Like Riding a Bicycle: Burnout Prevention

Everyone, it seems, is burned out these days. Frontline nurses, doctors, public health workers, and other healthcare providers who are weathering yet another vicious turn in the COVID-19 pandemic. Frontline service providers, short-staffed and short supplied. Parents struggling to parent well amidst the crazy-making politicized strife over a safe return of their children to in-person teaching at schools. Homeless and near homeless people trying to survive and maintain hope as eviction moratoriums end. Climate refugees and Afghan refugees. The list goes on.

How to manage the massive burnout we’re almost all feeling?

Having survived some rather spectacular professional and personal life burnouts in my life, and feeling it again as I face yet another academic year full of ‘pivots and uncertainties’ (words I now despise), with the responsibility to teach future nurses about our besieged public health and broken healthcare systems, burnout prevention is high on my list of priorities.

Cutting through the growing piles of research studies on burnout and its second cousins of moral distress , secondary trauma, vicarious trauma, and compassion fatigue, I am drawn back to two main resources that I find most helpful. The first resource is the book by Seattle-area social worker Laura van Dernoot Lipsky with Connie Burk, Trauma Stewardship: An Everyday Guide for Caring for Self While Caring for Others. I re-read sections of this book when I am beginning to feel ‘crispy,’ on the verge of burning out. I especially appreciate her inclusion of systematic oppression, trauma-informed care, clear explanation of trauma mastery, all combined with liberal use of appropriate humor. For a good introduction to her and her work, take a look at this TEDx talk from 2015 at the Washington Correction Center for Women, “Beyond the Cliff.”

The second resource I use and recommend to my students is the work of Rachel Naomi Remen, MD and her Heart Journal practice. She encourages asking yourself at the end of the day, “What surprised me today? What moved me or touched my heart today? What inspired me today?” Although I am an early morning journal writer, I try to incorporate at least some of these questions into my reflective writing, especially when I know I’m at risk of burning out.

As part of my Skid Road project on health and homelessness, I had the privilege of conducting a series of oral history interviews with thirty-six people working—and sometimes having lived—at the intersection of health and homelessness in Seattle. One of the questions I asked the interviewees was, “What advice do you have for people in terms of burnout prevention?” I loved the wide variety of responses to this question. Krystal Koop, MSW, replied, “And that’s another thing with burnout. You are going to get burned out every once in a while, and that’s okay. Don’t beat yourself up about it. It’s okay.”

But my favorite response to this question was from Benjamin Danielson, MD. He said, “Burnout is an interesting thing. I think about life balance the way I think about bicycle balance. If you are sitting still on a bicycle and you try to balance, you fall over. So keeping everything exactly balanced in a moment is pretty unlikely. But a bicycle in movement over time – the balance is very much there. It’s important to not examine just one moment and know whether everything is perfectly balanced, but it is important to keep track of the things that are important to you, and the people that you love and love you, and stay connected to those things.”

Carrying Stories: Beyond Self Care

Girl with Balloon, street art by Banksy. This one found at intersection of K-Road and Queen Street in Auckland, New Zealand. Photo credit: Josephine Ensign/2015.

What to do with difficult stories? Stories of refugees, victims of mass shootings, of hate crimes, of rape, of torture victims, of people dying alone and unnoticed ?  It all gets overwhelming and depressing to hear or read these sorts of difficult stories, to carry them in our hearts, to bear witness to so much suffering in the world.

Of course, for many fortunate (perhaps unfortunate?) people, there is the option of tuning out these stories, turning off the news, unplugging from any non-vacuous form of social media. Taking a break from difficult stories.

But what about all the other people who cannot or choose not to disconnect? What about people whose work involves listening to these stories on a daily basis? Frontline health care providers who work with people experiencing trauma (physical, emotional, sexual). First responders. Counselors, mental health therapists, lawyers. Human rights activists. Researchers working on social justice issues. What can they do to, if not prevent, at least deal effectively with, vicarious or secondary trauma? And for those of us who teach/train/mentor students in these roles, how do we prepare students to be able to carry difficult stories while maintaining well-being?

In a previous blog post, “Burnout and Crazy Cat Ladies,” I explored the issue of ‘too much empathy’ and of pathological altruism, linking to some of the (then/2011) current research. After writing that post and some related essays, I began incorporating a new set of in-class reflective writing prompts for soon-to-be nurses in my community/public health course. I used these in a class session I titled “Public Health Ethics, Boundaries, and Burnout.”

The first writing prompt: ‘What draws you to work in health care? What motivates or compels you to do this work?’ And then later in the class session– after discussing professional boundaries (how fuzzy they can be), individual and systems-level risk factors for burnout, and asking them to reflect on how they know when they are getting too close to a patient, a community, or an issue–I gave them the follow-up writing prompt: ‘Referring back to what you wrote about what draws you to work in health care, what do you think are the biggest potential sources of burnout for you? And what might you be able to do about them?’

Feedback from students about this in-class reflective writing exercise and the accompanying class content on boundaries and burnout, was invariably positive. Many of them said it was the first time in their almost two years of nursing education that anyone had addressed these issues. I understand that patient care, electrolyte balances, wound care and all the rest of basic nursing education takes priority, but it makes me sad that we don’t include this, to me what is fundamental and essential, content.

“…people who really don’t care are rarely vulnerable to burnout. Psychopaths don’t burn out. There are no burned-out tyrants or dictators. Only people who do care can get to this level of numbness,” Rachel Naomi Remen, MD reminds us in her book, Kitchen Table Wisdom: Stories That Heal (Riverhead Books, 1996). Something to remember when we are feeling overwhelmed by difficult stories.


Here are some excellent resources:


New Zealand Postcards: Self-care and the Sea

DSC01150…i nga wa o muri. The surge of the sea. Whether you think of time as something you move through, so that your past is necessarily behind you, or whether you conceive of time as an encompassing continuum (so that your past stands before you, while wrapping you round, and your future is never-present but ready, waiting behind—i nga wa o muri), there is always the pulse of the sea. In us and round us, the sea. We have that constancy. ~ Keri Hulme

This quote is from Hulme’s lovely book HomePlaces (Hodder and Stoughton, Auckland, 1989). I found the book yesterday as a ‘rare’ book in a bookstore in the town of Hokitika on the West Coast, South Island, New Zealand. For my community health course this quarter we’re reading Hulme’s The Bone People (one of my favorite books since it was published in 1984 and a good choice for teaching community health in New Zealand). After purchasing the copy of HomePlaces, I tramped up the beach several miles back to the hostel where we’re staying. A rouge wave from the wild Tasman almost took me—and the book—out to sea. Perspective. Being next to (and inadvertently in) the very cold sea, as well as being temporarily unhooked from the chatter of the internet, has reminded me of the importance of mindfulness training and of self-care in our personal and professional lives.

Professional burnout is never a pleasant thing to have (or to be around). I have crashed and burned in clinical settings at least twice in my life, so I know what it feels like and what personal and collateral damage it can do. And I’m beginning to feel a bit crispy in terms of my academic role this quarter. Something about living with my undergraduate students 24/7 for three months in ten different youth hostels all over both islands of New Zealand was just not a good idea. My passion for teaching is in serious need of refueling (along with the minivan I’m driving them around in).

Compassion fatigue, moral distress, and professional burnout—the gooey mess that health care professionals—and especially nurses—are prone to. What’s the antidote—besides getting whacked by a rouge wave from the Tasman and washed out to sea?

Self-care. Not the self-indulgent variety of going off to expensive spas and eating dark chocolate, but real self-care. What Rachel Naomi Remen, MD calls heart care: “ways of keeping your heart alive in health care.” David Bornstein wrote a nice NYT article “Medicine’s Search for Meaning” about Dr. Remen’s work (Sept 18, 2013). It focuses on physician burnout and mentions that half of all medical students burn out by the end of their training. Nurses burn out at even higher rates, especially in their first few years of practice.

I’ve read (and used in some of my courses) Remen’s book Kitchen Table Wisdom.  But after reading the NYT article, I decided to see what all the fuss was about. I signed up for Dr. Remen’s telephone conference/training call in mid-November. I’m often cynical about self-care, but I also know that cynicism is a marker for burn out. Plus, mid-November in Seattle is a dark and gloomy time, so a little brush-up on self-care sounded like a good idea.

Remen points out that the heart is devalued within health care. She states, “science (the head) is a tool of healing but is not the source of healing—that is the heart.” The heart is an organ of vision—that helps us discern the meaning of the work we do. She outlines a way of establishing a practice that supports the ability to ‘find meaning on purpose’ in one’s work (as opposed to having to be whacked over the head by it).

In response to several questions from some of the conference caller participants, Dr. Remen admitted that we’re all having to work within a broken health care system, but, “that doesn’t prevent us from taking time for self care; staying alive within the system isn’t about changing anything outside of yourself.” And she used this analogy: “If I can’t have a wonderful long drink of fruit juice, I won’t take another sip of water.” She deflected more questions along the same line by saying, “I don’t have an answer for changing the system.”  What I thought—and wanted to say—was that self-care keeps us alive (and healthy) and perhaps gives us more energy to work for systems change. And, of course, that is what Dr. Remen has been doing all these years through her work and writing.

She recommends a series of ‘heart practices.’ The following are the two that I like the most. 

  1. Connect to yourself by the mindfulness practice of attention to one’s breathing. “Paying attention at the very end of an out breath as a moment of absolute rest and peace.” Practicing this can build the capacity to come to rest.  
  2. At the end of the day, ask yourself “What surprised me today?” and “What touched my heart today?”

Sometimes in my more cynical moments this all sounds so woo-woo and kum-ba-yahish, but I am convinced that it works. And I will try to pass it on to my students.