The quality of care depends not only on medical skills but also on the communicative competencies of healthcare professionals. The article deals with the main psychological aspects of the professional activity of doctors in the medical team, namely, the role of the team, leadership, psychological profile, corporate culture, typical situations of interaction (counseling of patients of another specialist, clinical bypass), professional deformation, factors of formation and manifestations burnout, its prevention. Medico-psychological interventions aimed at enhancing the psychological competencies of health care professionals will improve the quality of care for patients and the psychological health of professionals.
Quality health services are determined not only by the professional skills of the medical professionals, but also by the team environment. It affects the patient's impression of the establishment and impacts on the productivity of the doctors.
The team is a dynamic system in which the defining and assignation of the roles, changes in activity, opinions, assessments, norms of behavior of group members, the impact on group members take place . There are various social roles as "coordinator", "idea generator", "enthusiast", "monitor-evaluator", "resource investigator", "implementer", "hard worker", " team worker" distinguished in the team. A leadership is also an important psychological phenomenon related to the concept of team. It is viewed as a process of influencing a person's personal authority on the behavior of group members, changing their views, positions, opinions, ways of behaving. Regarding leadership, there are emotional, business and information components. Depending on the predominant functions, the following types of leaders are distinguished: organizer, creator, fighter, diplomat, reassurer.
The relationship of subordinates with the leader, the psychological climate, the results of the team depend on the leadership style implemented by the leader . There are the following management styles: authoritarian, democratic, liberal-anarchic, inconsistent, situational, innovative-analytical, participative.
Given the fact that the patient is treated by a group of specialists today, the interaction in the team, which depends on organizational, situational and personal factors, becomes especially important.
Tashlykov V.A. developed the following psychological types of doctors. Knowledge of these types helps us to understand the consequences of the influence of the doctor's personality on the diagnostic and treatment process :
- Compassionate and non-directive. These are kind people, prone to compassion, evoking in the patient a sense of trust. They usually have a good range of relations with patients with hysteroid traits.
- Compassionate and directive. This type of doctor has a desire to penetrate into the inner worldview of a person, but they will act in relation to the patient directively, forcing the patient to do their will. These doctors have better relationships with patients who have anxious traits.
- Emotionally neutral and directive. They are characterized by firmness and confidence, the ability to bring clarity to the case. In relation to the patients, this type is a sensitive, attentive and restrained one. These doctors are more appealing to patients with neurasthenic traits, who have a need to maintain self-control.
Another psychological classification of doctors includes the following types :
- The ordinary doctor interacts with patients a lot of time, overworked, often ceases to individualize the patients.
- A doctor-robot is characterized by the mechanical performance of their duties. In their work, such doctors are careful, technically qualified, responsible, but non-empathetic and emotionally distant from patients. Relationships with patients have a lack of emotional compassion and empathy.
- The doctor-soldier is resolute, uncompromising, persistent, and reacts immediately to the slightest violation of "discipline". Such a doctor with insufficient culture, education, low level of intellectual development can be rude and even aggressive with patients. In favorable cases, if they are smart, educated, with such a strong character can become a good educator for young colleagues.
- "Maternal doctor" ("mother" and "doctor"). This type of doctors transfers to work with patients their warm family relations or compensates for absence at work thereof. Working with patients, caring for them is an integral part of such doctor’s life. They have a good empathy.
- "Doctor-Expert". This doctor is a narrow specialist. Due to the high need for professional recognition, they are especially curious in a certain field of professional activity and are proud of their importance in the field, where it sometimes even "overshadows" the doctor. Young doctors do not hesitate to turn to them for professional advice. Sometimes people of this type become fans of their narrow activities, excluding all other interests from their field of vision; they are not interested in anything but work.
- "Nervous doctor". This type of unprofessional behavior of a doctor should not be in a medical institution. Emotionally unstable, inflammatory, irritable, this person constantly gives neurotic reactions. They tend to discuss personal problems and can be a serious obstacle to the work of a medical institution. A "nervous doctor" is either a pathological person or a person suffering from neurosis. Such people often need serious psychotherapeutic help and are professionally unsuitable to work with patients.
- "The doctor involuntarily." This person may not have really wanted to become a doctor, so now is working clearly within one’s responsibilities. They have a formal, if not to say indifferent, approach to patients. However, such a doctor will not do anything superfluous to the patient! They assign only what has been tested for years. This doctor is especially convenient for those patients who suffer from something not very serious, such as ARD and for whom, first of all, a certificate and sick leave are needed.
- "Dr. Frankenstein." Such doctors are very competent and experienced. The stories about the fact that they are completely dedicated to medicine, pass from mouth to mouth. It is difficult to have an appointment with such a doctor quickly. However, this doctor is not interested in the person, but in the condition of one’s body - so the doctor will not feel sorry for you and sometimes will even be rude. However, it should not be taken to the heart! No unnecessary conversations. Clearly explain your problem to him - and he will begin to study the disease with interest and overcome it.
- "A doctor - a bright person." Everyone knows this person. Articles, TV interviews, books - all this gives the impression that you have a high-class specialist. However, after the consultation there may be double feelings - on the one hand, a feeling of having been chosen, on the other - surprise (because the district doctor at the district clinic said the same thing, and for free.) However, a visit to such a doctor is very useful for distrustful, anxious patients. A well-known doctor gives them much more confidence than "ordinary doctors", and the belief in a speedy recovery is still the key to success.
- "The doctor as a miracle." Attentive, responsive. This type treats patients as relatives - sympathizes, listens, reassures, advises. This makes it easier! And the reason is because this doctor is able to apply psychological techniques in communication. The doctor of this type is perfect for the elderly and children. Those are the people who need support, which allows to treat adequately both medicine in general and their health.
- "The doctor is an unrecognized genius." This type diligently shows high professionalism and incompetence of others ("Who ever decided to advise you?", "And why did they appoint you…?", etc.). Such a doctor often speaks sharply, intolerantly, almost aggressively. They are confident both in themselves and in the fact that they deserve more. Driven by the desire to become a recognized genius, such a doctor will deal with you seriously and comprehensively. The main thing is to show them how much you appreciate and respect them, tell them: “You recently helped my friend so much! He still says how grateful he is ... ”. And the doctor will do almost everything for you.
There are the following types of nurses according to I. Hardy :
- "Robot Nurse." Most nurses belong to this type. Performing their duties mechanically is a characteristic feature of such nurses. They perform the assigned tasks extremely diligent, precisely, with a masterly skill. But they act strictly according to the instructions and do not put their heart into work. Such type of nurses works like a machine and perceive the patients as a necessary supplement to the instructions for their service. Their relationship with the patient is devoid of emotional compassion and empathy. It is exactly this type of nurses who is able to wake a sleeping patient to give them a sleeping pill at the appointed time.
- "A nurse who plays a learned role." The behavior of such a nurse is unnatural, pretentious. They seem to play a learned role, striving to achieve a certain ideal. Such a nurse begins to play the role of a philanthropist. Their behavior becomes artificial, ostentatious. Unnaturalness in communication prevents them from establishing contacts with people, so such a nurse must clearly define professional goals, develop an adequate style of communication with the patient.
- "Nervous" nurse. Emotionally unstable, inflammatory, irritable, prone to discussing personal issues, which can be a serious obstacle to successful work with patients. Often gloomy, dissatisfied with work, patients. A "nervous" nurse is a pathological person or a person suffering from neurosis.
- "A nurse with a masculine, strong personality." Patients already know them by the walk, a loud voice and try to put in order the bedside tables and beds, to take away the unnecessary things. Such a nurse is characterized by persistence, authoritativeness, indignation over the slightest disorder. In favorable cases, a nurse with such a personality can be a great organizer, a good teacher. With a lack of culture, education, lower level of development, the nurse is too inflexible, often rude and even aggressive with patients.
- "Maternal nurse". Such a nurse performs their work with maximum care and compassion for patients. Work for such nurses is an integral part of life. Caring for patients is a life vocation. Often the personal life of such nurses is permeated with care for others, love for people.
- "Nurse-specialist". Due to their special personal qualities, such nurses are curious in a certain field of professional activity and receive a special appointment. Sometimes such nurses are so committed to their narrow activity, that they are incapable of and not interested in anything but doing this work.
So, apart from professionally incompetent types of medical professionals, there is no perfect specialist for all cases. Another important aspect for teamwork is well-balanced combination of the psychotype of the doctor with the psychotype of the nurse, the ability to jointly form a relationship of cooperation, their psychological compatibility.
Working in a medical team requires shaping of certain norms and rules of interaction, including collegiality and subordination.
Collegiality – a joint work, mutual support, joint responsibility, cooperation on mistakes.
Subordination – a strict adherence to the hierarchy in the performance of functional duties, responsibility within its competence, which in medicine is based on ethical and moral foundations.
Corporate culture defines a set of values, norms and rules that are not directly regulated, but accepted and adhered to by the employees. Similar rules are established for professional activities, interaction in the team, with recipients of assistance or services, colleagues from the other institutions. Along with the fact that a corporate culture exists in medical institutions regardless of the form of ownership, it becomes a part of the medical brand in private institutions.
Communication in the medical team is carried out at different levels: "doctor-doctor", "doctor-manager" and "doctor-nurse".
Typical situations of interaction in the medical team at the level of "doctor-doctor" and "doctor-manager" include :
- clinical discussion;
- clinical patient round together with the department chief (leading specialist, professor);
- consulting a patient of another doctor;
- consulting your patient with another doctor;
- transfer of the patient to another section of the health care center or medical institution;
- speech at the conferences, public presentation of scientific achievements;
- publication of scientific materials (remote, indirect interaction).
Clinical discussion is performed in order to develop treatment tactics for the patient in clinically complex or controversial cases, situations where related specialists should be involved and a comprehensive assessment should be conducted.
Introducing the patient at clinical discussion means structuring the information about the patient according to the accepted algorithm. In clinical discussion, in contrast to interaction with patients and relatives, the use of medical terminology is not only appropriate but also necessary, which shows the education and training of the specialist and facilitates communication, saves time.
Clinical patient round
The clinical patient round provides realization of the following purposes: medical-diagnostic, educational; deontological; sanitary-educating.
The therapeutic and diagnostic purpose of the clinical patient round consists in assessment of the patient's condition, the course of the disease and the effectiveness of the prescribed treatment.
The educational component of the clinical patient round is to teach the manner of communication with the patient, the methodology of the examination, which can be conducted in the form of micro-lectures for students and clinical residents in the presence of the patient. A more experienced specialist speaks in a friendly and simple language about the nature of the disease, the patient's condition, treatment recommendations, prevention of complications, the recommended lifestyle. As communication between medical professionals takes place in the presence of the patient, the patient's opinion about the course of medical and diagnostic process, satisfaction with the provision of medical care, nutrition, sanitation, attitude of medical staff is important.
All mobile phones must be switched off during the patient round. The round ends with a brief discussion of patients without their presence "behind closed doors". It is not ethical to discuss in the presence of the patient: issues of etiology, epidemiology, pathogenesis, features of the disease, differential diagnosis, prognosis for life, recovery and working ability, errors in diagnosis and treatment tactics, comments on medical records.
Evaluation of treatment (counseling) previously performed by the other specialists
It is quite often in a medical and psychological practice when the specialist deals with patients who have previously undergone treatment (consultation) with another doctor (psychologist). In this case, either the patient may be critical to his former therapist, or the new specialist may find errors, disagree with the previous diagnosis or methods of intervention. However, negative assessments of previous treatment, given in the presence of the patient or his relatives, not only violate corporate ethics, but also negatively affect the credibility of the source of assessment and medicine (psychology) in general, and, consequently, the effectiveness of further treatment.
In medical practice, it is sometimes necessary to consult a patient to whom the doctor provides the assistance with the other specialists: if necessary, additional professional opinion on the condition and methods of treatment of the patient, providing a protocol of examination of the patient before medical interventions, detection of comorbidities.
Consulting a patient with another doctor
The general steps of preparing and consulting a patient with another doctor include the following points:
- To identify and clearly articulate the need for consultation (according to the protocol, more information, doubts about the diagnosis, exclusion of concomitant pathology, etc.).
- To find the contacts of the relevant department, invite a consultant. To arrange a consultation with the head of the department (if necessary).
- To make a brief presentation of the patient's situation and the need for counseling.
- To provide all necessary medical documentation for review by a consultant.
- To organize a consultation (to warn and prepare the patient, premises, examination facilities, etc.).
- To introduce the consultant and help to establish a contact with the patient (if necessary).
- To get the results of the consultation in the form of an entry in the medical records.
- To thank the consultant and receive contact information (if necessary).
Consulting a patient of another doctor
In the case of consulting a patient of another doctor you need to:
1. Learn about the main features of a clinical situation from the attending physician, to outline the clinical tasks, to define the basic request of the consultation (to clarify what for your consultation is necessary).
2. Get acquainted with the medical documentation of the patient, to specify details of a clinical picture, the diagnostics, changes in a condition of the patient during treatment.
3. Introduce yourself to the patient, to outline the purpose of the consultation, to conduct an interview and examination of the patient, to inform about the preliminary results of the consultation (if possible), to give recommendations.
4. Provide a conclusion for a doctor, recommendations.
5. Make an entry in the medical records.
Given that the consultation of the patient of another doctor is an assessment of their professional competence, it is important to keep in mind the ethical presentation of information regarding the results of the examination, errors or omissions in the treatment process. It is prohibited to comment on professional actions of the doctor in front of the patient or their colleagues. If necessary, it has to be done privately and tactfully.
When transferring a patient to another section of a health care center or medical institution, it is necessary to coordinate organizational issues with the host party, to prepare the patient – to explain the purpose of the transfer. It is also necessary to give recommendations, and to fill in medical documentation carefully, succinctly and consistently outlining the clinical picture of the disease, its course, treatment.
One of the types of interaction in the medical environment is the presentation of the achievements of professional activity in the form of speeches at scientific medical forums, publications in professional journals.
Principles of interaction in the "doctor - nurse" system
- The principle of clear segregation of duties. The responsibilities of a doctor and a nurse are clearly regulated by job duties and derive from theoretical and practical medical training.
- The principle of clear functional limitation. The nurse performs their duties according to the doctor's prescriptions. The harsh approach of "do only what the doctor says" devalues the nurse's experience, blocks the initiative and independence of their thinking, reduces responsibility for the situation and involvement in the treatment process. Whereas, a nurse's over-insistence on giving advices to a doctor can lead to conflict.
- The principle of partnership. The modern ideology of treatment should be based on the principles of partnership and mutual assistance. The nurse must have some independence. Of course, they should not independently draw up a map of medical appointments, but they should be able to independently vary their behavior depending on the situation.
For a "doctor - nurse" couple, it is very important to work well together, i.e., to follow a style of joint activity that leads to the best results.
Modern trends are such that old stereotypes are gradually changing. Currently, the nurse acts as a real assistant of a doctor, and their partner.
Often, when nurses are on call in their schedule, the doctors - in their one, then the couples who do not match for some or other properties (temperament, upbringing) go on duty, and, as a result, the work suffers. It is very important to trust each other in the process of interaction. Professional trust is the foundation of synergistic interaction.
An important component in the professional activity of a specialist is the skill of rational distribution of working time.
Recommendations for time management:
- prioritize tasks according to their importance and urgency, focusing on the most important;
- strive to minimize time-killers in your schedule;
- regularly and systematically follow the planned schedule;
- be flexible in planning your time: if absolutely necessary, adapt your schedule without a strong loss of quality of tasks;
- effectively delegate tasks (which can be delegated) and monitor the progress of their implementation;
- skillfully use planning tools.
Features of professional activity of the doctor
Medical practice is characterized by being in close contact and interaction with patients who experience severe physical (often chronic) and mental stress.
The factors of professional stress of doctors are :
Communication and interaction with patients and their family members, including:
- reporting "bad news" to the patient and their relatives in connection with the disease;
- communicating with patients and their family members who are stressed and often show negative emotions;
- high complexity of communication with patients and the patient's family in the "critical" periods of treatment of the disease - recurrence, complications, the transition of the pathology to the terminal stage.
Characteristics of the patient's existing pathology as somatic nosology, which cause the fact that:
- medical staff is a "witness" of the patient's physical and emotional suffering;
- the complexity of the patient's problems and the inability to completely solve them (provide a complete cure);
- making decisions that significantly affect the duration and quality of the patient's life.
Particularities of the organization of activity and requirements to professional skills, namely:
- significant working overload, characterized by the provision of care to a significant overtime number of patients with the development of chronic fatigue syndrome;
- the need to have high skills, work with complex medical equipment;
- constant professional development concerning achievements in the theory and treatment of diseases (courses, conferences, acquaintance with publications);
- the degree of participation in the organization of their work, the possibility or inability to make important decisions.
Professional deformation in medical practice
Prolonged carrying out of professional activity by a doctor leads, in addition to the improvement of practical skills and clinical way of thinking, to the shaping of lasting psychological changes related to personality and behavior. The risk of deformations is especially high when the psychological structure of professional activity is superimposed on the individual psychological features of the person (professional and typological deformation).
Professional deformation is manifested in several aspects :
- Changes in the field of the professional activity, which are connected with changes in its concept and motives and reduce the effectiveness of this activity;
- Changes in the interpersonal field connected with the transfer of specific professional actions and attitudes to behavior outside of work;
- Changes in the intrapersonal field related to the application of professional skills to oneself.
Changes in the field of the professional activity, which are connected with a change in its concept and motives and reduce the effectiveness of this activity:
- the production of inflexible stereotypes of activity in communication with patients, the choice of treatment methods, etc., the belief in their own rightness in all cases;
- an attitude to the patient not as an individual, but as a carrier of the disease ("Today was such an interesting schizophrenia") or as a means of self-assertiveness, earnings, labeling clients;
- professional cynicism, formal performance of their duties or, conversely, increased responsibility and professional enthusiasm;
Changes in the interpersonal field connected with the transfer of specific professional actions and attitudes to behavior outside of work:
- with the predominance of directiveness in the style of professional behavior of a doctor (psychologist) - authority in relations with people outside work, a sense of superiority complex; fulfilling the role of "omniscient", "managing other people's destinies",
- excessive and depressing sense of professional responsibility outside the office, willingness to always come to the aid of others, sacrificing personal interests; self-blame for failure to provide this assistance for any reason;
- intentional or unconscious search of patients outside the business area, the desire to give advice on diagnosis and treatment;
- the desire to apply their knowledge in everyday life to explain everyday events ("it is a symptom of the disease", "it is the result of stress", "it is a transfer");
- excessive tolerance, invaluable attitude to others, especially for psychologists and psychiatrists (accustomed to the observance of deontological principles of communication with patients, the doctor and psychologist may become maladaptively tolerant of the actions of others);
Changes in the intrapersonal field related to the application of professional skills to oneself:
- tendency to constant self-observation and comparison of the mental and somatic activity with ideal norm for the purpose of self-diagnosis and "timely self-correction";
- for psychologists and psychiatrists - a tendency to rationalize their problems, to seek psychological explanations for the events of their own lives.
The occurrence of professional deformation in doctors and psychologists may be due to the following factors:
- division of labor and narrow specialization, leading to the emergence of rigid stereotypes;
- long-term performance of the role of a doctor / psychologist, which leads to "splicing with a mask";
- discrepancy of expectations regarding professional activity with reality (failures, ingratitude of patients, etc.);
- the specifics of the immediate environment - a doctor and especially a psychologist are constantly dealing with a large number of difficult life situations, communicate with carriers of psychological problems.
The latter, on the one hand, can lead to get used to the psychological state of patients (to varying degrees, depending on the scientific school to which they belong). On the other hand, it can lead to the development of the ability of "not to be involved" in the experience of patients, a detached attitude towards them.
Emotional burnout syndrome
The term "burnout" was coined by the American psychiatrist Herbert Freudenberger in 1973 to describe emergence in health care professionals of the "states of fatigue or frustration caused due to a certain lifestyle or relationship that were unable to bring the expected reward." Subsequently, other definitions of this phenomenon were proposed. The most popular of them was its description as a syndrome of emotional burnout, which includes emotional exhaustion, depersonalization and a decline in personal effectiveness. Currently, a number of authors interpret the term "burnout" broadly and include appropriate psycho-emotional reactions in athletes, men and women, parents. However, most researchers talk about burnout only in relation to professional activities such as "human-human", considering the emotional burnout syndrome as a type of professional deformity.
The phenomenon of burnout is an urgent problem in the field of activities related to the interaction in the system "human - human". The professional activities of a health care worker is refer to a helping profession, in which contacts between people are very close and important. High demands on qualifications and work results, constant interaction with people in a state of physical and mental stress, lead to burnout of health professionals. Changes caused by burnout have adverse consequences for the health and professional activity of specialists. This determines the need for the support and provision of medical professionals with the necessary knowledge and skills to deal with occupational stress, maintain their health and qualified personnel in the health care system .
Burnout is a long-term stress reaction that occurs as a result of influence on human of occupational stress of medium intensity, accompanied by physical, emotional or motivational exhaustion. It is a type of response to chronic occupational stress that allows a person to dose and save energy.
Burnout is formed as a stress response to the harsh production and emotional demands that result from excessive involvement in one's work and reduced time for family life and leisure.
Burnout is characterized by impaired productivity, fatigue, insomnia, increased susceptibility to somatic diseases, as well as the use of alcohol and other psychoactive substances in order to obtain temporary relief, which tends to development of physical addiction and suicidal behavior. Thus, the resulting somatic and psychological changes have adverse consequences for the health and professional activities of the specialist. In ICD-10, "burnout syndrome" is separated into an individual diagnostic taxon - Z 73 ("problems related to difficulties in managing their lives") and is coded as Z 73.0 - "burnout".
Sources of professional stress and factors of emotional burnout
There are the following sources of stress in the work of a medical worker: organizational, common and specific situational, personal .
The common situation includes: the needs for an expanded knowledge base, the need to interact with critically ill patients, the presence of a variety of ethical issues, lack or weakness of psychological support services. The specific one includes: lack of experience, burden of hard work, communication problems among staff and in communication with patients and their family members, high mortality among ward patients.
Personal sources of stress include: inability to overcome difficulties, low socioeconomic status, mental disorders (alcohol abuse, psychoactive substances), a family or personal crisis, conflicts with staff or patients, the death of a patient with whom close relationships were established, the beginning of work in a new department, lack of sufficient free time.
Numerous studies of the factors influencing burnout do not provide a comprehensive answer to the question of what is the main cause of this phenomenon. The decision of this question is of current interest for the organization of prevention of emotional burnout. A number of researchers consider the interaction of personal and situational factors in the occurrence of emotional burnout. Thus, J. Carooll and W. White expressed the opinion of an integrated approach to the study of burnout, which is considered as an environmental dysfunction caused by the integrated interaction of personal and environmental factors. The main idea of the approach proposed by S. Maslach and M. Leiter is that burnout is the result of a mismatch between personality and work . Growing of this discrepancy increases the likelihood of burnout.
The inconsistency areas are as follow:
- The discrepancy between the requirements for the worker and their resources. The main thing is making overstated demands on the individual and their capabilities.
- The discrepancy between the desire of the employee to have more independence in making decisions about their work (ways to achieve results) and the rigid position of management in the organization of the production process.
- Inconsistency of work and personality due to the lack of remuneration, which is experienced as non-recognition of their work.
- Inconsistency of personality and work in the context of loss of a sense of positive interaction with colleagues.
- Inconsistency between personality and work, which may arise due to the absence of justice at work. Fairness ensures recognition and consolidates the employee's self-esteem.
- The discrepancy between ethical principles and the principles of personality and work requirements.
Generally, the medical staff is constantly dealing with death, experiencing it on the emotional level. It can take three forms:
- real - inexpediency of resuscitation procedures, death in an ambulance, etc .;
- potential, when the health and life of a person depends on the results of the actions of the doctor or nurse, their professionalism;
- phantom - it includes complaints about the health of an anxious patient, fear of a chronic patient, relationships with relatives of the severely ill patient, the idea of death in the public consciousness.
Analysis of the causes of emotional burnout allowed to identify personal and situational (primarily related to the conditions of professional activity) factors in the development of this syndrome .
The first group includes:
- some personality traits (people are unquiet, impulsive, sensual, empathetic, prone to introversion and neuroticism, restrained in interpersonal contacts, externals with a humanistic life attitude, tend to identify themselves with others, more prone to this syndrome), especially if working conditions and professional activity does not correspond to the specified personal features of the individual;
- typical mechanisms of coping behavior (avoidance), predisposition to type A behavior;
- inflated expectations regarding the content and effectiveness of their work;
- unresolved personal conflicts, personal immaturity of the doctor.
Typical undeveloped personal qualities, that lead to the emotional burnout, include:
- dissatisfied ambition and selfishness - a professional who has such traits, seeks to help people not for their own sake, but for the pleasure of their power. When the mental set "I can do what others can't: I see people through, I can control them" collides with the patient's attitude "they will help me, they will solve my problems", the professional's self-perception is distorted, they have an illusory sense of power. The destruction of these illusions, which occurs when facing of the realities of life, may be accompanied by a syndrome of emotional burnout. The school of existential psychology postulates that a person who experiences burnout lacks existential meaning in relation to his work. They do not realize themselves due to work, but try to achieve power, prosperity, glory and other goals;
- perfectionism (the desire to do everything perfectly) and internality in failures create a fear of making mistakes and lead to constant stress;
- emotional rigidity - emotionally restrained, vulnerable person, whose emotions do not fade for a long time. They are extremely sensitive to maintaining their public image, to real or imagined injustices; if the importance of such people is not confirmed, they are prone to the development of emotional burnout;
- generalized professional identity (identification with professional activities) encourages the individual to feel like a doctor not only in the workplace but also in communication with family and friends, and can lead to both burnout and interpersonal disorders;
- desire for self- sacrification.
Socio-demographic characteristics of the individual - age, marital status, education. Regarding age, it was found that burnout is more pronounced in young professionals (20-30 years) and people over 50 years. The tendency of young professionals to burn out is explained by the emotional shock they experience when confronted with the reality of the profession, which goes against their expectations and ideas. While in older professionals, burnout is related to the level of satisfaction with their professional achievements.
In general, specialists with increasing experience tend to reduce the risk of burnout as a result of acquiring skills to adapt to their work.
The risks of burnout are high for both highly qualified and low-skilled specialists. In the first case, burnout is associated with a high level of claims, in the second - the inability to fully assert oneself and to be realized.
Most studies have found that women are more prone to burnout due to high workloads and a combination of professional responsibilities with household chores and family responsibilities. However, in some professions the levels of burnout are higher in men, especially those that require the manifestation of masculine qualities (physical strength, courage, restraint, achievement).
Regarding marital status, single people have a higher risk of burnout. The family in most cases acts as a resource of support and assistance.
The second group of factors of emotional burnout is related to the conditions of professional activity. The medical profession is increasingly perceived as conducive to the deterioration of somatic and mental health, reduced stability of marriages, the development of a tendency to use psychoactive substances. Addiction in British doctors is 30 times more common than the average in the general population, and suicide - 2-3 times more often than in other professionals. According to national (Ukrainian) statistics, doctors die 10-20 years earlier than their patients.
The second group of causes of emotional burnout include:
- Intense on a regular basis nature of the activity, intensive communication and a large amount of diagnostic and therapeutic activities that the specialist is obliged to carry out; in particular, the relationship between the length of the working week and the risk of emotional exhaustion, as well as overtime;
- Destabilizing organization of the activity - monotonous nature of work, strict regulation of time and procedure for its implementation, a large number of bureaucratic procedures, the inability to make decisions independently; unclear organization and planning of work, lack of equipment, lack of conditions for self-expression, professional growth; non-compliance of the volumes of health care financing with the requirements to the volume of diagnostic and treatment measures that the doctor is obliged to carry out; lack of comfortable working conditions;
- Psychologically difficult cohort, to deal with - professional invests the large personal resources in the work with insufficiently effective results (especially - when working with hopeless patients). They bear the risk of taking on the patient's problems, of "infectioning" with them;
- risk of administrative sanctions and legal action due to the errors in professional activities, incorrect filling of medical records;
- unfavorable psychological atmosphere - strengthening and conflicts in the professional environment (first of all - with the management, its excessive criticism), insufficient support from colleagues, insufficient authority at work;
- insufficient remuneration, especially perceived as a violation of social justice;
- family problems, as well as the lack of psychological support in the family, lack of understanding by relatives of the specifics of the medical profession.
There is the evidence that medical professionals and psychologists working in public health are more prone to emotional burnout than those in private practice.
A study of the level of interest in professional activity among medical students and doctors in Ukraine showed that students' interest in the medical profession is likely to decline from the third year of study. It should be noted that among those who worked in medical institutions before entering the university, the share of those who lost interest in the profession is lower than among those who got acquainted with the profession of doctor only theoretically (respectively 12.05% and 30.4%).
A study of interest in the activities of doctors with different experience found that it is likely to decrease from the second year of independent professional activity. After 15 years of work, 18.6% of doctors have no stable interest in medical practice. Among the main factors causing this situation are mistakes in choosing a profession and professional activity, as well as the low prestige of the specialty in society, its economic status.
The main psychodiagnostic techniques which allow to assess the presence of emotional burnout include:
- MBI-HSS questionnaire (Maslach Burnout Inventory-Human Service Survey);
- V.V. Boyko method of diagnosing the level of emotional burnout.
The MBI-HSS was developed by K. Maslach and S. Jackson to assess the components of burnout: emotional exhaustion, depersonalization, and attitudes toward professional achievement.
V.V. Boyko methods of diagnosing the level of emotional burnout identifies the phases and symptoms of emotional burnout :
- Symptoms of the stress phase: experiencing traumatic events, a feeling of "cage", anxiety and depression, dissatisfaction with oneself.
- Symptoms of the resistance phase: reduction of professional responsibilities, expansion of the sphere of saving emotions, inadequate selective emotional response, emotional and moral maladaptation.
- Symptoms of the phase of exhaustion: emotional deficit, psychovegetative and psychosomatic disorders, emotional detachment, personal detachment.
Burnout syndrome has a complex multifaceted structure that includes the presence of components, phases and groups of symptoms.
The main components of burnout are as follows: in the emotional sphere - emotional exhaustion, in the cognitive - depersonalization, in the motivational and volitional - the assessment of personal achievements .
Emotional exhaustion reflects feelings of emotional devastation and fatigue caused by one's own work.
Depersonalization involves distancing oneself and developing a negative attitude towards one's colleagues and patients.
An assessment of personal achievements reflects a self-assessment of productivity, efficiency, achievements of a specialist in professional activities, or the emergence of a sense of incompetence in their professional field, awareness of failure in it.
The question of the dynamic causal relationship of the three above-mentioned components of the emotional burnout syndrome remains open. Some authors call the primary pathogenetic link a feeling of reduced personal effectiveness and emotional exhaustion, and depersonalization - a coping mechanism. According to another authors, the emotional burnout syndrome begins with depersonalization, which results in low personal efficiency, and then - emotional exhaustion. The others believe that emotional exhaustion opens the way to depersonalization, which, in turn, leads to low personal productivity at work.
It was found that among doctors there is a high level of emotional exhaustion, which is determined in 15 - 25% of employees, depersonalization in 4 - 15%, self-esteem of personal achievements in 30 - 65% .
Phases and dynamics of emotional burnout syndrome
Burnout is a dynamic step-by-step process that develops over time under the influence of excessive and prolonged stress at work. Burnout goes through a series of successive phases: stress, resistance and exhaustion. The stress phase reflects the collision with the psychotraumatic components of the profession. The resistance describes ways to adapt to work stress, aimed at reducing the responsibilities associated with emotional expenditures. The phase of exhaustion indicates a break in psychological adaptation and changes in physical condition.
The presence, severity and range of symptoms of burnout depend on the interaction of the specifics of professional activity and personal characteristics of the employee. Specialists with a high adaptive resource are able to adapt to high levels of occupational stress, while workers with low - burnout can develop with minor occupational difficulties.
Professional adaptation of a young specialist is gradual. For example, professionals of palliative care have a period of 12 to 24 months, which consists of various stages during which professionals make progress in improving their skills in caring for terminal patients.
The medical staff goes through the following stages: "development of intelligence", "trauma / emotional survival", "depression", "emotional use", "deep compassion".
- stage 1 - "development of intelligence" lasts the first 3 months and is characterized by the acquisition of knowledge and the emergence of doubts about the correctness of the choice of medical profession. Healthcare professionals spend a lot of effort searching for professional information, including on the issue of death.
- stage 2 - "trauma / emotional survival" lasts the next 3 months. The medical professional experiences psycho-emotional anxiety, stress, and guilt over their healthy physical condition while the patient dies;
- stage 3 - "depression" also lasts 3 months and is experienced very painfully. The healthcare professional is aware of the scale of death as a part of human life. This is the stage at which specialists most often leave palliative care;
- stage 4 - "emotional survival". Specialists reach this stage when they learn to deal with the fear of death and guilt for their good physical condition. The depressive state passes, the pain of loss that accompanies the death of patients occurs periodically, but does not have such a negative impact as before;
- stage 5 - "deep compassion". At this stage, the specialist becomes capable of significant professional dedication, self-knowledge, there is a feeling of complete self-realization, there is a real awareness of illness and death.
Similar psychological phasing is also inherent in other medical specialties, when a young specialist is faced with new requirements and must master not only purely medical but also psychological competencies. Every doctor faces the loss of the patient sooner or later, the intense emotions of the patient and his family, when the possibilities of medicine are depleted, or it is impossible to achieve the "desired result" (cure completely). The palliative link is characterized by the fact that the health worker finds themself in such a stressful situation immediately.
Physical, emotional and mental symptoms of emotional burnout
There are physical, emotional and mental symptoms of burnout.
Signs of physical exhaustion include:
- chronic feeling of fatigue, weakness, loss of vitality;
- tension headaches, back pain, muscle tension, gastrointestinal and cardiovascular symptoms;
- sleep disorders;
- susceptibility to infectious diseases;
- increased morbidity and injuries.
Emotional symptoms are represented by:
- feelings of depression, anxiety, helplessness, hopelessness;
- increased tension and conflicts in the family;
- increasing the frequency and intensity of negative emotions and decreasing of positive ones.
Mental manifestations include dissatisfaction and negative attitudes towards oneself, work and life in general; work-related behavior of avoidance (absenteeism, sick leaves).
The study of the phenomenon of burnout is an important issue of practical medicine in connection with the negative consequences for workers and the industry in general.
Prevention and medical and psychological care for emotional burnout
High stress inducing and psychotraumatic character of professional activity in the field of medicine requires the development and implementation of medical and psychological measures for medical staff: information (psychoeducation) and training in basic skills of professional interaction with the patient (psychological training) [7,13,14].
In order to prevent the development of "emotional burnout", as well as to improve the interaction between doctor and patient there were actively developed lines of effort with medical staff in the form of psycho-educational programs and communication training in the 90s of the twentieth century. Communication skills training programs and consolidation seminars lasting up to 40 hours help to maintain the acquired communication skills with patients for more than 2 years. Usually, trainings are focused on learning the basics of effective listening, using open questions and generalizations in conversation, improving the recognition of the patient's emotional signals, regulating their own emotional state, increasing empathy (compassion and understanding). The acquired skills lead to the building of a sufficient therapeutic alliance with the patient, and as a consequence of the patient's involvement in the treatment process - to improve his psychological adaptation.
In combating emotional burnout, the role of raising awareness on patient psychology, psychology of the medical worker, psychology of medical-diagnostic interaction, propaedeutics of mental diseases is important.
The main psychological competencies of professional interaction of doctors that promote professional adaptation are skills:
- to establish and maintain contact with the patient, sufficient for the implementation of basic medical tasks;
- to report unfavorable news, severe diagnosis;
- to conduct "negotiations on therapy" - the ability in an accessible form to convey to the patient an important information about the treatment of the disease, to motivate for the therapy, justify changes in treatment tactics in accordance with changes in clinical tasks;
- a level of awareness on issues of medical psychology and medical-diagnostic interaction;
- to diagnose mental disorders at the level of norm / disorder, as well as guidance on the need to involve a mental health specialist and the use of psychopharmacotherapy;
- structuring and organization of working time;
- resistance to professional stress (safe methods of relieving mental stress, adaptive coping profile).
There are several ways to prevent and correct the emotional burnout syndrome:
Proper organization of working hours, a variety of professional activities:
- timely life/work balance;
- combining practical work with education, research, writing scientific articles;
- participation in seminars, conferences, meetings with new colleagues, exchange of experience;
- participation in the work of a professional group, which provides an opportunity to discuss personal problems related to work;
- receiving social support from colleagues and other reference groups;
- change of mindset regarding work;
- separation of professional activity from personal life (to "disconnect" from work outside of work), development of rituals such as "white coat ritual" (the doctors puts on a gown when coming to work and grow into their role: they are attentive, tolerant and kind to patients, seek to help them, at the end of the working day the doctors take off the gown and "remove" along with it the problems that have accumulated during the working day);
- rejection of inflated expectations - always to be a winner, to achieve quickly positive results in work and life;
- refusal to take more responsibility for the client than they do;
- openness to the new experiences;
Cultivation of other non-work interests:
- satisfactory social life; communication with friends - representatives of other professions;
- reading not only professional but also other good literature;
- a hobby that brings pleasure.
- Adherence to sleep and nutrition, mastering the technique of meditation.
To avoid burnout, the health care professional should periodically evaluate their life in general - whether they live the way they want, whether they like to do their job, and if not - what to do for positive changes.
That is, medical and psychological assistance to medical staff should consist of a program of consecutive psychoeducational and psychocorrectional measures aimed at:
- Identification of the main stressful situations that are perceived as psychotraumatic;
- Reflection on emotional states associated with a traumatic situation; awareness of the personal significance of a stressful situation;
- Formation of personal attitude to issues related to physical suffering, aging, death;
- Identification and selection of the main ways to reduce psycho-emotional stress and regulation of emotional states;
- Optimization of the organization of professional activity and working hours.
Psychoprophylaxis is important. Primary psychoprophylaxis measures include, on the one hand, the introduction of general hygiene recommendations for work organization, work and rest. On the other hand, they include the implementation of more specific measures that correct the initial manifestations of the syndrome at the preclinical level and increase resilience. For secondary prevention and psychological correction of burnout syndrome in the already formed stage of "resistance", measures are aimed at preventing the transition from the phase of "resistance" to the phase of "exhaustion". And in the formed "exhaustion" - to prevent the chronicity of psychosomatic and astheno-depressive disorders.
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