Avoiding Burnout with Both Your Patients and Your Staff

As we discussed development of this article, we struggled with even using the word burnout, because it seems that just isn’t typically part of the language of wound care clinicians and providers. Not that we don’t have our share of frustrations in our day-to-day practice, but burnout?
When you peruse the literature related to true burnout, there is a plethora of information about the signs and symptoms and warning signs. Burnout is described as an emotional and physical exhaustion caused by excessive and prolonged stress, which can reduce productivity and energy, and leave one feeling helpless, hopeless and eventually resentful, feeling that you have nothing more to give.
According to helpguide.org, you may be on the road to burnout if:
• Every day is a bad day.
• Caring about your work or home life seems like a total waste of energy.
• You’re exhausted all of the time.
• The majority of your day is spent on tasks you find either mind-numbingly dull or overwhelming.
• You feel like nothing you do makes a difference or is appreciated.

Additionally, physical signs of burnout may include:
• Feeling tired and drained most of the time.
• Lowered immunity, sick a lot.
• Frequent headaches, back pain,
muscle aches.
• Change in appetite or sleep habits.
For tips on avoiding burnout visit www.todayswoundclinic.com/burnout

As we read on about true burnout, while it may affect those working in wound centers and providers of wound care, it seems that those of us especially in wound centers, hopefully are at less of a risk. But that is not to say that we don’t have our own set of stresses and frustrations. We encounter those daily. Stressors contributing to wound clinician burnout are often a result of dealing with patients not adhering to treatment plans (“noncompliant”), the never-ending challenge of dealing with payers requiring multiple hoops to jump through in order to get authorizations for visits or diagnostics, and certainly with the current state of the economy and job losses, an increase in non- and under-insured patients who still require our care. The end result does cause an increase in frustrations among wound care providers, the difficulties can lead to longer visits for the patient, which effects productivity, and can lead to that frustration showing in clinician attitudes both towards the patients and each other.
While there aren’t simple answers to any of the aggravations encountered in our specialty, there are some ideas and hints that may help us get through a day. These come out of the author’s clinics, so certainly is not an exhaustive list. We would value any additional input from the readers that can be posted at todayswoundclinic.com as a resource to troubleshooting in all areas of wound clinic care. Both questions as well as ideas are welcome. Additionally, if tips and timesavers from other clinicians can make another person’s job easier, the ripple effect of daily frustrations can be averted, and hopefully the pathway towards “burnout” will be blocked.

THE UNINSURED PATIENT
With the numbers of unemployed on the rise, the number of uninsured patients is also rising. This is a difficulty not unique to wound care, but all healthcare providers. It is particularly challenging when we already have a relationship with a patient, have already begun treating them, and a new month begins and they inform you that they have lost their insurance. Do we tell them to cut the wrap off and go back to the primary care physician that referred them to us? Or to go to the ED and have their cast removed? The challenge is that we have a personal, ethical and legal relationship with the patient, which makes it close to impossible to just “turn it off.”
It is critical that with the type of care that we provide, that we have an ongoing dialogue with hospital administrators on how to handle these situations. Keeping patients out of the hospital and emergency department with complications makes more financial sense, so using the resources of the wound center may be the better alternative. Utilizing the hospital resources to look for financial alternatives and payer sources may be a stop-gap measure depending on local health department, state Medicaid programs or other sources.

THE UNDERINSURED PATIENT
A common dilemma encountered in our practice also revolves around the patient who may be insured but may not have coverage for the technology or dressings that would most benefit their wound, or for the antibiotics needed to be treated at home. That’s when we have to put our social worker hats on. Most high technology companies (NPWT, bioengineered tissues) have patient assistance or charity programs with specific financial and coverage criteria that must be met in order for the patient to qualify. The same goes with drug programs; the higher cost drugs generally have patient assistance programs, and locally there are usually programs associated with grocery or drug chains for minimal cost to free antibiotics. Researching and knowing the availability of local programs requires a bit of time spent up front but will save hours of time in the future. The other patient assistance programs can be investigated beginning with the company’s website or contacting local representatives.
The challenging part of all of this is the time consumption required for the additional phone calls and steps taken on the patient’s behalf. However, it is just what has to be done, and it gets easier the more that you do it. Developing a file of sample letters of medical necessity, for example, can save time in recreating a letter when you are in a time crunch. But we are the better practitioners to get what is needed, because we know the patient and the wound needs. Referring them back out to the primary provider to try to achieve these needs will inevitably delay the outcome.

PATIENT “NONCOMPLINACE” OR
PATIENT BURNOUT
In our clinics, it is quite easy to become frustrated and often exasperated at the patient who does not adhere to their treatment plan. The patient who’s blood glucose level becomes erratic because he or she is not monitoring their levels and appropriately medicating will send us not just to our practitioner “soap box” to provide a needed patient lecture but often over the professional edge as we realize the ramifications on not just the wound but also the overall health of the patient. The young pressure ulcer patient whose wound fails to improve and leads us to question how often he or she is offloading and changing position will usually make us question the patient’s commitment to their own healing process. Dealing with these types of patient situations often leads to feelings desperation and anger with resultant feelings of burnout for the clinician. During these very instances, we need to question whether the perceived “noncompliance” of the patient is actually intentional apathy or if they are, in fact experiencing their own burnout related to their disease process.
The patient’s that we treat, typically have chronic disease processes that require the patient to make radical lifestyle changes and major alterations to routine daily tasks 24 hours a day. Diabetic patients have to not only perform, often times, painful finger sticks to monitor blood glucose levels but must also be vigilant in dietary control, exercise tolerance and foot care. Younger, more active patients, often tire of this routine when trying to maintain a normal work, family and social life. Patients with chronic lower extremity edema as the result of chronic venous insufficiency or lymphedema grow weary of donning and doffing compression garments as well as elevation of affected extremities. Those affected by loss of sensation with resultant pressure ulceration, must be cognitively aware of position changes and off-loading as loss of protective and tactile sensation as well as proprioception don’t allow for the body to automatically “cue” the patient to move.
Understanding these factors and similar scenarios with chronic wound care patients can help us to better understand the reasons behind perceived patient noncompliance and their voiced burnout. There are things that we, as clinicians can do to help the patient work through this difficult time, to help diminish the potential for wound healing failure.
• Actively listen to your patient. Don’t simply assume noncompliance. Tune into signs of disease fatigue and burnout.
• Look at what else may be going on with the patient, medically, pharmacologically, environmentally, emotionally, financially or socially.
• Assess whether what we are asking of the patient is impossible for them. For example: “Stay off of work with your leg elevated” may mean that there is no money coming into
the household.
• Revisit the patient’s goals for wound healing.
• Revisit the Clinician/physician’s goals for wound healing (are
we being unrealistic given the patient’s lifestyle).
• Change treatment plan if needed. There are times when being less aggressive and utilizing palliative care is more important than loosing the patient or loosing ground in healing and overall healthcare.
• Allow the patient to take a “clinic vacation” if possible. As clinicians, we need vacations. Patients treated over a long period of time do as well.
• Refer the patient out to another practitioner if needed.
• Call upon outside colleagues
for help and ideas on alternative treatment options.
• Ensure that the patient is actively involved in the decision making process of his or her treatment plan.
• Make this difficult case a study or project, and actively involve the patient (Don’t just wait for the great cases).

Clinician burnout and patient noncompliance can fuel one another. It is imperative to recognize the signs of each one so that the exasperated clinician behavior and poor patient outcomes don’t blend into an unhealthy and unhappy clinic environment, benefiting no one. Positive change by the practitioner and the patient will have a synergistic effect on the patient’s treatment outcomes as well as the attitudes of the clinic staff members and the patients that they all care for. Staff burnout in a Wound Center is a rarity simply because of the unique specialty area. Typically, the clinicians in the center are there because they truly love the art and science of wound healing and working with this population of patients that many others don’t want or don’t know how to treat. The passion that drives the wound care specialist is the same positive energy that can be the catalyst for preventing patient burnout and subsequent noncompliance. n

Dot Weir, RN, CWON, CWS, is the Wound Care Director for Osceola Regional Medical Center in Kissimme, Fla and coeditor of Today’s Wound Clinic.

Val Sullivan, PT, MS, CWS is a founding member of TWC’s editorial board and the clinical manager of Advanced Wound Care Services and Hyperbaric Medicine at Capital Regional Medical Center in Tallahassee, Fla.