfering with clinical duties and impacting opportunities to consult with peers or have breaks. Some individuals deferred breaks to avoid becoming overwhelmed with such tasks.

Study participants noted that they limited interactions with peers when feeling stressed, and sometimes to mitigate how the stress would be perceived by coworkers. In contrast, study participants reported the value of seeking out coworkers for support in coping with stress, especially those with more experience. Critically important resiliency skills in coping with stress are maintaining a positive attitude, supporting one’s sense of efficacy in appreciating the benefit of their work, and physical exercise. The team was described as highly important in helping one not feel alone, particularly when treating difficult and challenging clients. Study participants reported positive supervisory such as open door policies, having a collaborative relationship and having opportunities to participate in decision making were beneficial. Participants preferred random acts of support like unplanned free breakfast or lunch for staff, creating safe spaces for study participants to share concerns, and administration reaching out consistently to solicit information and feedback.

Chambers-Baltz et al., 2022 present a model noting that an imbalance of risk factors and protective factors in the context of the work tasks and patient experience can lead to burnout and turnover. Risk Factors for burnout identified were adopting a perspective of a) “It’s just a job”, b) perceiving a lack of support and c) Institutional related challenges of caring for everyone, lack of communication, and shortage of staff.

Three levels of Protective Factors identified are Institutional (opportunities for growth), Interpersonal (making a difference, engaging coworkers/benefiting from work family, and learning from and engaging with patients) and Individual (engaging in self-care and self-improvement, recognizing work as a privilege and embracing special characteristics of empathy.

Building on protective factors and leaning on resiliency skills is vital to decrease burnout. From an institutional perspective, the study recommended that supervisors check in with staff, provide safe spaces for feedback, resist the urge to fix when listening and invite staff into decision making to address concerns. Staff are encouraged to check in with each other and invite coworkers to support shared work with a patient. Organizations may offer training in strategies to facilitate change. Motivational Interviewing and Acceptance and Commitment Therapy approaches have been used extensively in health care. From an individual staff member’s perspective, it is critical to embrace the unique strengths and qualities one brings to their work in making a positive difference in the lives of their patients. A gratitude perspective and a sense of efficacy are core to personal resilience. Value of the mission of their r work includes gratitude for the patient’s and families’ commitment to the rehabilitation process and gratitude for their coworkers’ expertise and dedication. A personal sense of efficacy is appreciating one’s individual strengths and contributions such that the person sees themselves as positive change agents in their work. Fostering team as community and work family encourages support and creativity in our work. Finding mentors and willingness to serve as mentors builds skill and character development. Self-care includes self-awareness. Chronic burnout and depression have similar symptoms such as depressed mood, sleep problems and low energy. We can review where we stand in the balance of protective versus risk factors. Getting back in balance may include talking with our physician and setting a plan of care to improve sleep, emotional wellbeing and energy level. Institutional support of staff may include an Employee Assistance Plan offering short term counseling.

References

1. Chambers-Baltz, S., Knutson, D., Chwalisz, K., Canby, A & Kante, T. (2022) Rehabilitation Psychology, 68:1, 53-64
2. Maslach, C, Schaufeli, W., &Leiter, M. (2001) Job Burnout. Annua. Rev. Psychol. 52:397-422.
3. Murray, G., Hart, T., Doyle, A., Bohrman, C., & Toth, C. (2019) There’s no cure for brain injury: work-related stress in brain injury rehabilitation professionals. Brain Injury 33:11, 1442-1448
4. Salvagioni DAJ, Melanda FN, Mesas AE, Gonza ´lez AD, Gabani FL, Andrade SMd (2017) Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLoS ONE 12(10): e0185781. https://doi.org/10.1371/journal. pone.0185781
5. Sixseconds: The emotional Intelligence network. Employees are Facing Burnout. 5 Evidence-based emotional intelligence strategies for leaders to rekindle the fire. Employees Are Facing Burnout. 5 Evidence-Based Emotional Intelligence Strategies for Leaders to Rekindle the Fire • Six Seconds
6. Wang, J., Wang, W., Laureys, S. & Di, H. (2020) Burnout syndrome in healthcare Study participants who care for patients with prolonged disorders of consciousness: A cross sectional survey. BMC Medical Services Research. https://doi.org/10.1186/s12913-020-05694-5