Chapter 19 Management of Self
The ever-changing nature of modern health and social care settings means it is necessary for occupational therapists to think about resilience. Resilience is the capacity an individual has to bounce back from stressful events and situations. It is not an innate quality or attribute, i.e. it is not one of those things like intelligence that you either have or not, which means it can be learned. Developing resilience can help in the prevention of problems occupational therapists may experience in the workplace, such as burnout. Burnout is a serious problem with a number of features, e.g. fatigue, exhaustion and the inability to concentrate. It involves a loss of interest in work coupled with a sense going through the motions. There are other less serious challenges experienced at work that can also make life uncomfortable, such as work–life imbalance. This means individual occupational therapists need to take personal responsibility for their self care by developing self-management strategies. In terms of self management there are some general principles, such as developing good habits, which can be applied to working life as well as specific techniques, such as mentoring, which occupational therapists can use to improve their self management.
Occupational therapists extol the virtue of work–life balance and promote it through occupational balance (Backman 2004). Much of the everyday work we do as occupational therapists is dependent on us as people, i.e. our therapeutic use of self (see Chapter 9). There has been a focus in occupational therapy literature on the need to avoid burnout (e.g. Hume and Joice 2002). Yet how many of us really look after ourselves? It is very easy for people in caring roles to neglect caring for themselves hence the aphorism ‘physician heal thy self’, which has been expanded to ‘healer heal thyself, or you won’t be any good at healing your patients’ (Chacksfield 2002a: 5). We are a precious resource and, as we are the main tool we have to do our work, if we do not care for ourselves we will become prone to burnout and so undermine our ability to be occupational therapists.
Although focus on burnout is still relevant today (and burnout will be discussed in more detail in this chapter) we need to rethink the issue of looking after ourselves. This is because the delivery of modern health and social care services places a wider range of challenges and demands on us. We work in an ever-changing environment focused on improvement, reform and modernisation of services. This requires occupational therapists to be able to act-into-the-situation and reflect on their experience in order to make a positive contribution. We also need to be able to change practice as required, using patient experience and working to challenge the conventions that no longer meet expectations of patients or organisations. This, in turn, means occupational therapists need not just to avoid burnout but also to develop resilience, which involves taking a more proactive approach. The bottom line is self care has become essential to good performance at work. It is something we can address and, in the light of this, this chapter will explore:
The chapter has been written in the expectation that you will make links between this chapter and the chapters on clinical supervision (Chapter 22) and leadership (Chapter 20) because each informs and supports the other. The overall aim of this chapter is to stimulate thought about how we, as occupational therapists, can perform at our best in our work by thinking about the measures we can take to care for ourselves.
Before considering self care and the need for self management it is necessary to be clear about why this topic is important. Self management is increasingly becoming part of an occupational therapist’s working life because we need to seek a balance between our professional development needs and the needs of the present and future health and social care system within which we work. In health and social care, as with other areas of employment, the landscape of work has changed. In essence organisations can no longer be defined as clearly as they once were as they have had to adapt to the changing environments in which they operate (Lee and King 2001). The key features of organisations today include:
This means occupational therapists can no longer expect cradle-to-grave job security and there is a need to take personal responsibility for developing the skills needed to function in today’s organisations. In the absence of structures we all need to learn how to be innovative, flexible, responsive and comfortable with ambiguity and change (Lee and King 2001). This involves developing an awareness of the strategic direction of health and social care, and identifying ways to read ourselves into it. An individual practitioner cannot rely on others to do this for them because with flatter structures there are fewer managers – and they often have a broader portfolio of responsibilities. More often than not there will be no direct professional line management (i.e. by an occupational therapist); so it cannot always be assumed that your manager will understand the contribution occupational therapy can make to new agendas. This shift in expectations means resilience is now a quality that employers look for when recruiting new employees (Contu 2003).
Resilience is valued by employers because it is the means by which many people face and overcome challenges in the workplace. It has been defined as ‘…the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors. It entails the capacity to bounce back from difficult experiences’ (APA Help Center 2004a). It ‘involves maintaining flexibility and balance in your life as you deal with stressful circumstances and traumatic events’ (APA Help Center 2004b: 5). It is essentially about hardiness (Contu 2003) and becomes ‘…a reflex, a way of facing and understanding the world, that is deeply etched into a person’s mind and soul. Resilient people and [organisations] face reality with staunchness, make meaning of hardship instead of crying out in despair, and improvise solutions from thin air’ (Contu 2003: 17–18). In a climate of constant change in the workplace the ability to adapt and be flexible consistently over time is a valuable skill. As occupational therapists, regardless of whether this is something our employers want to see us demonstrating, it should also be a skill we want to nurture because it will help us to function optimally. This chapter generally focuses on the use of resilience in the workplace. It is inevitable, however, that anything an individual does to develop resilience in order to help them cope with the challenges they face at work is also likely to have benefits in other aspects of their life.
If you are feeling overwhelmed by change in your place of work (or study) and do not feel particularly resilient remember that you can do something about it. The literature identifies that ‘Resilience is not a trait that people either have or do not have. It involves behaviours, thoughts and actions that can be learned and developed in anyone’ (APA Help Center 2004b: 1). By understanding the characteristics of resilient people you can assess where your personal weaknesses lie and develop strategies to overcome them. However, as with most things in life, this will require effort and commitment. It is not a one-off task that can be ticked off a ‘to-do’ list. The APA Help Center (2004b) has identified a combination of factors as contributing to resilience, i.e.
Of these the primary factor is having caring and supportive relationships within and outside the family. ‘Relationships that create love and trust, provide role models and offer encouragement and reassurance [to] help bolster a person’s resilience’ (The APA Help Center 2004b: 2). Therefore if you do not have good social networks you need to develop them to increase your resilience. This example clearly shows why developing resilience involves a long-term commitment; building caring and supportive relationships calls for considerable time and effort. Contu (2003) has outlined that there are three qualities needed for resilience, i.e. the capacity to accept and face reality, the ability to find meaning in some aspects of life, and the ability to improvise (Contu 2003).
It may be thought that a positive attitude, or optimism, is a prerequisite for personal development and/or change and that resilience stems from an optimistic nature. Whilst a positive attitude and/or optimism can be useful in the face of adversity or trying circumstances it is not enough. It is only useful in so far as it does not distort a person’s view of reality (Contu 2003). The reason for this is ‘…for bigger challenges a cool, almost pessimistic, sense of reality is far more important’ (Contu 2003: 7). Some people use ‘denial’ as a coping mechanism. This is a psychological process by which human beings protect themselves from things which threaten them by blocking knowledge of those things from their awareness (Community Alcohol Information Program 1997). It is a defence mechanism which distorts reality; it keeps us from feeling the pain and uncomfortable truth about things we do not want to face (Community Alcohol Information Program 1997). Denial or an overly positive or optimistic attitude in the face of difficult circumstances, e.g. the death of a colleague or redundancies, does not promote resilience. In fact it may be regarded as wholly inappropriate by others sharing the same experience (Dutton et al 2003). Being positive or overly optimistic can also stop an individual facing the reality of their situation. ‘The fact is, when we truly stare down reality, we prepare ourselves to act in ways that allow us to endure and survive extraordinary hardship’ (Contu 2003: 9). Accepting and facing up to a situation also calls for us to demonstrate our humanity and to be compassionate; having resilience does not mean that an individual is devoid of emotion or that they leave their emotions at the door when they are in work (Dutton et al 2003). In fact it may be that a compassionate response that allows people to make sense of a situation is a more effective response than one in which a situation is ignored because it is regarded as inappropriate to be emotional at work (Dutton et al 2003). This links with Contu’s (2003) second characteristic of resilience, i.e. the ability to find meaning in some aspects of life.
In difficult circumstances many of us take on a victim role revealed in the question ‘Why is this happening to me?’ The question can equally be posed ‘Why not me?’ Contu (2003) contends ‘resilient people devise constructs about their suffering to create some sort of meaning for themselves and others’ (p. 10). In this situation, meaning making becomes a coping mechanism, i.e. we cope by making sense of a situation for ourselves by setting it in a context. For example, we set the situation in the context of our life, future or past events or our faith (if we have one). Frankl (1984), a Jew who survived the German concentration camps in the Second World War, wrote ‘We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed…In some way, suffering ceases to be suffering at the moment it finds a meaning’ (p. 135). However, it is emphasised that ‘Resilience is neither ethically good nor bad. It is merely the skill [my emphasis] and the capacity to be robust under conditions of enormous stress and change’ (Contu 2003: 12).
The third characteristic, improvisation, links to flexibility and can be defined as ‘a kind of inventiveness, an ability to improvise a solution to a problem without proper or obvious tools or materials’ (Contu 2003: 14). It involves the ability to make do with whatever is at hand and organisations that survive regard improvisation as a core skill (Contu 2003). For example UPS supports its drivers to do whatever it takes to get its deliveries done on time but improvisation, as practised by UPS, ‘is a far cry from unbridled creativity’ (Contu 2003: 16). UPS also works within rules and regulations. It is recognised that improvisation has not been widely encouraged in health and social care services but it does highlight how individuals will sometimes have to take the initiative rather than rely on or expect existing hierarchies or systems to provide the solutions. This is not dissimilar to what Bennis and Thomas (2003) call adaptive capacity, that is an ability to transcend adversity and emerge stronger than before. These three attributes show how we need resilience to enable us to adapt to life-changing situations and stressful conditions. Therefore it is a useful skill for practitioners to develop to cope with the challenges they face at work.
For many occupational therapists it is not just that they face a challenge at work, it’s the sheer number and range of challenges presented by day-to-day work that can be wearing. Therefore it is important to be able to identify the warning signs and then do something to ameliorate the situation if problems arise. The most serious consequence of not being resilient is burnout but, whilst burnout is the worst-case scenario, there are other less serious problems that can also undermine our ability to do our job properly. These include a lack of work–life balance, being unable to keep abreast of technology, and succumbing to impostor syndrome.
Burnout is a serious issue in health and social care settings. Taylor (2005) has contended that allowing ourselves to burnout ‘is tantamount to negligence as burnout is next to impossible to treat once it is established’ (p. 220). It is not without its warning signs. There are three main symptoms – feeling emotional, loss of rapport and achievement. The danger signs of burnout include:
People experiencing burnout have described themselves as feeling used up, emotionally exhausted, seeing their patients as problems rather than as people and feeling that all the energy they are putting into their job is not achieving much (Taylor 2005). Other symptoms include fatigue, exhaustion, inability to concentrate, depression, anxiety, insomnia, irritability, increased use of alcohol or drugs, a loss of interest in one’s work or personal life, and a feeling of ‘just going through the motions’ (Gundersen 2001). Burnout is a complex problem that is not caused by any one factor so it makes more sense to prevent rather than treat it (Grosch and Olsen 1994). In trying to prevent burnout there are no simplistic formulas; it is not just about substituting a leisure activity with some of the time you spent at work. Grosch and Olsen (1994) have developed an approach to preventing burnout based on a theory of family origin. However it is possible to delineate steps to prevent burnout that stand alone from this theoretical perspective (see below).
By assessing ourselves regularly we can determine the difference between normal tiredness and early signs of burnout.
Recognise what the issues are that are contributing to burnout, e.g. perfectionism.
‘Overwork is the curse of our time. Working long hours has become a badge of honor among professional people, whose complaints about overwork are often mixed with a sense of pride in their dedication and importance’ (Grosch and Olsen 1994: 101). Overwork is perpetuated through a need for chronic busyness and is prevalent in the helping professions (Grosch and Olsen 1994). By contrast work–life balance is about achieving the right balance of focus, energy and time between your work and the other important areas of your life (Lee and King 2001). It is not easy to achieve because there is no prescription and everyone has to work it out for themselves but it is also not about being perfect in all aspects of your life (Lee and King 2001). Work–life balance helps us to be more effective at work because, for example, single-minded devotion to work is correlated with poor performance (Lee and King 2001). As has already been suggested in the discussion about resilience (above) the benefits of achieving work–life balance will not just be experienced in the work arena but in our personal lives as well. Lee and King (2001) suggest there are five strategies for achieving balance, i.e.:
The need to keep abreast of technological developments can cause anxiety as well as feelings of being out of control at work. There is no doubt that technology in health and social care will continue to need a wider community of practitioners to test technology solutions with the user/carer. A positive critical use of technology can optimise the care and rehabilitation experience. This demands a group of people who understand and are able to use technology in rehabilitation practice. Whilst there has always been new technology to keep abreast of this is an example of how generational shifts have an impact on work. ‘The technologies available as a generation matures influence their behaviors, attitudes, and expectations. People internalize the technologies that shape information access and use, as well as the ways they communicate. Matures (born 1946–1964) were exposed to large vacuum-tube radios, mechanical calculators, 78rpm records, dial telephones, and party lines. Baby Boomers grew up with transistor radios, mainframe computers, 33⅓ and 45rpm records, and the touch-tone telephone. Gen-Xers matured in the era of CDs, personal computers, and electronic mail. For the Net Generation, the prevailing technologies are MP3s, cell phones, and PDAs; they communicate via instant messaging, text messaging, and blogs. For each successive generation “technology is only technology if it was invented after they were born”’ (Hartman et al 2005). This means for those of us who are not part of the Net generation we need to work not only towards fluency in information technology but also understand how it has influenced the mindset and behaviour of society (Moore et al 2005). Keeping abreast of technological developments requires:
Impostor syndrome is the phrase used to describe people who feel like a fraud in their professional lives. These are people who play down their successes because they believe that they have only achieved what they have achieved through good fortune and it is likely that this will be exposed at any time. It used to be a phenomenon observed in the university sector but Bhargava (2007) has noted that ‘Researchers say that these vague feelings of self doubt, intellectual fraudulence and anxiety are so common among people, it’s almost an epidemic. The ‘impostor syndrome’ strikes people everywhere especially high achievers. It makes them discount their success attributing it to luck, not real ability. Along with it comes the fear that anytime they could be found out’ (p. 1–2). As the experience of impostor syndrome involves an inability to internalise success, strategies for overcoming it are linked to the need to internalise success.
Having considered what resilience is, and some of the challenges occupational therapists may face in performing well at work, the next step is to think about what we can actually do to develop or increase our resilience. Burnout has been identified as the worst-case scenario but it is avoidable. Taylor (2005) has emphasised that ‘Burnout is extremely difficult to recover from once well established. There is no pharmaceutical solution and too little internal energy to fight it effectively…Just as a bankrupt business cannot easily revive itself, so you will not have the resources to bounce back. And no one can do this for you. Prevention is our own personal responsibility, however ‘selfish’ the steps we need to take’ (p. 220). If this analysis is accepted it means preventing burnout is not an option but essential to good performance at work. In combating burnout Taylor (2005) identified that there are two fundamental points to consider:
This demonstrates that ‘self care’ is the foundation to developing resilience.
As with most things in life self care means different things to different people. Generally self care involves taking personal responsibility for ensuring the maintenance of health and well-being. Patients are increasing expected to take more responsibility for their own care, for example ‘Self care was highlighted in the NHS Plan as one of the key building blocks for a patient-centred health service. More recently self care featured as a component of the model for supporting people with long term conditions’ (DH 2005: 1). The NHS recognises that there are benefits for patients and services by supporting self care and so is committed to developing and supporting a range of initiatives to facilitate this (DH 2005). However, if there is an expectation that patients will increasingly take responsibility for their own health perhaps occupational therapists also need to practise what they preach? However, as Taylor (2005) highlighted whilst we may recognise there is risk of burnout if we do not take care of ourselves, we can often feel like we are being selfish if we put ourselves and our needs high on our agenda. So it is not just about recognising that we need to put our self first but we also have to actively take steps to care for ourselves however selfish we may feel that is.
Caring for yourself literally means ‘…you must look after yourself as well as you possibly can…When you look after your own needs as much as you look after those of others you become better able to do your work’ (Kersley 2004: 64). However, how we care for ourselves will depend to a certain extent on our personal interests, needs and circumstances. For example someone working full time with young children may have different needs in relation to work–life balance to another person who is under-stimulated by their work and feels the need to be stretched more. As each individual’s needs are different and change over time we need to monitor ourselves. Self care is not something that we can address once in our careers and assume all will be well for the duration; we need to revisit the issue every so often to ensure that the measures we put in place are still relevant to our needs. It may be a question we pose for ourselves annually, perhaps at the time of our appraisal, even if it is not a question on the official forms that we have to complete.
An overarching issue for all occupational therapists is the need to maintain health. Chacksfield (2002b) has outlined 12 strategies for maintaining good mental health (see Box 19.1) and although he was discussing mental health he also mentioned exercise. It is very difficult for any of us to have escaped the message that exercise has an essential role to play in maintaining good health and that it benefits our physical and mental health. However, how many of us integrate exercise into our everyday routines and habits? A quick win in terms of exercise can come through the use of a pedometer – ‘people with pedometers do more steps than people without’ (Hebert 2005: 221). Another issue in terms of health and burnout is that many of us come to work when we are ill. We know we should not do it but many do. This type of behaviour can play a role in developing burnout because when we go to work ill this is not caring for ourselves. Although maintaining health is required to actively prevent burnout, other issues, such as time management and the control we feel we have over our work, are also relevant. This is why self management, built on the premise of the need for self care, has a role to play in developing resilience.
Self-management refers to methods, skills and strategies by which individuals can effectively direct their own activities. Whilst employers have a responsibility to support their employees by providing a safe environment in which to work, in order to build resilience we also have to take responsibility for engaging in activities to promote our effectiveness at work. It has already been identified that occupational therapists are all different and so will have different needs and that these change over time. This means there is no ‘off the shelf’ self management plan because there is no one-size-fits-all solution. However there are a number of things we can do to help ourselves. As well as the specific suggestions for preventing burnout, developing work–life balance, keeping abreast of technological advances and overcoming impostor syndrome (see above) there are other tactics available. These can be summarised under two headings, i.e. general principles to develop good habits and specific techniques. The remainder of this chapter will present a range of ideas under these headings which you can use to experiment and explore what will work best for you. In the vignettes (below) I have used my own experiences to illustrate how I have tried to develop/apply self management strategies to myself. However, the ideas presented here only provide a flavour of the available literature. There is a lot of information available and there may be particular issues or ideas that you want to explore in more detail (a number of useful resources have been provided as a starting point for further exploration of these topics).
In Box 19.2 some simple, but effective, good ideas have been listed. Each of these ideas is relatively easy to implement but does require the person involved to act. After all actions only become habits when they become an integral part of what we do without conscious thought or attention. This usually occurs through repetition. We need to be proactive about developing good habits because ‘We often get so busy “sawing” (producing results) that we forget to “sharpen the saw” (maintain or increase our capacity to produce results in the future)’ (Covey et al 1994: 85). Covey (1989) calls the habit of taking time out to re-energise and renew ‘sharpening the saw’. You may find it helpful to reflect on the list of good ideas (Box 19.2) to see if there are any you could adopt to change your current behaviours around work. Even if you are quite good at caring for yourself are there other things you could incorporate into your life to increase your effectiveness? Whatever you decide to do set yourself a realistic goal and set a date to review this, perhaps as part of your appraisal?
Box 19.2 Examples of good habits that promote self care and will enhance your resilience
‘If you are to avoid the overworking trap you need to meet as many of your needs as possible by life outside work…think of enjoyable and creative ways to meet your needs outside work’ (Work life balance centre 2007)
Use structures that are in place (see, for example, Chapter 22 on clinical supervision), make use of the leadership literature (see the Chapter 20) and seek support from others.
Vary your daily routine but also vary your career (Taylor 2005). After all, variety is the spice of life!
‘Our patients have needs, but so do we. Balance them’ (Taylor 2005: 220)
Take small, frequent breaks. Avoid competitive negativity, i.e. the state of trying to ‘out busy’ everyone else you speak to (Work life balance centre 2007)
Sometimes our use of language reinforces our sense of being busy and/or out of control.
Only be limited by ‘your’ imagination. Do not let other people shape your views of what is possible.
Reading about the experiences of others can help to inspire us (e.g. Glicken 2006).
The general principles are inexpensive, relatively easy strategies to adopt. There are other more specific techniques that occupational therapists can use as part of their self management. These are more likely to require a higher investment of either time or money or both. You may be supported by your employer to use these techniques but whether you are supported or not, you may still decide that the investment is worthwhile because of the increase in your performance and effectiveness at work and other important areas of your life.
Vignette 19.1 Scholarly activity meeting
I am a part of an informal meeting with a group of colleagues who get together to support each other with continuing professional development. We each set goals annually and then use them to monitor our activity over the year. We have set-up a reminder system with an administrator who sends us a personal reminder to remind us what work we had agreed to complete by the next meeting. Although there is no obligation to attend the meeting all members are committed because we have found that by committing to goals, discussing progress and encouraging each other all of us have increased our productivity.
In the past I wanted to be more focused and felt I had lost some clarity about my work. Following a discussion with a colleague who had similar concerns we decided to set up peer mentoring to support each other. The publication of ‘The 8th habit’ (Covey 2004) coincided with this discussion and we decided to use the chapters from this book to structure our discussions. We committed to meeting once a month and to reflect on the reading we had done from the book and current issues from our work. Having a colleague to work with, who was equally committed to continuing professional development, was a privilege. However I am not sure if the sessions would have been as effective without the reading to structure it. The reading kept us focused on our task and both of us had a clearer sense of focus about our work and lives by the end of the year.
My organisation participates in the ‘Yorkshire Accord Mentoring Scheme’, a partnership between public sector organisations in York. The scheme aims to provide individuals with personal and professional development, support and challenges by offering them the opportunity to work one-to-one with another individual in a mentoring relationship. Following a promotion, having come across the scheme by accident, I applied for a place. I hoped it would help me focus on meeting the expectations of my new role. Being accepted as a mentee provided me with an extremely useful experience. I was matched with a senior manager from another organisation who was more experienced and knowledgeable than me. The meetings with my mentor not only focused on my needs but also provided me with an opportunity to reflect on my progress with someone outside of my organisation. This is an example of how serendipity, the faculty of making happy and unexpected discoveries by accident, can provide us with excellent opportunities within the workplace that we should try to take advantage of if we can.
Box 19.3 Roles and skills of a mentor
The roles of the mentor can involve any combination of these:
I subscribe to a weekly alert from BMJ Careers and many of the articles provide useful reflections on the different challenges we face in our working lives. A recent article (Hobbs 2007) helped me to revisit my time management skills. It provided a series of three exercises that I used to explore how I use my time
Exercise 1 Exploring the sense of control I have over my time
Exercise 2 Being a more effective planner and
Exercise 3 Planning for the unexpected (Hobbs 2007)
(There is also a website www.hobbspartnership.co.uk with additional exercises that can be used without charge.) These sorts of exercises provide a quick check on skills that can contribute to self management without having to take time out to go on a course. Often when I have read or completed the exercises I am reassured that I am working well but on other occasions it provides an early warning that I am not on top of my game and I need to invest some time in reviewing my habits.
In this chapter a process for self management has emerged (see Box 19.4). Although the need for self management is indicative of how organisations have changed, and that the work arena presents more challenges, it also means we can have more control over our careers. One of the exciting aspects of working in health and social care today is that we can truly have the careers we want to have. It is now possible for occupational therapists to enjoy 20 years of experience rather than having one year’s experience 20 times (Hollis and Clark 1993). However if we are to rise to the challenges and enjoy the diverse range of experiences on offer we need to be more resilient than previous generations.
BMJ Careers (www.bmjcareers.com). Whilst this publication has been developed for medics it has a range of useful resources related to self management. A lot of excellent writers in this field have written articles for BMJ careers and they are all archived on the site.
Center for Creative Leadership (www.ccl.org). This website has a number of useful resources particularly if you currently hold a leadership position but will be of use to anybody interested in personal leadership.
OT Coach website (www.otcoach.com/). This website has been developed by a company providing personal and professional development services for occupational therapists. It has a number of free resources as well as a monthly newsletter you can sign up to.
Productivity under pressure: how do you cope? (Broadhurst and Keyes 2003). This article suggests a number of tasks to facilitate improvements in personal effectiveness.
The Road to Resilience (www.apahelpcenter.org/dl/the_road_to_resilience.pdf). This workbook is concisely written and so provides a good introduction to the subject of resilience. It can also be used as a starting point for looking at how to develop resilience.
Work Life Balance Centre (www.worklifebalancecentre.org/). This centre researches work and its impact on people’s lives. It also has resources about how to overcome work–life imbalance issues.
Work Life Research centre (www.workliferesearch.org/). This centre undertakes research into the relationships between employment, care, family, leisure and community. An example of their work includes the Work-life manual; a practical tool for employers offering a step-by-step approach to implementing a work–life strategy.
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