Chapter 12 The health workforce

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Contents

• Unit 25: Human resources for health
• Objectives
• Unit 26: The healthcare team and interprofessional care
• Objectives
• Case studies
• Unit 27: Work stress and burnout
• Objectives
• Case studies

Unit 25: Human resources for health

Objectives

When you have completed this unit you should be able to:

• Explain why professionals may be reluctant to work in underserved areas.
• Describe how good human resource management can keep good staff in posts.
• Outline how underperformance in a colleague or co-worker could be addressed.

25-1 Why is there a global shortage of healthcare workers?

The delivery of healthcare depends heavily on having trained providers. There is a worldwide shortage of nurses, doctors and midwives, even in high-income countries, as populations become older and advances in healthcare mean that more can be done.

The problem is particularly bad in sub-Saharan Africa. A 2006 report by the World Health Organisation stated that sub-Saharan Africa had 11% of the world’s population, 24% of the world’s burden of disease but only 3% of the healthcare workforce.

Training of health professionals is expensive and very few countries are training enough to meet their needs. The shortage in many African countries is made worse when professionals migrate to richer countries in search of better working conditions or more opportunities.

Very few African countries are training enough health professionals.

25-2 Why might there be a local shortage of healthcare professionals in some areas?

Even within a country, healthcare providers are not distributed according to need. This is because:

• Professionals tend to prefer to work in urban rather than rural areas.
• Professionals tend to choose not to work in badly managed health services because they become demoralised.
• Vacant posts may not be filled even though suitable candidates have applied. This strategy is sometimes used as a cost saving measure.

25-3 Why don’t healthcare professionals want to work in rural areas?

There are several reasons, but these are the most commonly stated:

• Children and spouse preference: access to good schools can be difficult for those living in rural or remote areas. Spouses, particularly bread-winners, may fear boredom or lack of work opportunities in a rural area.
• Opportunities to develop: Professionals may fear being stuck in a “dead end” job and believe an urban job will offer more opportunities to specialise or develop new skills.
• Financial opportunities: there are usually better opportunities for private practice in the city.
• There is frustration when they are unable to provide effective care as a result of failures in the supply chain.
• Overwork, particularly on call: When there are staff shortages, a vicious cycle may be created when staff leave because the increased workload on staff remaining makes them more likely also to seek work elsewhere.

25-4 What strategies can be used to encourage healthcare professionals to rural and underserved areas?

An important role of human resource management is getting good quality staff. This process is called recruitment. Several strategies have been used to encourage staff recruitment to rural or underserved areas. These include:

• Training more professionals, in the hope that greater numbers mean more will spread out to underserved areas.
• Recruiting students from rural communities and exposing all students to rural healthcare when they are training.
• Offering bursaries to students in return for a commitment to work in a rural or underserved area for a time after qualification.
• Compulsory community service, where new graduates have to complete a service requirement before they can be registered.

Other strategies important to keep good staff (retention) where they are needed include:

• Task shifting: to reduce the workload on nurses, midwives and doctors.
• Good human resource (HR) management so staff believe they are valued by their employers.
• Fair pay.
• Providing opportunities to progress in their careers.

Staff need to be recruited and retained to work in rural areas.

25-5 What is “task shifting”?

Task shifting (sometimes called “task sharing”) involves taking tasks from a well-paid, better qualified person, who may be juggling a number of activities, and delegating them to somebody who is less well qualified and less well paid. It can include:

• Making sure that professional staff use their time on professional tasks, rather than clerical and administrative work that could be done by others.
• Having “lower grade” staff perform certain clinical functions such as health screening or counselling.

Although it is seen as one solution to the global shortage of health professionals and has had some successes, task shifting of clinical duties needs to be done carefully as “lower grade” workers can feel misused. There need to be clear guidelines about expectations and scope of practice, they must be properly trained and supported, they should be recognised and remunerated for additional responsibilities and there should be a chance of career progression for those who wish to move on.

25-6 What does good human resource management look like?

Good human resource (HR) management is critical if professionals are to be recruited and retained in areas where they are needed. With good management:

• Facilities have a staffing plan that meets service needs, and which has been agreed by the budget holders.
• All advertised posts are filled if qualified candidates apply.
• Staff members are paid on time and in accordance with their contracts.
• There is a performance management plan for individual staff members that recognises and rewards good performance while holding under-performing staff members to account.
• There are opportunities for professional learning and development.
• Staff are valued and know it: For example by providing childcare, wellness services or transport.
• Ensuring that staff have the necessary time, equipment and facilities to provide effective patient care.

25-7 How can underperformance in a staff member be addressed?

All staff members should have a job description that lists expected activities and standards. The staff member should agree to this job description. When performance is not up to standard, referring to the agreed job description makes a discussion about performance less personal. A performance management system is a regular meeting between a staff member and their manager to discuss their performance in various key areas. If performance has been below expected standards, a plan can be agreed upon between the staff member and manager to improve performance before the next meeting.

25-8 Do workforce shortages only refer to doctors, nurses and midwives?

No. There is also a shortage of skilled managers in many health systems in South Africa. One key area where skilled management can make a big difference is in the management of the supply chain. In the past, this has been a low prestige job, but it is vital to the optimal performance of a health facility and should be a well-paid, high prestige job.

25-9 What are the particular challenges in human resource management?

Making sure that the right people are in the right jobs and working effectively can be difficult when:

• It is difficult to remove people from their posts when they are unable or unwilling to do their jobs well.
• Senior managers are employed for reasons other than professional competency.

Unit 26: The healthcare team and interprofessional care

Objectives

When you have completed this unit you should be able to:

• Describe the roles of different members of the health team.
• Recognise the advantages of interprofessional care.
• Identify opportunities for interprofessional care.
• Assess a patient using the International Classification of Function, Disability and Health.

26-1 What do we mean by “holistic” or “biopsychosocial” care?

Many patients can be quickly and effectively restored to full health. However, some health problems can have a profound and long lasting effect on the way the patient looks, feels and functions. Burns, strokes and amputations are common examples of these. The goal for these patients is to get them back to their optimal level of physiological (biological), psychological and social function, so that they can participate as fully as possible in the world around them. This integrated approach to care is sometimes called “holistic” or “biopsychosocial” care. It is an overwhelming task for one person and therefore a healthcare team approach is necessary.

Holistic or biopsychosocial care addresses the physiological, psychological and social needs of a patient in an integrated way.

26-2 What is meant by “the healthcare team”?

In a successful company or business there is usually a team of experts from various fields working together towards a common outcome. They are experts in different things, and although they often work independently, they know their value to the whole project and they communicate with each other to keep on course to achieve this common goal. It is no different in healthcare. There are many different people and organisations that can play a role in the management of a patient, but they are most effective when working towards a common goal by communicating with one another. One of the most important team members and one who is often omitted is the patient.

Important role players in the healthcare team include:

• The facility-based team, including the nursing and medical staff and allied health professions
• Patient transport and emergency medical services (EMS)
• Community based services such as:
  • Community health services
  • Other government funded agencies
  • Non-governmental and private organisations
  • Other private individuals in the community

A healthcare team includes many different role players who work together to meet the patient’s needs.

26-3 How can holistic care be provided?

In order to provide effective holistic care for patients it is necessary to:

• Assess the patient’s physical, psychological and social (biopsychosocial) needs.
• Know what other people and organisations have to offer your patient, both within and outside the facility and:
  • How to communicate with them.
  • Whether your patient is able to access them.

26-4 Who are the nursing members of the health team in South Africa?

All 3 grades of nurses are important members of the health team. They are:

• A professional nurse (also called “sisters” in South Africa) has completed a 4-year diploma or degree course and is qualified to undertake a wide range of duties including the administration of prescribed treatments, the drawing up of care plans, health promotion, and the operational management of clinical departments. Their course includes maternity, psychiatric and community nursing. They have mauve epaulettes with bars for specialist training. These include: maternity (green), psychiatry (navy) and community nursing (yellow).
• An enrolled nurse (also called a “staff nurse” in South Africa) has completed a 2-year diploma course. Their scope of practice is similar to the professional nurse’s, but enrolled nurses are not allowed to give scheduled medicines or some high risk infusions, such as glyceryl trinitrate. Enrolled nurses tend to be more “hands on” than professional nurses because they do not have the same administrative and supervision responsibilities. They often build up extremely valuable practical competencies, such as difficult dressings. They have white epaulettes. Enrolled nurses can take a 2-year bridging course to convert their qualifications to a professional nurse grade.
• An auxiliary nurse (also called nursing assistants in South Africa) completes a 1-year training course. Auxiliary nurses wear a blue broach but no epaulettes. They do basic nursing procedures, can take observations and administer oxygen, but do not administer drugs.

All three grades of nurses have a very important role to play in providing good nursing care.

26-5 Who are the medical members of the health team in South Africa?

In most medical schools in South Africa, medicine is a 6-year training programme followed by a 2-year internship. Interns (sometimes called “housemen” in South Africa) are qualified to diagnose and make treatment decisions, but a fully qualified doctor should supervise their work. After completing their internship, a doctor is qualified to practice independently and set up a practice as a general practitioner, but is currently required by the Department of Health to first do an additional year of community service.

Doctors who stay in hospital practice but do not specialise are called “medical officers”. A doctor may then decide to undergo specialist training for 4 to 5 years, during which time they are called a “registrar”. Following specialisation, a doctor is known as a “specialist” or “consultant”.

26-6 Who else can diagnose and prescribe?

Clinical nurse practitioners (CNPs): These are professional nurses who receive advanced training and are authorised to diagnose and make a management plan within their scope of practice and usually based on approved protocols. They form the backbone of services in many primary care clinics. They may prescribe unscheduled drugs and drugs from schedule 1 to 4. Essentially a clinical nurse practitioner can prescribe most commonly used drugs, but excluding barbiturates, opiates, benzodiazepines and anaesthetic agents.

Note

A list of schedules can be found on the South African Pharmacy council website.

Clinical associates: These are mid-level health professionals who complete a 3-year degree as a Bachelor of Clinical Medical Practice (BCMP). The profession was developed in order to deliver routine medical services at district hospital level, working under the supervision of a doctor. The first clinical associates graduated in 2010. The Health Professions Council has published their scope of practice. There is also a lack of clarity over their overtime payments and concern that they may be misused to do the bulk of the doctor’s work. This means that the future of the profession is uncertain at the time of writing. Much of the work they do can also be done by a clinical nurse practitioner.

26-7 What are the roles of the allied health professions?

Allied health professionals are professional healthcare workers other than doctors or nurses. They work at all levels of healthcare from primary care clinics to tertiary hospitals. Allied health professionals include the fields of:

• Physiotherapy: They offer an array of therapies for musculoskeletal, neurological and respiratory conditions for both adults and children. The aim of their patient management is optimal physical functioning. For example, a physiotherapist may assess a person with walking difficulties after a stroke and train them in the use of a walking aid.
• Occupational Therapy (OT): They focus on the reintegration and participation of patients at their highest functional level by improving patient functioning, and by optimising home and work environments. For example, an occupational therapist may assess a person with walking difficulties after a stroke and advise how their house could be adapted so the person can still do the activities that are important to them.

Often physiotherapists and occupational therapist works closely together to get their patient functioning well in their home and work environment.

Physiotherapy and occupational therapy work hand in hand at getting their patients up and back out into the world.

• Speech-language and hearing therapy: They are experts in the field of neuro-linguistics. They focus on assessing and managing speech, oral communication and swallowing disorders. For example, helping patients who cannot communicate or swallow safely after a stroke. They can also assist with the diagnosis and management of hearing impairment using hearing aids and rehabilitation.

Speech and language therapists are the experts in managing communication disorders and swallowing disorders that are not caused by a physical obstruction.

• Human Nutrition (or dietetics): They focus on good individual and community nutrition, oral and intravenous therapeutic nutrition for ill patients, and food services management, such as the provision of hospital food.
• Social work: They focus on dealing with tasks, needs and problems arising from people’s personal relationships and social circumstances. For example they can investigate situations where social factors may be contributing to the patient’s problems, such as suspected child abuse, malnutrition or elder neglect. They will usually also help with adoption and assess people who have been admitted with attempted suicide.
• Pharmacy: They aim to supply medication in accordance with prescriptions, to ensure sufficient stock of medication, to counsel patients on and promote the correct method of drug administration and reduce side effects. They also advise on the management of minor clinical problems. Pharmacists are supported by Pharmacy Assistants, who can play an important role in stock control and dispense some medications.

Note

All the allied health professions play a big role in the prevention of disease and health promotion alongside their discipline specific functions in the team.

26-8 What are the roles of patient transport and emergency medical services?

Patient transport services and emergency medical services (EMS) are an essential part of patient management especially when it comes to patient follow-ups, transfers to other institutions and emergency transport for patients in urgent need. Emergency medical services personnel are usually the first responders for emergencies and most are trained in resuscitation and emergency care. They often have valuable information about what has happened to the patient at an accident scene, in the home, and while on the road, including their initial management. Facility based staff should listen carefully to their handovers and allow them to handover as soon as possible so that they can get back on the road again.

Emergency medical services providers have different levels of training. However, a paramedic has the highest levels of training and is the only emergency medical service provider qualified to look after a ventilated patient during transportation. If a patient who is intubated, or who has other critical care needs must be transferred, the station must be notified of this and a paramedic requested.

In some provinces very few paramedics are available and many patients have to be moved by emergency medical services personnel with only basic training.

26-9 Which other government agencies can help?

The following government departments can also be used when managing complex cases. Allied health professionals will often have the knowledge of who to call and how to access services, but the problems must be communicated with them:

• Department for Social Development (DSD): The social worker at the facility can help negotiate with the Department of Social Development which deals with issues around grants, placement for children or elderly, and is responsible for some poverty reduction programmes. Social grants are actually administered through the South African Social Security Agency, which reports to the Department of Social Development. The social worker can also advise about when and how to make contact with police services regarding a patient, and can also make contact with the Department of Housing when necessary.
• Department of Education: The occupational therapist and social worker often have good contacts with the Department of Education for any issues regarding the health and social well-being of school-going children.

26-10 What are environmental health practitioners?

South African environmental health practitioners (formerly known as environmental health officers) complete a 4-year degree course (formerly a 3-year diploma course). Local government employs them, although provincial health departments often employ environmental health practitioners in a coordinating role. They are responsible for monitoring water safety, public eating places, pollution and other environmental issues. They can investigate outbreaks of food poisoning, industrial pollution and “hotspots” for seasonal gastroenteritis. The environment health practitioner should be notified of all cases of agricultural poisoning.

26-11 How can non-profit organisations help?

Non-profit organisations (NPOs) have a great deal to offer patients, but doctors and other health professionals often know little about them. If you are starting work at a hospital or clinic, it is worth getting to know what non-profit organisations are in your area.

Types of non-profit organisations the health team might make use of include:

• Facilities for stable patients with lower care needs (sometimes called “step down” or “convalescent” facilities) or palliative and end-of-life care facilities such as hospice.
• Organisations for patients with cancer such as CANSA (The Cancer Association of South Africa), which can assist with transport, accommodation during chemotherapy and follow up planning, and provide psychosocial counselling. Reach for Recovery is an organisation where breast cancer survivors give support to other breast cancer patients.
• Organisations that support victims of domestic violence and offer a place of safety.
• Community health workers (also called “community healthcare workers” and “home based carers”) are often employed by government and non-profit organisations. They can make a huge contribution by monitoring and assisting with patient management at a community level. If there are community health workers in your district, you should find out which organisation manages them and make contact. One of the advantages of community health workers is that they can make regular home visits. As well as supporting the patient at home, they can provide useful information about the patient’s circumstances that might alter management.

Note

A non-governmental organisation (NGO) and a non-profit organisation (NPO) are essentially the same type of organisations, but NPO is the term more commonly used in South Africa. Both are outside of government and work for the public good. An NPO can receive tax deductible donations if it also a registered public benefit organisation (PBO).

26-12 What is the best way to find out which non-profit organisations work in the area?

In South Africa, the best way to find out what organisations exist in your community is to contact the community based services manager at the district health office, or the Department of Social Development where you are based, and request their list of funded and non-funded organisations. There may be an NGO/NPO governing body for the area such as a Multi-Sectoral Action Team (MSAT). If you are planning to work somewhere for a long time, it is best is to know these organisations “face-to-face” and find out what they have to offer your team.

If you plan to work somewhere for a long time, see if there in an umbrella organisation for NPOs in your area, such as a “multisectoral action team”.

26-13 Are there other potential team members within the community?

Yes. Sometimes, if your patient consents, it may be appropriate to involve other community members in your team, such as a family member, neighbour, a religious leader or school teacher.

26-14 In what ways can team members work together?

When 2 or more professional people from different disciplines work together towards a common goal and learn from one another this is referred to as an interprofessional team (it can also be called an “interdisciplinary” team). When there is a group of people from different disciplines work on the same problem, but write each other referrals rather than discussing things and working on common goals, this is referred to as a multiprofessional team (also called a “multidisciplinary” team).

Interprofessional work is preferable where possible, especially when patients have many, complex problems. There is nothing wrong with just writing a referral to a colleague, but when you discuss problems and work towards common goals, patient management is more comprehensive and effective than when everybody is working to meet their own goals.

In an interprofessional team members of different professions work closely together and learn from each other in order to achieve a common goal.

26-15 When should an interprofessional or multiprofessional plan be made?

If a patient is likely to benefit from the input of other professions, it is important to map out a holistic picture of the nature of your patient’s problems and make appropriate referrals during admission. While the patient is in the facility, an interprofessional team is available to do this assessment. Once the patient is discharged and possibly ‘lost in the system’ without appropriate referral, it is highly unlikely that comprehensive management will ever take place.

The best time to assess your patient’s needs and refer to other interprofessional team members is during admission.

26-16 What if you “don’t have time for interprofessional care”?

In academic or rehabilitation centres, interprofessional care is organised by having case conferences, where several professionals sit together and discuss their patients’ needs. This can be very time consuming and seems an unrealistic “nice to have” for hospitals with a high caseload. Fortunately, that is not the only way of organising interprofessional services. If you know your other team members, and you know what they have to offer, you can easily find opportunities to discuss cases with your colleagues, such as at morning tea, when passing in the ward, or on a ward round. In the long term, interprofessional care might even save some time because a person with a complicated problem who has been successfully rehabilitated is less likely to visit casualty with unresolved problems or unrealistic expectations.

Shared tea rooms are important spaces for practicing interprofessional care in busy hospitals.

26-17 How is an interprofessional management plan made for complex cases?

Many patients will benefit from interprofessional management that involves just one additional professional and involves one discussion. Others can be quite complicated and involve several other health professionals. In order to provide this sort of in depth, holistic management it is necessary to have a team leader, and some sort of tool for analysing your patient’s needs.

26-18 What is the role of the team leader?

A team leader or case manager is someone who is responsible for making sure that collaboration takes place, and that everybody knows what they must do. While the patient still requires acute hospital care, this is usually the doctor. Otherwise, it is the person responsible for the bulk of the patient care. This role can shift to other team members as the patient progresses through the healthcare system.

26-19 What tools can be used to analyse a patient’s needs?

There are many tools that can help you formulate a holistic picture of your patient. The International Classification of Functioning, Disability and Health (ICF) is one of them and can be found on the World Health Organisation’s website. The holistic (biopsychosocial) assessment is divided into 5 sections (domains):

• Impairment refers to any physical or medical problem the patient has. This is the “bio” part of biopsychosocial, e.g. right sided weakness.
• Activity limitations refers to the physical limitation that a patient now has as a result of their impairment. e.g. bed ridden.
• Participation restrictions refers to the restriction of the patient’s involvement in society, at home or in the work place. We often refer to this goal as ‘the thing that makes people ‘want to live’. This is mostly what ill patients strive to get back to when they are better. For example, being a mother to a 3-year-old, caring for a wife, earning money, or studying.
• Environmental factors refer to any barriers or facilitators in the physical environment that might hinder or help you with this patient’s management, e.g. the patient lives 50 km from the hospital, but his brother has a car and can drive him.
• Personal factors are internal factors that might also positively or negatively affect management, such as the patient’s fears, ideas and beliefs, level of education or motivation.

Looking at a patient’s life through the lens of these 5 sections helps providers to see what might be contributing to a patient’s distress. Each person on the team assesses the patient from a different angle and each team member’s contribution is valuable to the whole. An example of a full assessment of a patient using the International Classification of Functioning, Disability and Health is shown in the Resources.

26-20 Can interprofessional care be good for providers as well as patients?

Yes. One of the things most healthcare providers in South Africa complain about is burn out and stress, because patients present with complicated problems and come from home environments that make management difficult. Poverty, lack of education and access to resources are just some of the issues that have to be faced. It can be overwhelming to look at a patient from a holistic perspective, and sometimes it feels easier to ignore their other problems, because they feel too big for one person to manage. This can lead to job dissatisfaction, poor patient management, readmission and an even greater burden on the healthcare system.

The solution to providing interprofessional care is learning to work as a team. You are responsible for your patient’s wellbeing, but you cannot do it alone. You need to refer, discuss, make plans, find solutions and learn to work together. The need for interprofessional care will increase in future as a growing number of patients will present with multiple, chronic problems.

Case study 1

It is Friday night and a 34-year-old woman comes into casualty. She has been assaulted by her drunk husband and she has several bruises, a cut lip and a swollen eye. She also sustained a tibial fracture, which can be set in Plaster of Paris. She does not meet the criteria for orthopaedic admission. The social worker will only be available on Monday morning so the doctor discharges her with an above knee cast, 2 crutches and a letter to take to the social worker at the clinic where she lives. She has 2 children, one is 3 months old and the other is 2 years old. She lives and works on a farm 50 km from town picking grapes from 07h00 until 16h00. She has no transport.

1. Who else should be involved in this patient’s management?

She needs to see:

• A social worker.
• A physiotherapist to help her mobilise on crutches.
• The support of a community organisation that helps victims of domestic abuse or a Thuthuzela Centre if she has access to one.

Note

Thuthuzela centres are run by the Department of Justice and offer a “one stop” service to help the victims of domestic abuse.

2. What questions or concerns might you have regarding this patient’s welfare or the welfare of her family?

The following are concerns:

• Is it safe for her to go home after discharge?
• She has been discharged with a clinic follow-up appointment, but how will she get to the clinic to see the social worker? Who will take her?
• Who is looking after the children while she is receiving care?
• How will she be able to see the physiotherapist during working hours?
• If she cannot work for the next 3 to 6 months because she is in a plaster of Paris cast, how will she get an income? It may be necessary to refer her to social services for income support. The social worker can make this call.

This patient may be at risk of a further abuse or even homicide if she goes home. She needs to decide if she wants to make a case against her husband, but this choice can be difficult if he is the breadwinner. Most likely, the hospital doctor or nurse will have to help her make arrangements with a friend or family member, or arrange for her to go to a shelter or formal place of safety until the social worker, and possibly the police have seen her.

Case study 2

Mrs Apollis has been hospitalised with a stroke as a result of uncontrolled high blood pressure. She has a right sided paralysis and is unable to speak. Her blood pressure is 240/130. She has an insecure income and usually lives with her son but he is currently in prison awaiting trial. He is addicted to “tik” (crystal meth) and has been violent towards her in the past.

1. What are the roles of different team members in getting her back to the fullest possible health? Think about the doctor, the nursing team, the allied health professionals and the social worker.

• Doctor: responsible for controlling her blood pressure and finding a medication regime to which she can be adherent, together with any acute medical questions, such as whether she needs a drip or a urinary catheter.
• Hospital nursing team: responsible for helping her with activities of daily living that she cannot manage by herself in the acute phase, such as moving, hygiene and feeding. The nursing team is also responsible for administering necessary medication.
• Physiotherapist and occupational therapist: responsible for getting Mrs Apollis up and out in the world. The physiotherapist will focus on physical functioning, such as walking and the occupational therapist will focus on organising the environment so she can function and participate as independently as possible. The occupational therapist can also assist with screening and management of possible depression (with assistance from the doctor) as well as cognitive re-education should Mrs Apollis’s intellect and understanding be affected.
• Speech and language therapy: In the initial phase, the speech and language therapist should check how well she can swallow and make sure it is safe for her to eat (stroke patients can choke on food if this is not done). The therapist will assess how well she can communicate, and if she is unable to speak will usually provide an alternative communication device such as a picture board that she can point to if she wants to ask something. Speech and language therapy can assist with cognitive re-education alongside the occupational therapist.
• Social worker: The social worker will investigate the home circumstances and if the team decides it is unlikely that she will be able to look after herself at home, the social worker will look for somewhere else for her to live. The social worker might also get involved in counselling the patient regarding her relationship with her son and could assist the son with accessing support services.

Case study 2 continued

Mrs Apollis’s blood pressure is easily controlled with a single drug (she had stopped taking her regular medication). She is able to swallow, but talks with difficulty. She is able to walk short distances with a crutch, but the social worker and occupational therapist can see that she will not manage by herself at home. The social worker contacts Mrs Apollis’s sister who lives in the country – they had lost contact because their husbands did not get on. The sister would very much like Mrs Apollis to come and live with her. The social worker and Mrs Apollis discuss the son. Although she is sad about it, Mrs Apollis agrees that she can no longer be responsible for him and that he must look after himself. She is ready for discharge and looking forward to spending time with her sister again.

1. Over this time, the team leader has shifted from the doctor to the social worker. Can you think of another important step that the social worker should do before Mrs Apollis goes to her sister?

Mrs Apollis will need to continue treatment for her high blood pressure. The social worker should check with the medical team, see what arrangements have been made for the transfer of her chronic care and rehabilitative needs, and make sure that appropriate information has been transferred to her new clinic.

Unit 27: Work stress and burnout

Objectives

When you have completed this unit you should be able to:

• Explain what burnout is and what contributes to it.
• Describe strategies to manage work time better.
• Describe strategies to build mental resilience.

27-1 What is the impact of stress in the workplace?

Stress is unavoidable, but it is particularly common in health professionals, especially when the demand for health services overwhelms the abilities of providers. This can be made even worse when administrative or managerial support is lacking. Chronic work related stress is unpleasant and unhealthy. As a result, people who are able to, may leave their jobs or even leave the profession. Those who are unable to leave are at risk of burnout.

Chronic work stress is unpleasant and unhealthy.

27-2 What is burnout?

People often use the term “burnout” when they are tired or fed up at work, but it means something quite specific. It means a long-term state of exhaustion and reduced interest in work as a result of chronic work related stress, and it has 3 characteristics:

• Emotional exhaustion: Means feeling psychologically drained.
• Depersonalisation: Means becoming cold and indifferent at work.
• Reduced personal accomplishment: Means reduced feelings of success and satisfaction at work.

Burnout is a state of emotional exhaustion, depersonalisation and reduced personal accomplishment at work.

27-3 What are the risk factors for burnout?

Burnout is more common when people feel powerless at work, as a result of a lack of information, supplies or support. Burnout is more common in female healthcare workers, particularly when they have multiple care-giving roles and must look after children or the elderly when they go home after a long shift.

27-4 How can burnout be avoided?

Steps that can help avoid burnout include:

• Recognition by managers that lack of information, supplies and support can increase the risk of burnout in their teams.
• Using interprofessional teamwork to manage and share responsibility for difficult clinical problems.
• Learning time management skills to increase effectiveness at work.
• Learning resilience skills to reduce the impact of stress on minds and bodies.

27-5 What time management strategies can be useful in healthcare?

One of the most stressful things about being a clinician is dealing with competing demands on your time. It is possible to spend hours running around, but not be able to finish any tasks because you keep being called away for something else. This is highly frustrating. In the clinical environment, there are many things that really will not wait, and it is often not possible to decide how urgent something is without first listening to the story and sometimes assessing the situation yourself. The following can help:

• Efficient work practices: It is possible to save a lot of time by making sure that workspaces are laid out in a practical and sensible way.
• Prioritisation: Some tasks will be more urgent than others. Attend to these first and do not get side tracked. An unstable patient can quickly become very sick if not managed in time and you may then end up spending far more time on them in the long-run.
• Learn to say “no”: Many of the readers may be medical students, junior doctors, allied health practitioners, clinical associates and nurse practitioners who may find it difficult to say “no”. There are acceptable ways of saying “no”. If the new task you have been given means that you will not be able to complete something else, point this out to your senior and ask if they would like you to stop what you are doing, or whether the new task is something that can wait.
• Delegation: You do not have to do everything yourself and there may be others who can do it. It is usually worth spending time teaching others how to do things, even if you do not always get the benefit yourself. Students can provide a useful extra pairs of hands, but they should only be asked to do things they will learn from and should be appropriately supervised. You may find that you are the one to whom work is being delegated, and that this is causing an overload. If you are in a situation where work has been inappropriately delegated to you by a senior who should be in the facility but has chosen to “moonlight” in private practice and this is an ongoing concern, you should speak up.
• If you are a doctor, don’t neglect the ward: Sometimes, once a person has been admitted to the ward and is on treatment, they are seen as a less urgent concern. If ward patients are not seen regularly, the ward can become overcrowded. Then the demand on nursing services becomes unmanageable, complications and problems are picked up late and are more difficult to manage, and there is no room to admit other patients from casualty. Ward rounds should be done daily in acute wards. If you know your patients, this will not take very long and it is time well spent. In every patient you see, ask yourself “what can I do today to get this person closer to discharge?”

27-6 What is resilience and how can somebody learn to be more resilient?

Resilience is the ability to bounce back after being put under stress. Certain techniques have been shown to improve resilience. To master them requires some practice. They include:

• Clarifying and committing to values
• Staying healthy
• Cultivating positive emotions
• Practicing “mindfulness”

27-7 What are values and how does clarifying them help?

Values are the personal qualities that are important to a person. Values affect the life paths they have chosen, and the type of person they wish to be known as. When someone is stressed or overworked, it is easy for them to forget why they chose to follow a particular career in the first place. In this situation, demands can become annoying and may lead people to behave in ways they later regret.

If activities are connected to values, they become much less annoying and more fulfilling. As a first step, it can be useful to spend some time thinking about what our values are and what is important to us. Then a few behaviours in keeping with values can be identified and a commitment made to doing them. For example being on time, being compassionate and greeting people with a smile.

27-8 How does staying healthy help?

There is much truth in the expression “a healthy body is a healthy mind”. If a person eats well, exercises and gets enough sleep, they are more likely to be mentally healthy as well as physically healthy. This can be difficult, particularly if a person works long shifts. Healthy foods can be difficult to find particularly in the tuck shops of government hospitals, so it is worth spending the time to make a meal and take it to work. A healthy amount of moderate exercise twice a week. That means exercise where you can talk, but are too out of breath to sing. Walking is an excellent exercise, particularly if you are able to do it outside, away from traffic. Surprisingly, aerobic exercise after a tiring day at work usually makes you feel less tired.

27-9 What is mindfulness and how does practicing mindfulness help?

Mindfulness is a way of training the brain to operate in a more healthy way by focusing on the present. This is something that Buddhist monks do particularly well, but psychologists believe everybody can learn it. There is evidence that it will clear the mind, help concentration and decrease stress. Just like physical training, brain training takes practice and time.

Note

If this approach interests you, more information can be found on the following sites: http://www.helpguide.org/harvard/benefits-of-mindfulness.htm http://greatergood.berkeley.edu/topic/mindfulness/definition

27-10 What are positive emotions and how can they be cultivated?

Emotions are the way a person feels in response to a situation:

• A negative emotion, such as fear or worry, is unpleasant and causes a person to focus on the situation that caused it. Negative emotions can be useful when they cause us to respond appropriately to a threat.
• A positive emotion, such as joy or gratitude, is pleasant and causes a person to think more broadly and consider new experiences.

Emotions can be controlled to some extent just by recognising negative emotions and making a conscious decision to stop focussing on a negative situation. Positive emotions can also be cultivated (encouraged) by:

• Taking note of the small things in life that we have to be grateful for.
• Trying to do some small “random acts of kindness” for somebody else.
• Developing a hobby that we can lose ourselves in, such as joining a choir.
• Spending time with others, particularly those who make us feel good and avoiding spending too much time with those who complain.

Positive emotions can be cultivated. They make us feel better and they counteract negative emotions.

Case study 1

The previous professional nurse at Mahloko Clinic was Sr Magdalene. She had been working there alone for 25 years, including some difficult times when there was political violence and the local hospital had no doctors. She found herself feeling increasingly tired and uninterested in her patients. Non-adherent patients with chronic disease were a particular frustration. Community members complained that she was rude, and this hurt her feelings because she had served them for so long. She had developed diabetes herself and was often not feeling well. She decided she could not continue, so she left the clinic and the nursing profession.

1. What is the likely reason for Sr Magdalene’s loss of interest and “rudeness”?

It is very likely that Sr Magdalene had burnout.

2. There is a shortage of professional nurses in South Africa so it is always sad when one leaves the profession. What could her primary care manager have done to prevent this?

Primary care nurses in South Africa have many responsibilities, including inventory control, and are at risk of burnout. Their managers must be aware of this risk and need to make sure they provide supplies, information and support. There are several ways in which this could be done, but they include:

• A regular visit from a manager, where Sr Magdalene can express her needs or concerns
• Opportunities for continuing professional development
• Support from other professionals, for example a pharmacy assistant to help with inventory management

3. If you were Sr Magdalene’s friend and you had seen this happening, is there any help or advice you might have given her?

You could have advised her on techniques for time management or building resilience, but some techniques require quite a lot of practice. Easy things would include keeping healthy by exercising together, or cultivating positive emotions by joining a new club or taking up new activities together. Personal support is very important, but by itself it is not a substitute for appropriate work support from her manager.