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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Int J Pers Cent Med. Author manuscript; available in PMC Oct 23, 2013.
Published in final edited form as:
Int J Pers Cent Med. 2012; 2(1): 90–95.
PMCID: PMC3805943
NIHMSID: NIHMS518707
Relation of people-centered public health and person-centered healthcare management: a case study to reduce burn-out
Drozdstoj S. Stoyanov, MD PhD PGCerta and C. Robert Cloninger, MDb
aAssociate Professor, Department of Psychiatry and Medical Psychology, Faculty of Medicine, Medical University of Plovdiv and Deputy Director and Scientific Secretary, University Center for Philosophy and Mental Health, Bulgaria
bRenard Professor of Psychiatry, Psychology and Genetics, Washington University School of Medicine, Missouri, USA
Correspondence address. Dr. D. S. Stoyanov, Medical University of Plovdiv, Bulgaria. stojanovpisevski/at/gmail.com
Healthcare management is one practical tool for mediation and implementation of public health into clinical healthcare outcomes and is taken in our case study as an exemplar arena to demonstrate the vital importance of the person-centered approach.
Healthcare personnel are frequently at risk for the ‘burn-out’ syndrome. However, modern measures of burn-out recognize burn-out only at a late stage when it is fully developed. There are no available methods to assess the risk for vulnerability to burnout in healthcare systems. Our aim was therefore to design a complex person-centered model for detection of high risk for burn-out at an early stage, that has been termed ‘flame-out’. We accept the observation that decreased personal performance is one crucial expression of burn-out. Low personal performance and negative emotions are strongly related to low self-directedness as measured by the Temperament and Character Inventory (TCI). At the same time, burn-out is characterized by decreased interest and positive emotions from work. Decreased positive emotion is directly related to low self-transcendence as measured by the TCI. Burn-out is also frequently associated with feelings of social alienation or inadequacy of support, which is in turn related to low TCI Cooperativeness. However, high Persistence and Harm Avoidance are predisposing traits for burn-out in healthcare professionals who are often overly perfectionistic and compulsive, predisposing them to anxiety, depression, suicide and burn-out. Hence, people at risk for future burn-out are often highly conscientious over-achievers with intense mixtures of positive and negative emotions. The high demand for perfection comes from both intrinsic characteristics and from features of the social milieu in their psychological climate. Letting go of the unfulfillable desire to be perfect by increasing self-transcendence allows acceptance of the imperfection of the human condition, thereby preventing burn-out and other negative emotions while promoting positive emotions and work in the service of others.
Hence, we can evaluate vulnerable populations via a person-centered diagnostic method using the TCI and also relate wellbeing to the psychological climate of the work place. The proposed diathesis-stress model can directly impact on the management of human resources and related decision-making. The introduction of such person-centered assessments can encourage and improve public health outcomes by promoting the personal wellbeing of healthcare employees.
Keywords: Burn-out, flame-out, harm avoidance, negative emotions, people-centered public health, persistence, person-centered healthcare, personality, positive emotions, professional exhaustion, psychological climate, self-transcendence, temperament
Contemporary public health and clinical medicine seem to be equally estranged both from people (as cultural, professional and other groups) and from the person (in clinical judgment). Healthcare management is one practical tool for mediation and implementation of public health into clinical healthcare outcomes and is taken in our case study as an exemplar arena to demonstrate the vital importance of the person-centered approach.
Healthcare personnel are at high risk for the ‘burn-out’ syndrome. However, modern measures of burn-out, such as the Maslach Burnout Inventory (MBI) [1,2], only recognize burn-out at a late stage when it is fully developed. There are no available methods for the early detection of personal vulnerability and increased risk for burn-out in healthcare systems.
Our aim is therefore to design a practical person-centered model (i.e. a battery of assessment tools) for early detection of burn-out, including its initial stage – the ‘flame-out’.
We accept the observation that decreased personal performance is one crucial expression of burn-out. Low personal performance and negative emotions are strongly related to low self-directedness, as measured by the Temperament and Character Inventory (TCI). At the same time, burn-out is characterized by decreased interest and positive emotions from work. Decreased positive emotion is directly related to low self-transcendence, as measured by the TCI [3]. Burn-out is also frequently associated with feelings of social alienation or inadequacy of support, which is in turn based on low TCI Cooperativeness.
However, high Persistence is a predisposing trait for burn-out in healthcare professions who often are selected and trained to be highly conscientious. Persistence is often highly valued because it leads to outstanding achievement from being hard-working and ambitious, as measured by the TCI. However, being highly persistent also leads to perfectionism, which has a great cost in psychological and social terms [46]. The combination of high Persistence, high Harm Avoidance and low self-directedness often leads to perfectionism. Unfortunately, healthcare professionals are often overly perfectionistic and compulsive, predisposing them to burn-out with anxiety, depression, guilt, shame, pain hypersensitivity and suicide [7,8]. Hence, people at risk for future burn-out are often highly conscientious over-achievers who are harshly judgmental of themselves and others with intense mixtures of positive and negative emotions [810]. Healthcare environments may exacerbate these problems by placing external demands for perfection on workers, rather than emphasizing that everyone makes mistakes sometimes, so that the system needs to provide for checks on the inevitable fallibility of individuals. It is not enough for each individual simply to be self-directed and cooperative if people are perfectionistic, because perfectionism still leads to a negative emotionality.
Fortunately, letting go of the unfulfillable desire for self-centered perfection is possible by increasing self-transcendence along with self-directedness and cooperativeness. The development of self-transcendence eliminates the outlook of separateness that leads to negative emotions and burn-out. In other words, acceptance of the imperfection of the human condition prevents burn-out and other negative emotions while promoting positive emotions and work in the service of others [11]. In terms of prevention and mental health promotion, we expect that high persistence is a potent risk factor for development of burn-out except when both Harm Avoidance and self-directedness are low. We also expect that when persistence is average or low, all three TCI character traits (i.e. self-directedness, cooperativeness and self-transcendence) are protective (resilience) factors.
We hypothesize that flame-up and burn-out may emerge from perfectionism that is poorly regulated by various combinations of low character development in different individuals (particularly low self-transcendence) or, in the absence of perfectionism, whenever character development is inadequate to cope with external and internal stressors. In individuals who have previously been responsible, conscientious and productive, it is most likely that low self-transcendence and high Persistence are associated with low positive emotions and high negative emotions, thereby reducing job satisfaction and enjoyment. So, if self-transcendence is a crucial personality dimension for regulating emotional conflicts such as those induced by perfectionism, then at an incipient stage of flame-up we expect that self-transcendence will be low and Persistence will be high. The addition of high Harm Avoidance and low self-directedness are also expected to increase risk for flame-up and burn-out. At at early stage, burn-out may be averted by psychological interventions aimed at prevention [12]. Hence, we can evaluate vulnerable populations via a person-centered diagnostic method such as the TCI. This allows us to relate two basic constructs relevant to burnout: wellbeing and the psychological climate of the work place.
In terms of comprehensive assessment, we need to search for correlations with other tools as well. One of them is the control condition - the MBI test of Maslach [1]. The other is inductive measurement of psychological climate, which should correspond to the respective constructs in TCI. We shall attempt to establish external construct validity with a specific test for the measurement of burn-out as well as with determinants of burn-out and low maturity of character (particularly self-transcendence) in the social environment. However, we should not focus only on negative measures of burn-out, but also measure wellbeing so that we may be well positioned to treat and prevent burn-out by pointing out what promotes resilience to burn-out. This implies short measures of life satisfaction (like Pavot and Diener's 5 item measure) and possibly a measure of positive and negative emotion like PANAS (20 item version).
The proposed model for person-centered assessment of vulnerability from burn out in healthcare personnel can directly impact on the management of human resources and related decision-making. Furthermore, the introduction of such positively person-centered assessments can encourage and improve public health outcomes by promoting the personal wellbeing of healthcare employees. In this context, we regard this case study as an approach to person-centered healthcare management and hence as a relevant connection between person-centered medicine and people-centered public health.
At present there is unanimity in the specialized literature about which professional groups are most likely to develop the Burn-out Syndrome within healthcare institutions. At the same time, there is no standardized way of evaluating vulnerability to such professional burn-out. The available standardized methods, such as Christina Maslach’s MBI, can only account for irreversible functional changes in the individual after they have already taken place [13]. In light of this fact, the high distress levels and common occurrence of professional burn-out within medical institutions that are funded by the national budget of Bulgaria have prompted our interest in this subject.
Given the above assumptions, our objective is to design an intervention with a new working method that can give a complex assessment of the psychological climate of healthcare organizations. It will aim at early assessment of the process, thereby helping to reduce and prevent burn-out.
According to our model, there are vulnerable groups of people for whom there is an effective way of preventing professional burn-out by psychosocial intervention. The Burn-out Syndrome is a type of professional exhaustion, which takes place in three consecutive stages [14,15] that differ in their manifestations and intensity. Therefore, monitoring of the interaction between the psychological functioning of the individuals with the organizational climate in terms of psychological and social wellbeing should occur between the first two stages of the process – flame-out (i.e. stress of futile effort) and burn-out (i.e. exhaustion and demoralization). This early period in the burning process is propitious to identify means of intervention for the sake of preservation and recovery of the psychological potential of the workers in such vulnerable groups of medical specialists. At an earlier stage, the phenomenology of professional ‘burning’ is not difficult to differentiate from the symptoms of psychoemotional stress, whereas at a later stage (described by the term “rust out”), there may be less benefit from psychological interventions as the harm is thought to be irreversible. We are choosing to focus on early intervention, but hope that late interventions might also be helpful in future work.
According to our hypothesis, the high-risk pattern that accounts for vulnerability to professional burning within particular sectors of the healthcare system has three components. It includes characteristics of the interaction between the psychological and organizational climate that is combined with the personal traits of the workers. As a result, Burn-out Syndrome has three dimensions that can be measured and which are shown in Box 1.
As is evident, our model is focused on two crucial determinants of exhaustion of professionals within the healthcare system: stressors in the psychological climate of the organization and vulnerabilities in the personal mental health of the workers. The dimensional description of the psychological climate is carried out according to the methods of Koys and De Cottis, courtesy of the authors and according to their working definition:
“The psychological climate is an empirically based, diverse, long-lasting and perceptive phenomenon that is freely shared among the members of a particular organizational department. Its main function is to regulate and direct the personal demeanor towards that type of conduct, which corresponds to the needs of the organization” [17].
In their research, the authors find more than 80 measurable characteristics of the psychological climate. They say that it is vital that we distinguish between the psychological climate of the organization and the work satisfaction of people within the organization.
Koys and De Cottis have studied some criteria that describe the psychological climate. However, these criteria evaluate the conduct of individuals, which is not part of the aspect of the organizational structure. Therefore, the authors pay no more attention to the criteria that serve as an index when forming the specific characteristics of the organizational structure. The analysis of the facts and the validation that is carried out are used as means of control and contribute to the removal of all criteria that apply to more than one sector of the organization. As a result, only 45 of the original 80 criteria were retained for describing the climate. These criteria are distributed in 8 basic categories, set out in Box 2.
Responses are rated according to a 7-class Likert scale. It is noteworthy that these measures of psychological climate can distinguish a climate of unity and connectedness among the workers, which accepts the fallibility of individuals while encouraging mutual support and interdependence and a climate of separateness which harshly demands that people strive to be error-free. The difference between a climate of unity versus a climate of separateness can be crucial as an external influence that triggers burn-out in vulnerable individuals.
The second determinant is measured by the personality profiles of individuals within the organization. Here, personality is observed along with how well a person is able to function in the teams and groups that make up the organization. Personality is studied through descriptive and causal analyses of the biological, social and psychological determinants of human behavior. One component of personality is temperament, which includes vulnerability to anxiety (i.e. high Harm Avoidance), anger and resentment (i.e. high Novelty Seeking), social rejection (i.e. high Reward Dependence) and perfectionism (i.e. high Persistence). Temperament is the emotional core of personality.
In addition, we are measuring character traits that describe a person’s goals, values and outlook on life. Hence, the TCI provides a way to distinguish whether an individual has an outlook of unity or separateness that guides their way of living. According to Cloninger’s psychobiological model of personality, individuals have an outlook of unity when they are highly developed in all three dimensions of character (i.e. self-directedness, cooperativeness and self-transcendence).
As a result, a person’s characteristic outlook can be measured with the TCI and the psychological climate of the workplace can be measured by the test of Koys and De Cottis. In this way, these two tests complement one another and may logically be combined in our assessment battery.
Cloninger’s test is based on his psychobiological theory of personality which proposes that there are four aspects of the temperament, based on four different brain systems. These are: (i) pursuit of novelty; (ii) avoidance of danger; (iii) dependence on social approval & (iv) persistence. Cloninger developed the TCI in order to study these four components. TCI actually represents a group of scales, which observe the differences among people in 7 basic dimensions that reflect the personal features of character and the temperament. Temperament is understood to be moderately stable throughout life, whereas character developed in response to individual and social influences on a person’s goals and values. The TCI has been widely translated and has been found to be useful in diverse cultures on all continents around the world [11]. It is currently standardized for the Bulgarians, so it is particularly suitable for use in Bulgaria in combination with the Maslach’s scale. The full TCI has 240 items, but there is a short form with 140 items that is often adequate for research purposes related to health psychology [3]. We have decided to employ the 5 point Likert scale 240 items TCI.
Previously, the TCI has been used mainly to perform psychological diagnostics of personality disorders and to study wellbeing in terms of health psychology. We will validate it for the first time (with the author’s cooperation) so that it can be properly used to understand the organizational psychology of the healthcare systems. We will use it for making a complex assessment of the psychological climate and wellbeing so that we will be able to recognize the symptoms of Burn-out syndrome at an early stage.
Significant levels of stress and professional burn-out have been well documented among healthcare specialists. One of the methods currently employed is Maslach’s Burnout Inventory (MBI), which consists of 22 questions and there is a 7-class scale for each one of them. Its proper application enables the analysis of the consequences of the professional burning process along with analysis of the psycho-emotional environmental effects. However, alone it may turn out to be insufficient in terms of the evaluation of numerous details and specific characteristics of every contingent studied. Therefore, we intend to combine the MBI with the test of Koys and De Cottis on psychological climate and the TCI. The TCI appears to be crucial in order to understand personal traits that explain individual differences in vulnerability to burn-out. The dimensions of the TCI have been described in detail elsewhere in relation to person-centered therapeutics [18].
Self-directedness (i.e. purposeful and resourceful) has strong positive correlations with all health indexes, including those that are connected to the mental health (subjective satisfaction), social health and physical health (in terms of health perception). Cooperativeness (i.e. empathetic and helpful) is strongly associated with social wellbeing and subjective happiness. Self-transcendence (i.e. self-forgetful, transpersonal and spiritual) is strongly related to individual differences in positive emotions regardless of the development of the other two character traits [3]. Our previous study has suggested that self-transcendence also has a strong role in reducing vulnerability to burn-out by facilitating the development of an outlook of unity and connectedness to what is beyond the individual self. Self-directedness and Cooperativeness are always crucial to a person’s capacity for working and loving, but unless self-transcendence is also developed, people often feel and act like they are separate individuals, which places a great burden on them psychologically and increases their vulnerability to burn out.
Figure 1 illustrates the outline of our study’s working hypothesis. It gives an account of the particular way the profile of personal vulnerability, the anomalies of the psychological climate and the Burn-out syndrome are interconnected [12].
Figure 1
Figure 1
The relationship between personal vulnerability, anomalies of the psychological climate and burn-out.
We expect that the earliest and the strongest phenomenology of professional burn-out is observed as poor personal performance. However, as noted earlier, healthcare workers who are at risk for burn-out are likely to be perfectionists who are initially hard-working overachievers. In other words, burn-out may be a way for perfectionists to escape from trying to do the impossible. No one can be perfect, so what does a person do when they desire to be the best and perfect at everything they do? What happens when the demands of their work environment demand that they make no mistakes? The inevitable result is stress, guilt, shame, pain and other features of burn-out.
Such weak performance in terms of insufficient personal achievements and self-perfection is likely to be associated with a state of low self-directedness in TCI in people who were previously more self-directed. At the same time, decreased interest in work and loss of positive emotions are also part of the Burn-out Syndrome. The latter is expected to correlate with low self-transcendence as measured by the TCI. The Burn-out Syndrome is also connected to the feelings of social alienation and lack of support. These feelings are likely to be associated with low levels of Cooperativeness as measured by the TCI.
The combination of high Persistence, high Harm Avoidance and weak character development are suggested to increase personal vulnerability to the Burn-out Syndrome. But this personality profile is not sufficient to induce Burn-out on its own. According to our diathesis-stress model, if professional burning is to take place, the vulnerable person develops difficulties in response to a provocative psychological climate. Therefore, the design of our test battery includes the test of Koys and DeCotiis, too. Personal vulnerability interacts reciprocally with the psychological climate of the organization to induce the Burn-out Syndrome. Thus, they create a vicious cycle of cause and effect interaction. We expect that identifying these causal phenomena early, rather than focusing on later occurring symptoms, will enable us to introduce adequate schemes aiming at the prevention of professional burn-out among healthcare specialists.
Box 1 Three measureable dimensions of burn-out
  • Inductive measurements of the interaction between the psychological and organizational climate [15,16]
  • Lower levels of self-actualization that accounts for stronger personal vulnerability to professional burning
  • Standardized assessment of burn-out as a method for internal validation of the burn-out construct
Box 2 The 8 basic categories derived from 45 of the original 80 criteria describing the psychological climate
  • Independence – That is when a worker decides for himself about the work procedures, aims and priorities.
  • Unity – The perception of sharing and thoroughness about the organization, which includes the giving of material help to those who are in need.
  • Confidence – That is when the worker is able to talk freely to those who are at higher organizational level about personal problems and topics only in case the integrity of the process of communication is not harmed.
  • Pressure – Taking into account the time in which the obligations must be fulfilled as well as the standard required.
  • Support – Tolerance from those who are with higher position. That includes the act of giving workers the opportunity to learn from experience without fear or repression.
  • Recognition – Appreciation of the contribution of the members of the organization.
  • Honesty – The acknowledgement that the rules of the organizations are equally applicable to everyone and are undisputable.
  • Innovation – The belief that change and creativity should be promoted, which includes taking risks in some spheres, where the workers have little or no experience at all.
Footnotes
FROM THE FOURTH GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE: CONTRIBUTIONS TO THE ADVANCEMENT OF PERSON-CENTERED CARE
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