What sustains and what depletes the spirit and morale of care workers?
Once this question is asked, it is not so hard to answer. The problem is that the question is not asked often enough because the morale and spiritual energy of care workers is not sufficiently acknowledged to be a major mediating factor in the quality of care. Quality of care is usually perceived to come primarily from training in skills, techniques and competencies. The morale and spiritual state of those providing care is often regarded merely as a background factor or simply overlooked. This means that conceptualising the 'competence' of care as incorporating a spiritual dimension involves a major paradigm-shift. It is time to fully recognise that the human spirit needs to be factored into the science of health care, not factored out as a 'non-specific' variable. This is essentially the point behind the excellent concept of 'intelligent kindness' articulated by John Ballatt and Penelope Campling in their book of the same name (11). These authors, who both have an NHS background, argue that humanising the culture of our public health care, including for those who work in it, is vital if the whole enterprise is to become liberating and successful rather than oppressive and dysfunctional. They outline the unintended human consequences of a politically and financially driven performance management culture obsessed with organisational restructuring. They also look at ways of restoring the heart and soul of public care services through reclaiming the ancient and public-spirited concept of kindness.
Similarly, Stephen Wright (12) calls burn-out a 'spiritual crisis' and outlines the factors that he believes cause burn-out and those that prevent it. Wright makes a clear distinction between burn-out and stress. He emphasises that stress is a more specific and transient phenomenon whereas burn-out is a more lasting state of spiritual depletion and a defensive shutdown that develops cumulatively when daily stresses are built up without being relieved or attended to. Burn-out manifests itself in numbness, detachment and disengagement, in many ways like a kind of 'depression'. Wright makes it clear that at the root of spiritual burn-out is a spiritual disconnection from self, from others and from sources of meaning. This conception of burn-out also fits very well with the findings of Menzies-Lyth (13), who showed how nursing care systems in general hospitals can quickly become defensive and depersonalised to avoid overwhelming anxiety and distress in staff. The danger of burn-out for all concerned can be seen very powerfully in Dobbin's report on General Practitioners (14):
The measure of burn-out that impacted most on the patient satisfaction was depersonalisation, described as an 'unfeeling or impersonal response toward recipients of one's service, care, treatment or instruction'. That is about as close a description of a lack of compassion that I can think of. You cut yourself off from understanding your patient's viewpoint, from empathising with their position, mirroring their circumstances emotionally.
Seager et al (2007) (cited in [1]) list the top five universal psychological and spiritual needs of the human condition, which can be simplified as follows:
- 1. To be loved
- 2. To be heard
- 3. To belong
- 4. To make a difference
- 5. To have meaning and purpose
These universal needs apply equally to all of us whether we are giving care or receiving it. As carers we cannot sustain the caring role if our own human needs too are not met within our working environment. Mike, in his workshops on looking after care practitioners, regularly states that 'we cannot deliver any hardware if we do not at the same time look after the software'. Martin argues that emotional nutrition, like physical nutrition, is vital in maintaining a 'receptive' state of mind that is needed to care for others. Without emotional nutrition there will be emotional toxicity and emotional depletion (9). According to this view, even in an environment filled with good intentions, emotional toxicity and depletion result from an unhealthy ratio between emotional burden and support or between emotional expenditure and input. Martin outlines three domains that influence the spiritual energy levels of care givers: (a) capacity factors, (b) burden factors and (c) support factors (see more below).
The act of caring in itself carries a necessary emotional cost. Psychologically, caring for others means identifying with pain and suffering, and this means willingly entering difficult emotional spaces. Caring for another cannot work in relieving pain unless the person being cared for can see an impact on the carer. Seeing that one's suffering affects another is the very psychological and spiritual basis of change and transformation in suffering. Touching and being touched by the heart and mind of another creates the spiritual connection that enables relief and comfort. This happens from the cradle to the grave as all of us seek recognition and understanding in the responses of others.
Of course, there can therefore be an intrinsic value and meaning in caring for others which feeds the spiritual resources of the carer. However, identifying with suffering and entering difficult emotional spaces is draining and can be toxic, especially if those spaces are traumatic. This means that if there is no thought given to how the spiritual and emotional cost of care will be compensated for and replenished, any care-giving individual or system is at constant risk of breakdown.
