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As practitioners, we design personalised interventions for those with whom we work. . This may mean that we set goals for people based on our own clinical agendas, hoping that we can encourage our clients to take an active role in their own health and wellbeing. This process commonly occurs alongside high administrative demands and tight timelines. Some clinicians may feel they are investing more energy and effort than the individuals with whom they work. A consequence of this may be compassion fatigue and practitioner burnout. I hope that this article will provide you with some strategies to empower you and those you work with, reduce your workload, and assist you to support individuals to thrive rather than survive with their diabetes, while at the same time lower your risk of burnout.


The term burnout was coined in the 1970s by the American psychologist Herbert Freudenberger. He used it to describe the consequences of severe stress and high ideals in “helping” professions. Doctors and nurses, for example, who sacrifice themselves for others, would often end up being “burned out”– exhausted, listless, and unable to cope1.

There are three main types of symptoms that are considered to be associated with burnout:
▪ Exhaustion: People affected feel drained and emotionally exhausted, unable to cope, tired and down, and do not have enough energy. Physical symptoms may include pain, and digestive problems.
▪ Alienation from (work-related) activities: People who have burnout find their jobs increasingly stressful and frustrating. They may start being cynical about their working conditions and their colleagues. At the same time, they may increasingly distance themselves emotionally, and start feeling numb about their work.
▪ Reduced performance: Burnout mainly affects everyday tasks at work, at home or when caring for family members. People with burnout are very negative about their tasks, find it hard to concentrate, are listless and lack creativity1.
Although our profession has a dedication to serving the interests of the person with diabetes, which is the heart of medicine’s contract with society, let’s ensure we are not doing this to the detriment of our own health and wellbeing, and longevity in the health profession.

There are many contributors to health professional burnout, some of which may be more difficult to address. These include professional isolation, lack of support from an employer and time pressures. However, this article will focus on the use of engagement and empowerment strategies as one way to reduce burnout.
Motivating people with diabetes
One way of reducing burnout is to be able to utilise our time efficiently and effectively to engage and empower those we work with during our consultations. To achieve this, it is helpful to know what motivates an individual.

▪ What are their motives to make changes?
▪ What will they gain from the process of change?
▪ What do they value?
▪ What gives them energy?
▪ What is non-negotiable for them?
▪ What do they feel most ready to implement or sustain at this stage of their lives?

Asking powerful questions like these elicits practitioner understanding and provides context to the person’s current perception of self and their priorities, the key to transforming our consultations. What we know from self-determination theory is that people are more motivated and can sustain lifestyle and behaviour changes for longer if we foster intrinsic motivation. There are conditions that support an individual’s experience of autonomy, competence and relatedness, and will foster more volitional and high-quality forms of engagement in activities, performance, persistence and creativity2.

Approaching each individual as an expert in their own lives and utilising our sessions to maximise their potential and strengths is more uplifting for both the practitioner and the person with diabetes. Understanding the person and their perspectives will also allow you to provide in-time education that you know they will be more readily engaged in, and allows for greater growth, learning and sustained change.
When we are providing people with lots of factual information, or attempting to enforce and reward compliance regimes for health outcomes, we are using extrinsic motivators3. There is ample evidence that simply imparting knowledge is not the most useful approach to inspire sustainable behaviour change. Education is necessary but far from sufficient to self-manage a chronic illness4. Moreover, providing information prescriptively or with an expert attitude is counterproductive to individuals becoming involved in their own care4.
Putting people with diabetes in the ‘Driver Seat'
Two systematic Cochrane reviews of diabetes self-management have revealed that disease education is beneficial but that behavioural education is better, and that altering approaches to incorporate behavioural techniques is required. (4) Researchers have proposed that behaviour change coaching complements disease education programs, which are considered vital but alone do not necessarily translate into successful self- management strategies4.
Behaviour education honours “unconditional positive regard” for our clients, meaning that the individual is doing the best they can with their current resources. . If we understand a person’s perception of the resources they believe they have at their disposal, then we have a deeper understanding of how to best support them moving forward. If a person perceives that their self-efficacy (their belief in their own ability to make changes at this stage in their lives) is low then we know that we should be actively working on building their self-efficacy.
Accepting an individual unconditionally and not enforcing compliance regimens, builds trust and rapport, and more importantly keeps the individual more connected to their health care team. We want those who we work with to feel that they can seek out their health care team when they need to problem solve, strategise and learn, rather than avoid and resist timely interventions. The latter can lead to overburden on our healthcare system and potentially an avoidable hospital admission.
We can utilise a few coaching theories to assist us to cultivate this environment. Essentially starting with Appreciative Inquiry (AI); using positive leading questions to discover what the person is capable of by asking them:
▪ What is working well for them at that moment?
▪ What do they feel they are consistently able to do that is supporting their health and wellbeing goals?
▪ What have they done in the past that has been of benefit to them?
▪ What could they reintroduce?
▪ What supports or resources do they have that could support them?

If we are noticing resistance or ambivalence during a consultation we can turn to Motivational Interviewing (MI) theory. MI asks the person to set an agenda of their choosing and the practitioner then asks permission to explore that topic with the individual in that session.
For example, if the person’s desire is to reduce sugar in their current diet.
▪ Nominate the length of time that you have available during the consultation
▪ Use open ended questions to unpack and hear their perception
▪ Ask them about the pros and cons of continuing their current behaviour
▪ Ask them about the pros and cons of making some changes to their current behaviour.
▪ Ask them if there was anything discussed today that they feel ready to make any changes in at this point and be accountable for between visits.

This will provide greater insight and cultivate awareness for both you and the person with diabetes about their readiness to adopt any changes. It also fosters and supports the self-determination theory, honouring that the individual has a choice.
If the individual is ready to move forward and set a goal, it’s important to ensure that the goal is measurable and also realistic. This will foster and build self-efficacy along the journey of change and cultivate an experimental approach to goal setting. More importantly, it will also allow the person to learn and grow from the process of change.
Bringing your “Best Self”
To ensure that we are cultivating the right environment for those we work with to thrive, we need to ensure that we are bringing our best self to their consultations. Compassion and empathy are the cornerstones to working with people to maximise their potential. These traits allow us to understand an individual from their perspective without taking on the situation and emotions ourselves. Case reports on credentialed nurse coaches find that addressing holistic self-care for the coach themselves is a critical keystone to ongoing professional development and prevention of burnout. (4)
Before we can continually bring empathy and compassion to our consultations, we are required to fill up our own “self-care cup” before we can give to others. Think of moments in your day whereby you can bring some nurturing time to yourself.
▪ Deep breathing before next consultation starts to begin with a clean slate
▪ Mindfulness for a few minutes to reset
▪ Laughter with a colleague
▪ Calming tea to soothe the soul

Self-care outside of the workplace is just as important and consideration should be given to:
▪ Exercise
▪ Social Supports
▪ Good Nutrition
▪ Rest and Restoration including activities such as yoga, meditation, reading and gardening
Conclusion
Understanding how to motivate people and facilitate the process of behaviour change will be empowering for you as a clinician and for your clients. . To provide ongoing quality transformations and support to people with diabetes, we can utilise the behaviour change theories of AI and MI to build trust and rapport, provide choices around self-care management and work through ambivalence in our consultations. Using measurable and realistic person-centred goals will build and foster self-efficacy, engagement, and empowerment. The theories will assist you with a frame of reference and the necessary tools to bring about sustained change, leading to greater personal job satisfaction and reducing your risk of burnout.

[Breakout Box: Further reading and resources}

Mindtools Burnout Self-Test
Beyond Blue Health Services Program
Alfred Health Mindfulness App for hospital workers
Australasian Doctors Health Network
Mindtools Stress Management (includes a number of articles on burnout)

For more information on practitioner burnout, or for additional behaviour change training, do not hesitate to contact me at: kim@medicoach.com.au
References
1. PubMed Health. (2018). Depression: What is burnout?. [online] Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/ [Accessed 4 Apr. 2018].

2. Selfdeterminationtheory.org. (2018). selfdeterminationtheory.org – Theory. [online] Available at: http://selfdeterminationtheory.org/theory/ [Accessed 4 Apr. 2018].
3. Deutschman, A. Change or Die: The Three Keys to Change at Work and in Life, pg. 6-12, New York, HarperCollins, 2007.
4. Vumc.org. (2018). [online] Available at: https://www.vumc.org/pmr/files/pmr/publication_files/Chapter%2032%20Coaching%20in%20Healthcare.pdf [Accessed 4 Apr. 2018]