GUEST EDITORIAL

Low morale and burnout; is the solution to teach avalues-based spiritual approach?In the busy and stressful environment of hospitalsand community care how can we bring the bestcare to our patients and at the same time feelenriched by the work?

Craig Brown

Summary

In times of low morale and burnout in staff it isimportant to return to the values that formed thefoundation of medical and nursing practice. It ispersonal values that form the foundations of team andorganisational values. A newly developed modulareducational package is described that advocatesvalues as an essential part of the training of healthcareprofessionals at all levels. A spiritual approach isadopted to bring a fresh look to these deep rootedproblems and concludes that self-development and

self-care of the professionals is an essential compo-nent in providing excellent patient care.

Current challenges of low morale andburnout

It seems that over recent years there has been adecline in morale in health care professionals and afeeling of not being valued where once a sense ofvocation flourished. A survey of general practitionersshows two-thirds saying morale was low or very lowand the same survey 80% reported work-relatedstress was unmanageable.1 A recent editorial titled,‘Why are Doctors so unhappy?’ suggests ‘the mostobvious cause of doctor’s unhappiness is that theyfeel overworked and under supported’.2 The authorgoes onto to suggest other factors are ‘diminishedcontrol, more change and increased accountability,’and acknowledges the cause runs much deeper.

Doctors and nurses may feel worn out by work attimes but when this becomes a chronic state theysuffer from burnout. Burnout is ‘a state of physicalemotional and mental exhaustion caused by longterm involvement in situations that are emotionallyexhausting’.3 It is characterised by feelings of beingemotionally drained (emotional exhaustion), nega-tive attitudes and feelings towards patients (de-personalisation) and a growing devaluation of self-competence and achievement (reduced personalaccomplishment).4,5 Nurses are considered to beparticularly susceptible to burnout as their jobs aretypically stressful and emotionally demanding.Nurses are repeatedly confronted with people’sneeds, problems and suffering.6

Seeking solutions

How do we bring hope to beleaguered healthcareworkers? How do we prevent burnout, raise moral,

1353-6117/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S1353-6117(03)00012-X

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enjoy our work and feel good about ourselves? Howdo we not only survive but thrive at work?

Early in 2000 a registered charity called the JankiFoundation, that is committed to promoting holisticcare, invited a group to meet and explore thesequestions.7 This core group brought their experiencefrom work and teaching in their own specialties ofgeneral practice, psychiatry, nursing, medical edu-cation, complementary therapy, occupationalhealth, and organisational consulting and they drewon a wide variety of other sources. They consideredthat these issues were essentially a spiritual problemand that healthcare professionals needed to findmeaning and purpose in their work and reconnectwith their personal values so be able to create apositive vision for their future. They decided todevelop and design an educational programme toteach values using an innovative spiritual approachto tackle the issues on a personal level and itsconsequences at an organisational level.

Values

Prompted by the perceived decline in morale, theBritish Medical Association held a summit meetingon ‘Core values for the medical profession’.8 Theyconcluded that changes in society, demography,healthcare organisation, patients’ expectations,and techniques of medical care were challengingdoctors’ traditional role and core values. Thesummit called for a re-evaluation, redefinitionand restatement of core values, which it definedas ‘ancient virtues distilled over time’, andrecognised these values as the profession’s greatestasset, greater even than scientific knowledge andsophisticated technology. The core values of themedical profession identified by that summit werecaring, compassion, integrity, competence, confi-dentiality, responsibility, advocacy and the spirit ofenquiry. An earlier publication by the Royal Collegeof General Practitioners ‘What sort of doctor’stresses good communication skills, reflectivepractice and an obligation to maintain one’s ownhealth.9 Knowing and living our values can help usunderstand the purpose in our lives and form thebasis of our judgments about what is good and bad,right and wrong. Learning to understand and act onone’s values is the key to thinking about renewal.10

Not only do values act as a guiding principal forindividuals but are essential for leaders andorganisations to know what they stand for andhow they govern their affairs.8,11

However, much of our professional bodies give usthese guiding principals to practice by, values

derive from our own inner values. We need tounderstand that values are part of the very fabricof our work and make them part of our education atall levels.

Teaching values

As healthcare professionals much of our training isgeared towards acquiring knowledge and learningpractical skills. Less time is spent on communica-tion skills and even less time is spent on lookingafter ourselves. With this in mind the JankiFoundation core group adopted three key principleswhen teaching values.

The first was to put professional caregivers at thecentre of healthcare delivery by adopting the idealof ‘physician heal thyself’. The belief is thatnourishing and supporting ourselves and payingattention to our self-development will raise moraleand restore within ourselves the sense of purposeand altruism we had at the outset of our careers.The second is that spirituality is best learnedthrough direct experience, so the style of teachingis important and the program should be facilitatedrather than taught. There should be time forsilence, reflection and sharing in a supportive, easyenvironment. Thirdly, the learning experienceshould be relevant to both our work and lives, withan emphasis on action planning and evaluation witha commitment to ongoing learning.

Many of the sessions were piloted and tested anda consultation group of trainers and educationalistswas sent the material for comment. The challengefor both the core and consultation groups was todevelop an acceptable educational programme thathealthcare professionals can relate to, while at thesame time maintaining the essence of spirituality.

A spiritual approach

The healthcare professionals use many differentmethods to teach the skills and the art of eachrespective discipline, including formal lectures,personal study, tutorials, and practical experiencealongside apprenticeship learning. The core groupfelt that to teach values it would adopt a spiritualapproach with the exercises being experiential,personal and at a deep level. Meditation andvisualisation was felt to be essential as was theneed for deeper reflective and listening exercises.The group used ‘Appreciative Inquiry’ as a methodof adopting positive attitudes.12 Finally, the groupfelt the teaching needed to be creative and playful.

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Meditation

Meditation is being silent and using the time tolearn about our mind and our thoughts. The methodwe advocate does not involve reciting any mantrasor using incense or chimes. It is a way of simplyfocussing our awareness on the peace within. Byusing positive and peaceful thoughts we can movetowards the calm and silent centre of our con-sciousness. There is a powerful sense of wonderwhen that peaceful place within is found. It is not astate of passive emptiness, quite the contrary; byactively letting go of negative feelings we open upspace to experience very positive feelings. Suchmeditative practice helps to quieten our mind andbring calm to our work.

Visualisation

Often images we have in our mind are of pastnegative experiences and when we dwell on them itcauses us unhappiness or frustration. Visualisationis simply using our mind to create new positiveimages which will help us be more optimistic in ourattitude. By using exercises to build up positiveimages of past successes and a better future it canhave profound affects on our self-respect andcreate positive attitudes.

Reflection

‘Reflective practice’ is learning from past experi-ence and in healthcare is a well-established methodof evaluating concerns with the aim of improvingclinical practice. It is a useful discipline to create astructure that reviews our professional progress.

The spiritual approach to reflection is to evaluateour inner response with the aim of helping our selfdevelopment. It is taking a detached view of asituation by standing back and examining our ownemotional reactions and feelings. It is a way ofmoving into a place of calm and peacefulness so wecan observe how we responded. This way we canbegin to understand our own feelings of anger,anxiety and attachment are something that can bereleased. We can then focus on what went right andthe positive contributions we make. The aim of thistype of reflection is to strengthen self-esteem bylearning from mistakes, observing our feelings andbuilding on positive experiences.

Listening

Perhaps the most important aspect of any commu-nication is how we listen. The spiritual approach

involves a deep listening. Such listening is depen-dent on the listener finding peacefulness within andgiving his or her full attention without distraction.This can be practiced by keeping the mind clearand focussing on what the other person is saying ina non-judgemental way. Finally with this type oflistening it is good to have an open heart by havingan attitude of kindness. It brings benefit not only tothose being listened to but the listener themselves.

Appreciation

In healthcare we are taught to be careful anddevelop a critical attitude. This is appropriate formany situations in the technical side of medicalcare but is not when dealing with many aspects ofpatient care, interactions with colleagues and ourpersonal lives. Appreciation looks at individuals andgroups from the perspective of valuing what worksbest, drawing on existing skills and shared values toseek solutions rather than focusing on the problemand apportioning blame. It assumes that in everyteam, group or society, something works and thetask for the group is to embrace this. This approachis used throughout the programme to encourage co-operation during the sessions and to take it into ourteams at work.

Creativity

There are an unlimited number of ways to becreative and a spiritual approach encouragescreativity as a way of discovering new solutions.Ideas often come to us when we give ourselvessome silent space. Equally sometimes when we aretaken up totally with something ideas may thenbegin to flow. Some practical ways of being creativeare painting, drawing or writing poetry. Weencourage facilitators to experiment with newways of exploring and developing exercises toteach values. It may mean taking some risk andbehaving outside our normal role.

Playfulness

Fun and laughter is essential to balance some of theserious discussion that may occur during theteaching sessions. Being playful is being sponta-neous, carefree with a willingness to risk getting itwrong. It is a good way of letting go of barriers andovercoming difficulties. Having a ‘lightness’ in ourmanner encourages tolerance in our listening andsoftness in our judgments. Playing simple games issomething many of us are at first inhibited to do butwhen we do, it can be a moving experience. It helps

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to connect at a deeper level beyond normalconversation and discussion and in a group whenwe have fun we can drop all our pretences and justbe ourselves.

Modules for values

Using the spiritual approach we focused on seventhemes that can be run as modules over a daysession; values, peace, positivity, compassion, co-operation, self-care and healing. Each sessionstarts with an introduction and outline of the daywith a space for silence. The theme of the moduleis investigated using reflection and listening in pairswith feedback to the group. There may then be ameditation or visualisation. There is time forbreaks, suggested movement exercises and playfulexercises. The first session of each module tends toexplore the theme of the module and the secondsession applying what has been learnt. Each sessionends with some time spent on summarising,evaluating and closure.

Values

An exploration of what values mean to us personallyand how they apply to our life is the foundationof the spiritual approach. They are the principalsthat we choose to live by and are an inner resourcethat we can draw on. Knowing and living by ourvalues enriches our self-development and leadsto an understanding of the purpose of our lives. It isthe key to bringing meaning to our lives and raisingmorale.

Peace

Central to this theme is the idea that being peacefulis our natural state. In each one of us there is aninnate core of calm and tranquility. In the session weuse simple yet powerful ways to rediscover our innerpeace. By practising peacefulness we access ourpositive qualities, which build our self-respect andcontentment. It is the medicine for burnout.

Positivity

Even as healthcare professionals who, out of habitand training analyse things critically and oftennegatively, we have the choice and power tochange the way we think. Relearning to observeour thoughts and changing them to be morepositive benefits our patients and colleagues.

Compassion

Compassion brings humanity to healthcare and is theexpression of our innate qualities such as patience,generosity and kindness. It is something that we candevelop and practice, yet there are barriers pre-venting the true expression of compassion that weneed to acknowledge in ourselves. Anger, anxiety,guilt and attachments are the ever present ‘sha-dow’, unacknowledged side of ourselves that needsto be examined in such an education programme.

Co-operation

For a group of people to work well together it isessential that they understand what thoughts,attitudes, feelings and behaviours help them co-operate successfully. One can then build team spiritin non-competitive ways so that tasks becomecreative and enjoyable.

Self-care

The focus on this session is looking after oneself byreflecting on what we already do and what wewould like to do in the future. The question, ‘whoam I?’ explores this theme at a deeper level.Ultimately by recognising our own worth we arebetter able to acknowledge the intrinsic worth ofothers. This leads to mutual respect and harmony inall our relationships. We benefit, our colleaguesbenefit, and our patients benefit.

Healing and caring

There is a need for individual clarity concerning thewords health, healing, spirit and spirituality so wecan continue to develop the ideals of holistic healthand make spiritual care intrinsic to our work ashealthcare professionals

Guidelines for trainers

The success of the sessions will be largely depen-dent on how they are conducted, so there aredetailed guidelines and training sessions for thefacilitators. We encourage facilitators to draw ontheir own personal experiences, anecdotes andstories. This will reveal not only their wisdom inspiritual terms, but also their vulnerability. Ex-ercises should not be rushed and conducted at aneasy pace as some of the questions in the exercisesmay seem simple but they can be quite profound.Sharing in pairs and small groups can be a rare

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opportunity for healthcare professionals to discussome of their own issues.

Conclusion

We already know that low morale and burnout areprevalent in doctors and nurses and needs to beurgently addressed. There are some excellentvalues statements produced by professional bodiesbut to make them real they need to be owned at apersonal level first, then integrated into the work-place. We contend this is best done through aspiritual approach using meditation, visualisation,reflection, listening, appreciation, creativity andplayfulness. An educational package has beendeveloped that is presented in a practical, personaland experiential way that focuses on self-develop-ment and self-care. It builds self-esteem andrenews a sense of purpose amongst healthcareprofessionals, consequently improves patient careand reverses the trend of deteriorating morale andburnout amongst staff.

References

1. BMA. National survey of GP opinion. London: British MedicalAssociation, 2001.

2. Smith R. Why are doctors so unhappy? Br Med J2001;322:1073–4.

3. Pines A, Aronson E. Career burnout: causes and cure. NewYork: The Free Press, 1988.

4. Maslach C, Schaufeli WB. Historical and conceptual devel-opment of burnout. In: Schaufeli WB, Maslach C, Marek T,editors. Professional burnout: recent developments intheory and research, New York: Taylor & Francis, 1993.p. 1–16.

5. Maslach C. Burnout: a multidimensional perspective. In:Schaufeli WB, Maslach C, Marek T, editors. Professionalburnout: recent developments in theory and research, NewYork: Taylor & Francis, 1993. p. 19–32.

6. Bakker A, Killmer C, Siegrist J, Schaufeli W. Effort–rewardimbalance and burnout amongst nurses. J Adv Nursing2000;31(4):884–91.

7. Janki.The Janki Foundation, 180, High Road, Willesden,London NW 10 2PB, UK, 2000.

8. BMA Core values for the medical Profession. Summit Meet-ing. London: British Medical Association, 1995.

9. RCGP. What sort of doctor? Royal College of GeneralPractitioners, London, 1985.

10. Clever LH. A call to renew. Br Med J 1999;319:1587–8.11. Pendleton D, King J. Values and leadership. Br Med J

2002;325:1352–5.12. Cooperrider D, Whitney D. Appreciative inquiry. San

Francisco: Berrett-Koehler, 1999.

Dr Craig Brown has been a full time NHS generalpractitioner in Rustington, West Sussex for 24years. He has a long standing interest in holisticmedicine and has had a variety of complementarypractitioners working at his surgery over the years.He has trained as a spiritual healer, was Presidentof the National Federation of Spiritual Healers from1997 to 2001 and presented the research evidenceon healing to the House of Lords select committeeon complementary and alternative medicine. Hehas published a book ‘Optimum Healing’ whichoutlines a spiritual approach for patients towardstheir illness. He is a member of the core group ofthe Janki Foundation designing the training pro-gramme teaching spirituality to healthcare profes-sionals.

Craig BrownWest Court 12 The Street,

Rustington, West Sussex BN163NX, UK

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