Forward-Facing® Professional Resilience: Prevention and Resolution of Burnout, Toxic Stress and Compassion Fatigue

By J. Eric Gentry, Ph.D and Jeffrey Jim Dietz, M.D.

A Mission To Help Others Heal. A mission to help others heal and regain productive lives is likely what led you to pursue a career in professional caregiving. But what happens when all the accumulated suffering and trauma that you have witnessed and the pain that you have experienced starts to cause problems in your own personal and professional life? Insidious and often steeped in shame, compassion fatigue burnout and traumatic stress are very real issues that members of the caregiving community are not only at risk for but will inevitably confront at some point in their careers. The key is not to fight against or run away from these consequences of caregiving, but to recognize their normalization, origination, and the applicable steps available to heal your existing stress and build resilience for the future. In Forward-Facing® Professional Resilience: Prevention and Resolution of Burnout, Toxic Stress and Compassion Fatigue, trauma and compassion fatigue expert Dr. J. Eric Gentry and medical director and practitioner of emergency medicine Dr. Jeffrey “Jim” Dietz combine over seventy years’ worth of experience treating patients and caregivers to present a two-part text that first examines the cause of compassion fatigue, followed by a proven, simple five-step solution for healing and a renewed sense of mission. Drawing from their Professional Resilience workshop that has been attended by over 100,000 international participants, Drs. Gentry and Dietz address these issues with their readers in ways that are candid, heartfelt, insightful, and most of all—filled with hope.

• Language: English
• Publisher: Outskirts Press
• Release date: Mar 5, 2020
• ISBN: 9781977223609

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Forward-Facing® Professional Resilience

Prevention and Resolution of Burnout, Toxic Stress and Compassion Fatigue

All Rights Reserved.

Copyright © 2020 J. Eric Gentry, Ph.D. & Jeffrey Jim Dietz, M.D.

v1.0

The opinions expressed in this manuscript are solely the opinions of the author and do not represent the opinions or thoughts of the publisher. The author has represented and warranted full ownership and/or legal right to publish all the materials in this book.

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Dedication

This book is dedicated to the memory of Michael H. Dietz, M.D.

We would also like to dedicate our work to other healthcare providers whose lives have been tragically diminished while helping others, and to those who remain bravely committed to their missions and continue onward.

TABLE OF CONTENTS

Foreword

Introduction

Section One: The Problem

Chapter 1: Normalization and Engagement

Chapter 2: Tools for Hope: Perceived Threat and the Autonomic Nervous System

Chapter 3: Compassion Fatigue

Chapter 4: Burnout

Chapter 5: Secondary Traumatic Stress

Section Two: The Solution

Chapter 6: Forward-Facing® Professional Resilience and the Skills

Chapter 7: Self-Regulation

Chapter 8: Intentionality

Chapter 9: Perceptual Maturation

Chapter 10: Connection and Support

Chapter 11: Self-Care and Revitalization

Chapter 12: Building A Self-Directed Forward-Facing® Professional Resilience Plan

Chapter 13: Our Vision

Appendix I: The Forward-Facing® Accelerated Recovery Program (ARP) for Compassion Fatigue

Appendix II: Professional Quality of Life Scale (Pro-QOL)

Acknowledgments

About the Authors

Endnotes

FOREWORD

Jim: By the spring of 2016, I’d been working with Eric on developing our professional resilience materials for seven years. We decided that we should write a book in order to capture what we had created, and make it available to professionals (those who had taken our course and others who had not). Although Eric had written several books before, this was new territory for me. We began using a working title of Professional Resilience and Optimization, and knew that as the book was formulated and revised, we would likely readdress the title.

I observed that the phrase forward-facing appeared in much of Eric’s writing. I struggled with the meaning and implication of those words; they seemed like psycho-babble to me, and my physician mind rejected such verbiage out of hand.

Eighteen months later, as we were completing the last chapter of our book, Eric proposed that we change the title to Forward-Facing ® Professional Resilience—and in that moment, having immersed myself in the material for over a year and a half, I had an epiphany of how appropriate the Forward-Facing® concept is. What changed for me was that those words were no longer akin to gibberish, but presented the idea of perhaps the most important element of our work together.

Forward-Facing® is a declaration of hope!

You will discover in the following pages that burnout is pervasive among professional caregivers, and that we tend to think of ourselves as victims of poorly designed and implemented processes. It’s this flawed perception that is the cause of the dissatisfaction and stress most of us experience when we offer our professional skills to help others. We’ve lived under this paradigm for decades, conditioned by our training to believe that we must be stoic and simply buck up to handle these challenges.

The truth is that there is little in our past training and current interactions that we can turn to in order to change these stressful environments or manage them differently. The distress that many of us feel seems to be inevitable.

When I was a young man, I experienced episodes of fairly profound depression. I recognized that based on some childhood trauma I had experienced, I was frightened of the future and afraid to take the necessary steps to become an adult. I was paralyzed by indecision. Around this time, an insightful friend sent me a comic from The New Yorker. I have tried to find the exact image to include here, but my internet searches have not yielded a successful result. Instead, I have recreated it here with another graphic:

HAVE FAITH

The graphic is of a huge dragon staring down menacingly at a very young knight, who regards the dragon with a grimace that could easily be interpreted as fearful and unsure. A small shield in one hand, a heavy sword in the other—they are all the protection the knight has against his enormous foe. Imagine what this boy is feeling: He has trained for battle, certainly, but he could’ve never prepared himself for such a lethal opponent as a massive, fire-breathing dragon ten times as big as he is. Below is the caption that simply reads: Have Faith.

I was given this cartoon about forty years ago, and it still has an impact on me. What you will learn as you read through this book is that no matter how hard we try, we have little power to change the environment in which we work, and that everyone experiences some negative effects from being a professional care provider. You will see that this is normal, not abnormal, and is a function of the way in which we perceive and respond to our environments.

We will help you learn techniques to modify your response and develop skills that have been shown to significantly reduce the effects of compassion fatigue (burnout). This skillset will enable you to be the professional you wish to be, to sustain yourself as such, and to not only better tolerate your experience of work, but to thrive in your professional endeavors.

We cannot refer back to our training nor the currently established paradigm and expect different results—that much is abundantly clear based on the rampant amount of discomfort, pain, and burnout afflicting many areas of modern-day professional caregiving. What you will read in the following pages will offer you an alternative way to perceive and engage in your work that can vastly change your experience. Take what you learn here and look forward to how you can implement these changes in your life and benefit from them indefinitely.

Stare up into the eyes of the dragon that represents the incredible challenges of being a healthcare provider, and believe that you are capable of developing skills that will enable you to better manage these challenges with grace and find resilience.

Face forward. Have faith.

Jeffrey Jim Dietz, M.D.

Novato, CA

September 3, 2018

INTRODUCTION

John sat in the idling sedan he’d parked a few doors down from his childhood home, watching billows of white exhaust swirl upwards through his back windshield. It was Friday evening on a frigid pre-winter night in early December. John could just make out the figures of his mother, father, and fiancée Beth through the dining room window, their heads wreathed by a warm glow as they sipped on red wine and waited for him.

Damn it, John mumbled, rubbing his aching eyes and trying to blink the bleariness away. This family dinner had seemed like a good idea two weeks ago, when some old friends from high school had invited John out for a Christmas get-together at their favorite pub in his hometown just outside of Chicago.

Let’s visit your parents too! Beth had proclaimed when John showed her the text message invite, and John had nodded, eager to get into the Christmas spirit, especially after the last few hectic months he’d had at the hospital.

John was approaching his fourth year working as a medical hospitalist, a position he’d thrown himself into with passion after completing his residency, and one that still consumed a majority of his thinking whether he was at the hospital or not. Tonight John had stayed an hour past his scheduled shift—which wasn’t unusual—but as the minutes ticked by marking John’s increasing lateness to his parents’, his stomach had churned with impatience.

Finally he’d left the ward with his gut no more settled as he thought about the complex issues of the patients he was leaving behind, hoping the signoff he’d left for his colleagues was sufficiently detailed. The fifty-minute drive through waning rush hour traffic had only given him more time to perseverate about some of those patients. Had he done right by them? Had he done enough? What would happen in the thirty-six hours until his next shift that might reveal something he’d missed, or a way he’d failed in alleviating their suffering?

John white-knuckled the steering wheel, dreading the meaningless small talk with his mom, the overly chipper smiles from Beth (that did nothing to hide her concern about John’s demeanor as of late), and his friends’ boisterous but well-intentioned heckling at the pub later. They seemed so full of joy, so close to one another, so quick to laugh and tease and forget all about their workdays…while John felt more like an outsider than ever. It wasn’t as if he could actually tell them about the things he’d encountered that week: the new mother who’d been diagnosed with Stage IV metastatic breast cancer, the young man who’d overdosed on a bottle of pills and insisted it’d been an accident, refusing any suggestion of counseling or support group options, and the newly widowed elderly man who’d sustained a pelvic fracture while home alone, and never failed to mention how much he missed his wife whenever John came to check on him.

John’s phone buzzed in the cup holder, and he stared at it for a good five seconds before checking the screen.

Where are you???? Beth asked in a text message, and he cringed at the multiple question marks being used. She was mad.

He began to type: Couldn’t get away from the hospital, one of my patients took a turn for the worse. You know how it is. Sorry honey, but erased it before hitting send. He needed to man up. This was what he’d signed up for, and sure, sometimes he felt like he was suffocating under the pressure, and he regularly fantasized about driving away from that hospital and never returning…but didn’t everyone feel that way at some point in their career?

John turned the sedan’s key and cut the engine, gaze trained on that yellow square of cheer streaming through the window two houses away. He texted Beth: Walking up now, forced the car door open, and trudged with exhaustion through the chilly air, mentally preparing himself for the night ahead.

***

How many of you find yourselves identifying with John’s story above as you read along? How many of you empathize with the struggle to engage in mundane, everyday activities beside family and friends after spending the day sitting across from someone who has just lost their spouse, underwent a serious surgery, or shared their horrific experiences of sexual abuse?

There are very real consequences for those of us who spend our working lives caring for people contending with serious illness, trauma, pain, and loss. Anyone who has ever committed themselves to being of service to someone who is suffering can attest that while there are definite rewards in this work, it comes at a cost. For some, that cost is physical illness. For others, it is chronic low-grade depression or anxiety. Still others report difficulties in relationships or sleep problems. A multitude of research has shown that the effects of compassion fatigue are widespread and detrimental for all helping professions, and particularly those in healthcare.

PHYSICIANS

A 2009 report stated that compared to other professionals, a male physician’s proportionate mortality ratio from suicide is nearly 1.5- to 3.8-fold higher, while female physicians have a 3.7- to 4.5-fold increased risk of death from suicide.¹

A study of British Columbia-based physicians revealed that 80 percent reported suffering from moderate to severe emotional exhaustion, with 13 percent of physicians revealing that they had taken antidepressants during the past five years.²

A 1989 article found that male general practitioners in England showed significantly higher levels of anxiety and had lower job satisfaction than the general population.³

A recent survey held in Ireland evaluating junior doctors (medical residents) discovered that higher burnout levels correlated with more medical errors, with 64 percent of residents who had reported symptoms of burnout stating they had made a medical error, compared with 22 percent of residents reporting no burnout symptoms making a medical error.⁴

EMERGENCY MEDICAL TECHNICIANS (EMTS)

A report by Donnelly and Siebert discovered that between 80 and 100 percent of emergency medical technicians (EMTs) are exposed to traumatic events during their work, stating that there are direct linkages between occupationally related stress exposure, including chronic and critical incident stress, PTSD, and high-risk alcohol and other drug use.⁵

NURSES

A Canadian-based study in 2005 reported that depression was more common in nurses than in the general population of employed people,⁶ with 9 percent of both male and female nurses experiencing depression in the previous year compared to 7 percent of employed women and 4 percent of employed men.

A 2007 meta-analysis based on several studies revealed that severe burnout syndrome (as measured by the Maslach Burnout Inventory) was found in approximately 50 percent of critical care physicians, and at least 33 percent of critical care nurses.⁷

The Agency of Healthcare Research and Quality estimates that burnout affects between 10 and 70 percent of nurses, and between 30 and 50 percent of physicians, nurse practitioners, and physician assistants.⁸

LAW ENFORCEMENT

A 2015 doctoral dissertation exploring the effects of frequent exposure to violence and trauma-related incidents on police officers found that such exposure led to symptoms related to post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, suicide, and hypertension or other medical issues, in addition to employment and marital problems (i.e. relational issues) and citizens’ complaints about harassment and use of excessive force.⁹

CHILD WELFARE

A 1999 survey of Child Protective Services (CPS) workers in the South found that 37 percent of respondents reported clinical levels of emotional distress associated with secondary traumatic stress symptoms.¹⁰

A 2010 study discovered that high levels of burnout in social workers, in particular depersonalization and emotional exhaustion, were correlated with higher reports of flu-like symptoms and gastroenteritis.¹¹

PSYCHOLOGISTS AND MENTAL HEALTH

Australian psychologists have reported high levels of burnout, with no significant difference found in burnout levels for those working in private practice versus those in non-private practice settings. A strong negative relationship between burnout and mindfulness was discovered, as was a low but still significant relationship between a psychologist’s burnout levels and their years of experience in the current work setting.¹²

A sample of military mental health service providers found that approximately 21 percent reported significant symptoms of burnout, with several domains correlating with high burnout levels.¹³

A 2015 meta-analysis collected from fifteen studies over the last two decades concluded that burnout results in a significant negative effect on the cognitive performance of mental health clinicians. It noted that these effects are noticeably prominent when a clinician is engaged in taxing or complex professional activities.¹⁴

ASSISTED LIVING NON-MEDICAL CAREGIVERS

A 2018 survey reported that among 124 non-medical care providers working in assisted living facilities, 40 percent had symptoms of burnout.¹⁵

As these negative effects from all forms of caregiving begin to pile up, they can derail careers, destroy marriages, cause serious illness, and even result in premature death or suicide.

Healthcare providers are not the only victims of compassion fatigue and burnout—patients and medical institutions are also affected, as evidenced in research that revealed physician burnout could increase the chances for suboptimal patient care practices and medical errors.¹⁶ Salyers et al. stated in their study that more than half of clinicians (58 percent) described burnout as having a negative impact on the quality or amount of their work. Additional negative impacts included withdrawing from others, having less patience and less energy, poor communication and listening skills, worse consumer outcomes, and poor attitudes of others (consumers and colleagues).¹⁷ These ramifications extend beyond human interaction and wellbeing; in 2014, Privitera et al. reported that excessive workplace stress not only impacts medical providers’ health and cognitive performance, but has a direct financial impact on the institution in which they work.¹⁸ Even academics are not immune to compassion fatigue’s wide array of symptoms: Schindler et al. found that 20 percent of academic faculty who participated in an anonymous questionnaire examining depression, anxiety, work strain, and job/life satisfaction had significant levels of depressive symptoms, with even higher levels found in younger faculty.¹⁹

While these widespread effects of compassion fatigue (including burnout) have been a figural issue in mental health for the past twenty-five years, they have only recently begun to receive acknowledgement across all spheres of healthcare. A longtime dark secret of the medical world (one maintained for reasons we will explain later), these effects have been shrouded in shame and misunderstanding—until now. A light has begun to shine on burnout as a legitimate issue affecting healthcare providers, with significant consequences to the quality of care being provided to patients and clients.

SCOPE OF THE PROBLEM

Over the past twenty years facilitating resiliency workshops, we have met many fine clinicians who shared their experiences suffering from the traumas they had encountered in their healthcare careers.

One young physician told us a story that seemed particularly poignant: two years into his first job as an attending physician in an excellent emergency department, he reported that the most common conversation he had with his peers, aside from specific case presentations, focused on their exit strategies for leaving the field. How troubling is that? After four years of undergraduate study, four years of medical school, and four years of residency, this young man shared with us how he and his fellow physicians were struggling to consider how they could possibly remain in the profession after only two years of actually practicing medicine.

Another worrisome interaction occurred in 1999 when a gifted social worker who specialized in working with child survivors of sexual abuse and torture came to one of our early workshops, disclosing to us how she was seriously considering leaving her profession to become a toll collector on the Florida Turnpike. (Note—she completed the workshop and went on to treat thousands of traumatized children, and now teaches others these same methods without suffering symptoms of compassion fatigue).

Neither of these cases were isolated incidences; every year, millions of caregiving professionals across the globe struggle with the devastating effects of compassion fatigue on their quality of life and performance at work. In a 2016 survey,²⁰ 49 percent of all U.S. physicians polled said they often or always experience feelings of burnout, and would not recommend medicine as a career to their children.

In January of 2017, Medscape published the results of its most recent Lifestyle Report on bias and burnout in the field, revealing that despite the field’s awareness of the problem, symptoms seem to be increasing. Of the 14,000 physicians who participated, the overall rate of physician burnout was found to be 51 percent—a 10 percent increase from a similar survey conducted in 2013. Furthermore, emergency department physicians had the highest burnout rate (59 percent) of the specialties evaluated, with OB/GYNs and family medicine practitioners following closely behind (56 and 55 percent, respectively).²¹

Additional research done by Shanafelt et al. in 2012 found that physicians were more likely to exhibit symptoms of burnout than other working U.S. adults, with those at the front line of care (emergency medicine, general internal medicine, etc.) seeming to be at the greatest risk.²²

The New England Journal of Medicine’s Catalyst Study saw respondents rating increased clerical burden as the leading cause of daily workload stress contributing to burnout (62 percent), including the expansion and more comprehensive use of electronic health records. In their current form, EHRs disrupt the workflow that many physicians have established over years in their practices, forcing them to carry their workload into off-hours, stated the Insights Report,²³ which also detailed that the second-highest reported factor of physician burnout is an increase in productivity requirements and expectations. The study also revealed that 96 percent of clinical leaders, clinicians, and executives concur that physician burnout is a serious or at least moderate problem in the healthcare industry.²⁴

The field is finally beginning to grasp the actual impact of the burnout crisis on caregiver and patient outcomes, with multitudes of publications extrapolating on the seriousness of this issue. A 2012 article by The Wall Street Journal observed that compassion fatigue has been linked to decreased productivity, more sick days, and higher turnover among cancer-care providers. A 2008 study led by the University of Nevada, Reno’s nursing school found that about 12 percent of registered nurses in the U.S. weren’t working. Of those, more than 27 percent cited burnout or stressful work environments [as the reason why]. High turnover and the subsequent increased workload on remaining nurses can result in higher death rates and reduced patient safety, studies show.²⁵ According to a special report published in The New England Journal of Medicine, Physicians’ dissatisfaction with the practice of medicine may have public health implications over and above the obvious problems of recruiting new members into a troubled profession. The authors noted that physicians’ dissatisfaction with their careers breeds poor clinical management, as well as dissatisfaction and noncompliance among patients, and that the rapid turnover of unhappy doctors in offices and hospitals may lead to discontinuous, substandard medical care.²⁶ There is growing evidence to support that work-related stress is a significant contributing factor to practice errors and ethical violations,²⁷ with one study stating that major medical errors reported by surgeons are strongly related to a surgeon’s degree of burnout and their mental QOL.²⁸

The greater the distress experienced by a care professional, the more likely they are to engage in poor judgment, shortcuts, exploitative behaviors, and illegal activities.²⁹ There are huge costs—financial, emotional, relational, personal—for professional caregivers continuing to practice while symptomatic. Yet that seems to be exactly what many professionals do. We deny that we are experiencing any problems, or we blame our distress and discomfort upon the workplace environment. Many practitioners gradually develop an attitude of entitlement that helps them justify their less-than-professional behavior.

In addition to potential issues regarding quality of care, there are real financial implications that result from compassion fatigue and burnout.