STAFF COPING AND BURNOUT IN INTELLECTUAL DISABILITY SERVICES

Burnout can be described as a prolonged response to chronic interpersonal and emotional stressors in the work environment. Staff burnout is considered an occupational hazard in people.oriented professions and it is commonly reported amongst frontline staff working in intellectual disability services. In this article Sile Murphy and Claude Watters provide an overview of measures to prevent staff burnout, and potential interventions for staff within intellectual disability services who are experiencing burnout. The role of staff attributions within the context of challenging behaviour will be examined.

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The main features of burnout are an overwhelming exhaustion, feelings of cynicism, frustration, anger, failure and ineffectiveness. Burnout negatively affects both personal and social functioning. It is associated with absenteeism, intention to leave the job and actual employee turnover- Burnout results in reduced employee satisfaction and reduced quality of care for service users. Rose, Jones, and Fletcher (1998) reported that staff exhibiting higher levels of stress have been observed to undertake fewer positive interactions with service users.

Measuring and monitoring staff burnout

The predominant measure of burnout in research and clinical diagnosis is the Maslach Burnout Inventory Human Services Survey (MBI.HSS; Maslach and Jackson 1981.) This measure assesses burnout through three dimensions: emotional exhaustion, depersonalisation and reduced personal accomplishment.
Emotional exhaustion represents the basic stress dimension of burnout. Features associated with this dimension are emotional over-extension, negative affect, lack of energy and a perception that one’s emotional resources have been depleted. Exhaustion is not just an experience or emotion; it may lead people to distance themselves both cognitively and emotionally from their work. It is the most extensively reported and researched aspect of burnout. Emotional exhaustion generally precipitates the two other documented dimensions of burnout— depersonalisation and reduced personal achievement. As such, it is useful for services to monitor and recognise the earliest signs of emotional exhaustion in order to intervene to prevent burnout.

Depersonalisation represents the interpersonal dimension of burnout. It is self-protective initially—an attempt by individuals to cope with work stress by distancing themselves from others. It manifests itself in a callous or uncaring response that often includes a loss of idealism. This distancing is accomplished by developing a cynical or indifferent attitude. Depersonalisation develops in reaction to emotional exhaustion.

Reduced personal accomplishment denotes the self-evaluation dimension of burnout. It is characterised by feelings of reduced productivity and competence. This lowered sense of self-efficacy has been associated with depression and an inability to cope with the demands of the job (Maslach and Goldberg 2001).
The Conservation of Resources model (Hobfall and Shirom 2000) provides a means for understanding the process through which burnout occurs. This theory posits that individuals endeavour to obtain, retain and protect things they value (termed ‘resources’). These include material resources such as money, personal resources such as self-esteem, condition resources such as social support, and status and energy resources such as credit, knowledge. Stress arises from actual or potential loss of resources. Resources are linked, thus loss of one resource leads to further loss. A loss of confidence in managing stressful situations at work may impact on self-esteem, which may impact on reputation or perceived status as an employee. This cycle is referred to as a loss cycle and it helps to explain the links between the three dimensions of burnout posited by Maslach. The opposite also holds—an increase in resources leads to a gain cycle; mastery of a task at work leads to increase in self esteem, feelings of accomplishment and status as a valued employee. This theory suggests that services should be actively working to promote resource gain to prevent the process of burnout.

Maslach advocated examining burnout in the person-organisation context. Maslach identifies six areas where a person.job mismatch can become apparent:
1) Work overload—the most obvious, is where job demands surpass human capabilities
2) Lack of control—employees do not have scope to innovate, customise or improve. This results in lowering of self-efficacy or not feeling responsible for outcomes in work
3) Insufficient rewards—deficiencies of either external (salary) or internal (sense of accomplishment) on the job
4) Breakdown of community—people getting isolated in work, or unresolved conflict with other people in employment
5) Absence of fairness—inequity in pay or work load or promotions handled inappropriately
6)  Value conflict— people feeling constrained to do things they feel are unethical or that go against their own set of values.

The most frequently reported work stressor among disability support staff is challenging behaviour among service users (Jenkins et al. 1997, Hastings 2002). Emerson et al. (1987) defined challenging behaviour as ‘culturally abnormal behaviour of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities’. Although challenging behaviour is a known work stressor, the relationship between challenging behaviour and burnout is unclear. Some studies indicate a relationship (e.g. Mills and Rose 2011), and some find no relationship (e.g. Mutkins, Brown and Thorsteinsson 2011). There is some research that suggests that it is not the level of the challenging behaviour which impacts on staff stress, but the way that such behaviour is viewed by staff (Phillips and Rose 2012).

Dilworth, Philips, Rose and Factors (2011) reported that staff considered physically aggressive behaviours as being more under the control of the individual than self-injurious behaviour; thus physically aggressive behaviours were associated with more negative emotions experienced by staff.

These results point to a role for staff training with regard to challenging behaviour. Psycho-education regarding the function of the behaviour may impact on staff attributions and may help reduce negative emotions experienced by staff.

Howard, Rose and Levenson (2009) compared groups of staff who worked in a direct supportive capacity in medium.secure units and community settings with adults with intellectual disabilities. All staff in the medium-secure setting received training in managing aggressive behaviours, as opposed to only eight staff in the community setting. Although staff in the medium.secure setting were exposed to considerably more incidents of challenging behaviour, they reported lower levels of fear and higher levels of self-efficacy than community staff. A similar finding from Chung and Corbett (1998) was that staff working with people with intellectual disabilities reported lack of training as a cause of stress.

Other forms of training such as emotion-focused interventions have also demonstrated some beneficial results. There is some evidence reported for the efficacy of interventions based on cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT) and mindfulness approaches to enhance staff coping responses and preventing burnout. CBT is a Problem-focused coping strategy that addresses dysfunctional emotions, behaviours and cognitions through goal.orientated, systematic processes. Problem-focused strategies identify and alleviate the stressors giving rise to the strain. CBT attempts to teach people to better control their thoughts and feelings. Gardner et al. (2005) found that CBT and a behavioural coping model were shown to be effective in reducing work related stress.

Acceptance and commitment therapy (ACT) is an emotion.focused coping strategy that targets undesirable thoughts and emotions aroused by work stressors. It encourages people to live in accordance with their values and to contact the present moment with openness and acceptance. ACT attempts to teach people to notice and accept unpleasant or difficult thoughts and feelings without trying to change them.

Noone and Hastings (2010) reported some positive findings through their PACT (Promotion of Acceptance in Carers and Teachers) workshop. The one.and.a.half day PACT workshop is based on the core principles of acceptance and commitment therapy. Thirty-four staff were provided with information on stress and well-being before and after their PACT workshops.

A control group of six staff also completed the measures over a six.week period. Two.thirds of participants had improved well-being scores, as measured by the General Health Questionnaire (GHQ.12). Staff perceptions of work stressors (measured by the Staff Stressor Questionnaire (SSQ)) did not lower significantly over the same time period. These results suggest that the ACT strategies did not have a direct impact on levels of work stress, but rather that they influenced the manner in which individuals coped with this stress.

Singh and colleagues have developed a mindfulness skills.training programme for staff, incorporating the use of meditation exercises. Mindfulness approaches involve a non-judgemental awareness of the present moment (Kabat.Zinn 2003). Benefits reported include a reduction in use of physical restraints and medications (Singh et al. 2009), levels of aggression (Singh et al. 2006) and increased levels of happiness among service users with profound multiple disabilities (Singh et al. 2004).

This brief review has discussed the risk of staff burnout amongst frontline workers who provide supports to individuals with intellectual disabilities, particularly amongst staff supporting individuals with challenging behaviour. We have described ways of measuring and preventing staff burnout by providing positive work environments with cognisance taken of the person-job match. Finally, we have presented the findings of promising research on the provision of staff training and support using mindfulness, cognitive behavioural therapy and acceptance and commitment therapy principles that may offer means of improving staff well-being and the quality of care received by service users.

Sile Murphy is a psychologist in clinical training with the National University of Ireland, Galway. Sile completed her intellectual disability placement with the Muiriosa Foundation at Moore Abbey in 2012.
Claude Watters studied psychology in Trinity College Dublin and graduated in 2011. Claude has been working in a voluntary capacity with the clinical psychology team at the Muiriosa Foundation, Moore Abbey since 2011.

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