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Trauma and violence informed care - Chapter 8

Keeping the health professional safe and healthy: Clinician support and self-care

      1. Keeping the health professional safe and healthy: Clinician support and self-care

‘When we are working in difficult areas, we can begin to feel overloaded, frustrated and even hopeless. Pulling ourselves together and pushing through might seem helpful in the short-term, but it’s a slippery slope into compassion fatigue and burnout’ 
Associate Professor Jill Benson, General Practitioner

Key messages

  • Staying safe and healthy is essential for all healthcare workers including GPs, practice nurses, support staff and Aboriginal and Torres Strait health workers who care for patients who are, or have been, involved in abuse and violence. This includes when caring for people who inflict abuse and violence as well as caring for those to whom it is happening.
  • It is important to be aware of the early signs of stress, compassion fatigue, burnout and vicarious trauma. Clinicians should have a personal and professional management plan to prevent progression.
  • Stress can be reduced by personal actions, increased social connectedness, professional development, working as part of a supportive team and engaging other agencies.

This chapter highlights the importance of staying safe and healthy for the GP, practice nurse or Aboriginal health worker when working with families experiencing violence and abuse. It encourages self-reflection, peer support and working as a part of a wider team with these families.

Managing patients who have been involved in situations of domestic abuse or violence with compassion and empathy can be stressful, and a health professional’s own health can suffer because of compassion fatigue, burnout or vicarious traumatisation.1

Stress and burnout

A generic definition of stress is the physical, mental or emotional response to outside circumstances that are too overwhelming for our personal resources, a common scenario for health professionals when working with patients who have been involved in abuse or violence. Burnout has been defined as a syndrome of emotional exhaustion, depersonalisation, and a sense of lowered personal accomplishment that leads to a decreased effectiveness at work.2

Dealing with the effects of stress is important, not just for the health professional’s own health, but also so that they can maintain as objective a stance as possible to facilitate a successful outcome for the patient, and maintain good relationships with their own family, friends and community. Dealing with the effects of stress also enables the healthcare team to work together more effectively.

The trauma that many patients have been through constantly challenges the health professional’s individual limits and drains personal and professional resources.2,3 The health professional may feel personally frustrated, helpless and hopeless, which can lead to substance abuse, broken relationships and even suicide, and may also face professional stress leading to important professional consequences such as ‘lower patient satisfaction, impaired quality of care, even up to medical errors, potentially ending up in malpractice suits with substantial costs for caregivers and hospitals’.2

Health professionals can begin to address chronic stress by asking for assistance in dealing with any stressors outside of their work and working to enhance their personal and professional resources.

Vicarious traumatisation

Vicarious traumatisation is a particular danger when an empathic health professional is dealing with people who are experiencing or have experienced abuse and violence. It involves the inner transformation of the carer’s view of themselves and their world as a result of listening to the patient’s stories and empathic engagement with their trauma.4

Vicarious traumatisation manifests as a spectrum of symptoms, including loss of appetite, fatigue, irritability, inattention, numbness, sleep disorders, fear, and despair. Frequently, these symptoms are accompanied by trauma responses and interpersonal conflicts. However, the symptoms often remain at subclinical level.5,6

Vicarious traumatisation can be similar in its symptomatology to post-traumatic stress disorder (PTSD) and can also resemble burnout in its symptoms and the effects it has on the personal and professional life of the health professional.7 Hypervigilance, nightmares, avoidance and fatigue can be combined with a lack of motivation, cynicism, sense of failure, lack of accomplishment and emptiness, leading to lower job satisfaction, increased job turnover, absenteeism and decreased quality of patient care.1

Burnout and vicarious trauma can also be associated with ‘self-medicating’ with substances, interpersonal conflict, disrupted relationships and a poor quality of life.

Compassion fatigue

Compassion is a ‘sensitivity to suffering in self and others with a commitment to try to alleviate and prevent it’. It is an essential characteristic to successfully work with patients who have been victims of domestic abuse.8

It is important to maintain an environment where there is adequate protection from the ‘compassion fatigue’ that may come from actively listening to the stories of patients involved in abuse and violence. ‘Compassion fatigue is characterised by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to make decisions and care for patients and/or clients.’9

Health professionals with compassion fatigue will have a depleted emotional reserve and have difficulty experiencing or expressing empathy and effectively responding to it. Along with emotional exhaustion and a lessened sense of accomplishment, such detachment is a symptom of burnout, and if not addressed, may also lead to vicarious trauma.10

Positive effects of working with these patients

Working to help patients and their families be safe and resilient can also lead to health professionals feeling energised, empowered and hopeful. It can align with their personal values and give a sense of purpose, which can further enhance the doctor–patient interaction and relationships with colleagues.11

‘Compassion satisfaction’ derives from an alignment of values and work, a feeling of self-respect and being able to do work effectively.11 ‘Vicarious post-traumatic growth’ and ‘vicarious resilience’ can occur when health professionals’ self-perception, interpersonal relationships and philosophy of life are positively affected by the resilience of their patients, usually in the setting of supportive social and organisational environment.12 Some of the professional and organisational factors that can contribute to this enhancement are ongoing training, clearly delineated practice policies, case management supervision, clear doctor–patient boundaries, and a developed network of resources and referrals.

Considerations for healthcare professionals of specific backgrounds

Health professionals who have a similar background to the community they serve are at a higher risk of burnout and vicarious trauma.7 This includes those of Aboriginal or refugee background, international medical graduates, and doctors who themselves have experienced child abuse or intimate partner abuse/violence (IPAV). Recent pandemics and environmental crises such as bushfires have also impacted health professionals and can add to the burden of traumatic events faced by many.6

GPs who work in rural areas are also at a higher risk of problems with stress, compassion fatigue, burnout and vicarious trauma.13 They are highly likely to find it difficult to access locums, peer support and ongoing training, usually have more after-hours work, are more isolated and find it more difficult to maintain clear boundaries between themselves and their patients.14,15

Many rural GPs are international medical graduates, who have the added burden of having to negotiate different cultures, ethnicities, language, religion, and rural and urban differences in Australia. They will also have to learn about the expectations Australian patients have of their doctor and about a new health system with its attendant bureaucracy. As well as the risk of ‘culture shock’, their anxiety, isolation and insecurity in the face of all these differences is likely to be much higher.16

Younger doctors and doctors in training are at higher risk of stress, depression, burnout and vicarious trauma; those with more training, familiarity with workplace expectations and increased years of service have a lower risk.11,12

Many health professionals themselves may have experienced abuse, or have family or friends in that situation: doctors and nurses have been found to have a rate of family and domestic violence that is at least as high as the rest of the population.17

On the one hand, personal experience of abuse or violence may make health professionals more understanding and willing to ask about it; on the other hand, such personal experience may cause them distress. Health professionals therefore need to be aware of how personal experiences may affect their own health and wellbeing and how to seek help to deal with what is happening in their own lives.17,18

‘You cannot give to others out of emptiness in yourself.’ – A GP

The medical profession has a ‘long and admirable, but often unhealthy, tradition of self-sacrifice to work’.14 Those who work in this field need to be vigilant about ways to overcome corrosive issues such as being the ‘messiah’ (‘I’m here to fix all your problems’), presenteeism (going to work when unwell) and imposter syndrome (insecurity for fear ‘someone will find out that I’m not perfect’).

It is also important to develop ways to renew the joy in practice, create work/non-work balance, and adequately care for their own physical, mental, social, emotional and spiritual health.19,20

A useful concept is self-compassion. This involves:

  • self-kindness, rather than self-judgement
  • an awareness of a common human fragility, rather than suffering in isolation
  • acknowledging difficult thoughts and emotions, rather than over-identifying with them.

Self-compassion and mindfulness can de-activate the internal threat system and activate the internal caregiving system. This can lead to self-healing, acceptance and joy with decreased risk of compassion fatigue, burnout and vicarious trauma.11

The ABC model

Saakvitne and Pearlman developed a model for self-care whereby health professionals can explore their situation and think about solutions.4 This occurs by identifying issues of awareness, balance and connection (ABC) in each of the health professional’s ‘realms’:

  • personal
  • professional

Using this model and the strategies shown in Table 8.1 may help set the stage for good self-care.3,21

Table 8.1. Example ABC strategies

 

Personal

Professional and organisational

Awareness

  • Reflect on realistic self-care strategies
  • Understand and improve your awareness of the early signs that you are stressed, tired, overwhelmed or burning out
  • Practise mindfulness, cognitive behavioural therapy and meditation techniques
  • Find a suitable mentor or supervisor who is willing to give feedback about your needs for professional development
  • Ensure that you have adequate training in dealing with trauma
  • Consider formal or informal debriefing for yourself and in your practice
  • Cultivate open and supportive dialogue with your colleagues and practice team
  • Ensure organisational boundaries are known and understood by patients and supported by the organisation (eg home visits, consultation length)

Balance

  • Review your lifestyle and consider realistic healthy options for sleeping enough, eating well, moderate exercise, hobbies and humour
  • Seek work/non-work balance in all spheres of your life
  • Review workload regularly to ensure that all members of the practice team are adequately supported
  • Take care in scheduling patients with complex care needs with adequate time and breaks between

Connection

  • Consider joining a social action group where your passion for change can have a different outlet
  • Talk to selected others about work and the effect it has on your life
  • Nurture and make time for positive relationships with family and friends
  • Join a peer support or Balint group, or find a mentor to share experiences in a safe environment where you are understood and your work valued
  • Undertake regular continuing professional development with your colleagues

 

The following explores the ABC model more specifically in relation to managing people who are experiencing or have experienced abuse or violence.

Awareness

Personal

  • Health professionals of a similar background to the patient might find the possibility of family violence more difficult to consider, as they may have ‘normalised’ the abuse and therefore disregard it.5,22
  • Some health professionals may feel more personally vulnerable or uncomfortable when abuse is disclosed. It is important that GPs are aware of this and do not ignore their own feelings.
  • The health professional can be drawn into a patient’s difficulty acknowledging the abuse, the shame and secretiveness about what is happening, or even the deceit that can build up around the circumstances, and hence develop an unwillingness to openly discuss or report the violence.22
  • The health professional may feel powerless and fearful for a patient’s safety when that patient chooses a path that the health professional considers dangerous. The patient could remain at risk and the health professional has to learn to live with that concern.22
  • It is a difficult and stressful path to support and empower a patient while resisting the temptation to direct and ‘take over’.22
  • Dealing with complex and seemingly hopeless situations over and over again can erode the health professional’s ability and self-confidence and diminish their sense of purpose and enjoyment of their career.23
  • It is important for the health professional to stay connected with their values and core reasons for choosing to work in a challenging area and to maintain a respect for the patients themselves.20
  • Health professionals need to recognise their own early signals of distress and find ways to articulate the feelings and act to redress the distress.20 This may include seeking formal help despite fears of stigma or of showing weakness or vulnerability.
  • The lack of safety and security in the lives of patients can confront the health professional’s own beliefs about the family and the world. The health professional may also be left with the same feelings of physical and emotional perceptions of alarm, danger and its impact, a personal sense of vulnerability and an intolerance of violence.
  • Courage involves health professionals stepping outside their comfort zone and persisting even though the results are not what they hoped for, but not so far that they lose their own sense of safety.15

Professional

  • Dealing with a perpetrator can be even more difficult than dealing with a victim/survivor, especially in rural practices or Aboriginal medical services, where the entire family is likely to be well known to the health professional.22
  • Health professionals are likely to feel at risk, especially if they are drawn into the power dynamics of the violence or if they are dealing with a perpetrator.22
  • Maintaining an ‘intellectual engagement’ with difficult work can be protective.20
  • It is important for health professionals to recognise their own limitations and those of their practice or organisation and ask for professional support appropriately

Organisational

  • Health professionals, doctors in particular, are trained to deal with individuals and to take personal responsibility rather than delegate; however, shared responsibility and a therapeutic alliance with a patient-centred team is likely to be more successful in challenging areas such as family and domestic violence.24
  • The organisation or practice should be aware if health professionals are struggling with maintaining boundaries, or if they are dealing with both a victim/survivor and perpetrator.22 It is recommended that the same health worker does not manage the perpetrator, victim/survivor and children in the family (refer to Chapter 2: Intimate partner abuse: Identification and initial response’).
  • Dealing with abuse and violence as a team will mean reflecting together on the need to develop new skills.
  • Organisations and staff should be aware of the risks to staff of stress, burnout and vicarious trauma and deal with any organisational issues involved.13
  • Addressing issues of burnout at an organisational level will include an awareness of the administrative burden placed on health professionals, as this gives little workplace satisfaction. On the other hand, improving the meaning of work and ensuring transparent communication and collaboration can be protective.25

Balance

Personal

  • Lifestyle choices that promote ‘wellness’ include supportive relationships, religion or spirituality, focusing on even small successes, and a positive outlook, as well as simple measures such as getting enough sleep, exercise, good nutrition, meditation and laughter.19
  • There is a need for flexibility, adaptability and tolerance of uncertainty, and purposeful physical, intellectual, spiritual and relationship sustenance.19
  • Without a positive countervailing exposure to human good and world order, health professionals may experience the same loss of a sense of personal control, freedom and trust as their patients.7
  • The health professional needs to balance their own expectations with the expectations of the patient, the organisation, their colleagues and their own family and find a practical path through the conflicting priorities of each.

Professional

  • Appropriate support for the doctor in both training and clinical practice needs to be readily available, especially considering that up to 24% of male doctors and 42% of female doctors have a personal history of child abuse or IPAV.26
  • Health professionals with less perceived control, greater stress from uncertainty, higher job demands and fewer social supports are at greater risk of burnout.27,28
  • Professional development and specialised trauma training will decrease the risk of vicarious trauma.11
  • One of the difficult balances in abuse and violence is the tension between maintaining confidentiality and still receiving added support from other health professionals.
  • Learn to celebrate small achievements, rather than feel overwhelmed by the big picture.5,20
  • As with other complex and time-consuming occupations, it is important to have clear boundaries between work and home, find role models and mentors, attend peer support groups, and maintain professional development and training activities.23
  • As a defence against the sometimes-intense feelings of helplessness, a health professional may take on the role of a rescuer or saviour. There is a fine line between caring for someone and disempowering them from finding their own solutions.20 The use of motivational interviewing techniques<<link to chapter 4>> will assist the health professional to explore the patient’s solutions and ensure that the patient is empowered.
  • Mindfulness training is associated with a lower reactivity to stressful situations and negative emotional stimuli and increases the health professional’s ability to judge a situation more objectively and in a more positive light.8

Organisational

  • It is important to provide necessary organisational support services to health professionals providing care for patients in crises. Organisational balance involves a sense of control over the practice environment, social support from colleagues, and satisfaction with work demands and resources.27
  • Many organisations seem to be caught in a struggle between promoting the wellbeing of their patients and trying to cope with policies and structures in a system that tends to stifle the empowerment and wellbeing of their staff.13 It has been noted that too much emphasis has been placed on the individual healthcare worker, rather than supportive organisational processes, to recognise and manage distress, burnout and negative mental health consequences of work circumstances.6
  • There needs to be a balance between caring for patients appropriately by giving them the time they need, earning a reasonable income and satisfying the organisation’s requirements for performance.5
  • Health professionals need physical security and a safe, confidential workplace, support for continuing education, and adequate vacation and sick leave.
  • A ‘problem-solving’ culture rather than one of blaming others helps both patient and health professional be more objective and balanced.16
  • Staff will be supported by a shared aim and purpose, adequate staffing and a sense of team management. This will decrease the risk to individuals within the practice, as well as to the organisation.
  • Providing a peer support or supervision group for the staff can make a positive contribution.
  • Control working hours in the challenging area and if possible, balance this with other less challenging jobs.20
  • Devote at least 20% of time to work activities that are especially meaningful.29
  • For women health professionals, particularly doctors, addressing organisational barriers to career progression and to a balance between career and family can be helpful in preventing burnout (eg family leave, lactation and childcare policies and support).30

Connection

Personal

  • Working in a supportive team is associated with being better able to cope with stress.31
  • If a health professional is becoming burnt out, there may be increased substance use, pessimism or suspiciousness of both patients and colleagues.23
  • If a health professional is aware that they are suffering from compassion fatigue or burnout they may need to ask for professional help11 and find activities that connect with mind, body and support networks.23
  • Social support systems can provide understanding and renew emotional reserves.23

Professional

  • Confidentially debriefing with colleagues can reduce stress levels by sharing the experience, and colleagues can enable help-seeking when necessary.
  • Peer support groups, professional development and training activities can also be replenishing and reinforce the value and meaning of work.

Organisational

  • Working and communicating well as a team with the GPs, practice nurses, Aboriginal health workers and receptionists within the practice or Aboriginal health service, and with public health nurses, teachers, police and other agencies, is very important in the identification and management of abuse and violence.22
  • DRS4DRS – an independent, safe, supportive and confidential doctor-to-doctor service, providing online resources, referral and help finding a GP. Includes a confidential telehealth service for doctors and medical students who are struggling with their mental health.
  • Self-care and mental health resources for general practitioners – an RACGP guide to resources and services.
  • General practice – a safe place: A guide to preventing and managing patient-initiated violence – an RACGP guide providing tips and tools.
  • First do no harm: Being a resilient doctor in the 21st century – a book by L Rowe and M Kidd, McGraw-Hill Australia, 2009.
  • Understanding and addressing vicarious trauma  a course of online self-study from the Headington Institute.
  • RACGP GP support Program − a free service offered to RACGP members, providing access to professional advice to help cope with stressors such as handling work pressures; managing conflict, grief and loss; relationship issues; concerns about children; anxiety and depression; alcohol and drug issues; and traumatic incidents.
  • The following helplines are available in each state or territory:
    • NSW and ACT: Doctors Health Advisory Service, 02 9437 6552
    • Queensland: Doctors’ Health in Queensland, 07 3833 4352
    • South Australia and Northern Territory: Doctors’ Health SA, 08 8366 0250
    • Tasmania and Victoria: Victorian Doctor’s Health Program, 03 9280 8712
    • Western Australia: Doctors Health Advisory Service WA, 08 9321 3098
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