DYNAMICS OF BURNOUT

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CHAPTER 3: COACHING INTERVENTION FOR BURNOUT

Introduction

This chapter highlights literature on general recommended interventions for burnout and emphasises the lack of properly designed scientific based interventions for burnout in the various populations including Generation Y medical doctors working in the South African public sector. It further examines the limited empirical evidence regarding the effectiveness of the generally available recommended burnout management, treatment and prevention interventions. The chapter concludes by giving the foundation of the group coaching intervention for burnout used amongst Generation Y medical doctors in the current study and provides the actual group coaching intervention for burnout used in the study.

Conceptual Foundation of Burnout Interventions

This study contextualised burnout as described by Maslach and Jackson (1981) and the proposed process model by Leiter and Maslach (1988). Burnout according to Maslach and Jackson (1981, 1986) is a three-dimensional construct that consists of three core components and manifestations. The three constructs are increased emotional exhaustion, depersonalisation or cynicism, which implies a negative attitude towards several matters, especially clients and, lastly, increased tendency for negative evaluation of self as lacking professional accomplishment or competence (Maslach & Jackson 1981, 1986). Leiter and Maslach (1988) proposed a process model of burnout, which begins with emotional exhaustion, often leads to depersonalisation and subsequently to reduced personal accomplishment.
Burnout is linked to job-related stress and can be reinforced by the workplace. It regularly overlaps with psychological disorders and the stress experience but is independent of both. It is seen as a process that develops over time (Schaufeli, W.B. & Enzmann, 1998). Burnout is often linked to certain risk factors such as psychosocial work environment, sociodemographic characteristics of employees, social relationships, and lifestyles outside work and personality aspects (Milićević-Kalašić, 2013). Burnout affects at a personal, group, organisational and societal level. Burnout is linked to dysfunctional coping (Costa et al., 1996). The subjective perception of stress depends on appraisals, which are not necessarily made consciously by the person in a stressful situation (Lazarus, 1974).
Very limited empirical studies have been done on burnout interventions and there seems to be no specific treatment for burnout (Hemmeter, 2013; Sorenson et al., 2016; Werneburg et al., 2018), particularly for Generation Y medical doctors employed in the South African public sector. Despite increasing incidence of burnout, there are few scientific studies regarding the value of intervention and limited information regarding how interventions actually work (Haiten et al., 2007; Le Blanc & Schaufeli, 2008; Werneburg et al., 2018). Maslach et al. (2001) stated that there has been a great need for effective interventions for burnout that focus on treating burnout after, or preventing it before it occurs, but there has been very limited systemic research (Gregory et al., 2018).
There is no formal diagnosis of burnout due to the lack of symptoms that could fulfil criteria the warning signs or presentations of burnout can be treated or coached, prevented or managed before they develop into secondary manifestations of physical or psychological disorders (Hemmeter, 2013; Panagioti et al., 2016). Symptom manifestation of burnout should be treated and many studies highlight the need for intervention studies (Marine, Ruotsalainen, Serra, & Verbeek, 2006; Lemaire & Wallace, 2017; Panagioti et al., 2016).
A systematic review was done that categorised intervention strategies for burnout into person-directed and work-directed strategies (Marine et al., 2006). Person-directed intervention strategies include cognitive behaviour therapy, relaxation and massages. Work-directed intervention strategies include attitude change and communication, support from colleagues, changes within the organisation and, lastly, participatory problem-solving and decision-making (Lemaire & Wallace, 2017; Marine et al., 2006; Panagioti et al., 2016; Sorenson et al., 2016; Werneburg et al., 2018). According to the aforementioned researchers, there has been limited evidence to support the effectiveness of either approach to reduce burnout in healthcare workers. However, they concluded that such interventions could lead to benefits that might be visible from up to six months to a number of years. The findings from the review further led to the conclusion that a thorough stress management programme with supporter sessions over a two-year period might possibly produce better outcomes for treating burnout in employees (Marine et al., 2006).
General suggestions for burnout intervention in literature included a need to focus on a combination of self, organisational and situational factors (Felton, 1998; Lemaire & Wallace, 2017; Panagioti et al., 2016; Sorenson et al., 2016; Werneburg et al., 2018). Models of coping with burnout focus on individual and outside influences such as organisational, environmental, familial and societal factors (Cooper, Dewe, & O’Driscoll, 2001; Panagioti et al., 2016).
Prevention and intervention strategies could be individual or group directed, or focused on the organisation, or a combination of both (Lemaire & Wallace, 2017; Panagioti et al., 2016; Sorenson et al., 2016; Walter et al., 2013; Werneburg et al., 2018). The prevention, management and intervention for burnout that comprise parallel efforts could include, for example, presenting individual worker sessions, having group meetings, ensuring better top-down communication, recognising individual worth, redesigning jobs, introducing flexible hours, giving full orientation to job requirements, making employee assistance programmes available, and/or mentoring of employees in different jobs (Felton, 1998; Kumar & Mellsop, 2013; Panagioti et al., 2016). Individual interventions and workplace-based interventions have both shown therapeutic and preventative results (Kumar & Mellsop, 2013; Panagioti et al., 2016).
The job environment and stressors need to be included in all intervention and prevention programmes for burnout (Lemaire & Wallace, 2017; Panagioti et al., 2016; Walter et al., 2013). The intervention for burnout ideally should be interdisciplinary to involve medicine, psychological and societal expertise that influence the job environment (Weber & Jaeckel-Reinhard, 2000). To ensure such holistic interventions, there has been a suggestion that burnout centres similar to cancer centres should be initiated where there are multi-disciplinary integrative interventions (coaching, medical, psycho-educational etc.) that aim to prevent, manage, and treat burnout (Milićević-Kalašić, 2013).

Coaching Intervention for Burnout Amongst Generation Y Medical Doctors

This section introduces the theoretical foundation and the actual coaching intervention for burnout that was used in the study for Generation Y medical doctors working in the South African public health sector. The study was done in three phases over a seven-month period. The focus of the overall group coaching intervention was at the individual level. Phase I was the pre-coaching intervention for burnout amongst Generation Y medical doctors; Phase II was the coaching intervention for burnout amongst Generation Y medical doctors; Phase III was the post-coaching intervention for burnout amongst Generation Y medical doctors.
Phase I of the study involved getting ethical approval from the academic institution and the hospital’s ethics committee for approved access. The study was classified as a psychological risk at a low level (See approval letters in annexure A). A literature review and panel discussion with four clinical psychologist specialists in burnout were done to finalise the group coaching intervention for burnout amongst Generation Y medical doctors.
Additionally, it entailed selecting 16 participants for Phase II and Phase III using three criteria. The fourth and final criterion of participation involved using an objective tool, the MBI-GS, in Phase I. Phase II was the signing of the informed consent and actual exposure to the group coaching intervention. This was meant to be done in three focus group sessions. However, due to various challenges that unfolded as described in Chapter 5, the group coaching intervention was adjusted after a discussion with my supervisor to one focus group session of 4.5 hours. Initially 16 participants divided into two groups of eight were envisaged; but 18 were interested and were invited to participate. Only ten of the 18 attended the session.
Phase III targeted to elicit the participants’ descriptions of their experiences after the group coaching intervention for burnout and to evaluate the overall effect of the coaching intervention. This was done in a focus group session a month after the intervention. The session was attended by six participants. Their descriptions of their experiences and their objective measures of burnout after the intervention were used as empirical evidence for the coaching intervention for burnout amongst Generation Y medical doctors.

Theoretical foundation for the coaching intervention

Person-centred coaching psychology

Person-centred coaching psychology was regarded as relevant to form the foundation of the group coaching intervention process for burnout amongst Generation Y medical doctors. There are deliberations around whether coaching psychology should adopt or if it is fully within the meta-theoretical perspective of the person-centred theory as opposed to the medical model (Joseph, 2006; Van Zyl, Stander, & Odendaal, 2016). There is agreement that coaching is about facilitating well-being and optimal functioning (Joseph, 2006), which is closely linked to Rogers’ (1959, 1963) person-centred approach that is not about fixing dysfunction and adopting a diagnostic stance such as the medical model. The focus is more on facilitating clients towards more optimal functioning by using the environment where people are likely to realise their inherent potential (Rogers 1959, 1963). It advocates for using certain skills to achieve that environment. The environment according to Rogers (1959, 1963) has to have three elements to facilitate the client towards more optimal functioning: congruence or genuineness; unconditional positive regard and acceptance; lastly accurate empathetic understanding.
Some Rogerian attitudes, skills and behaviours were applied in the burnout coaching intervention to establish rapport with the group of Generation Y medical doctors and to further facilitate an environment where the participants can begin to gain skills; hopefully towards optimal functioning (Rogers, 1959, 1963). I as the coach in the group coaching intervention used the following combination of Rogerian attitudes, skills and behaviours in no order of significance (Rogers, 1959, 1963):
Using a stop-and-pay attention skill, which is applied to ensure that a comfortable, non-threatening atmosphere is created for interaction using physical listening, facial expressions, and tone of voice.
Asking appropriate questions, which are used to indicate that the coach is following the topic and is showing interest.
Restating, which means that the listener repeats or summarises what was said to clarify, demonstrate interest, and grasp what the participants say correctly.
Paraphrasing, which is encapsulating what was said to ensure dominant features are depicted and explored.
The following skills were also used (Rogers, 1959, 1963): reflection of feelings and listening for feelings as they speak even when the participants do not actually verbalise any emotion (discretion is key to ensure it is not focused on emotions); summarising, which implies putting together several statements into a theme and confirming with the speaker if the meaning is accurate.
Lastly, the following Rogerian attitudes, skills and behaviours (Rogers, 1959, 1963) were combined: sharing, which is important to indicate reactions appropriately, discretion is taken about what is said and how it is said in a way that supports the speaker and moves on; acknowledging of differences as there were areas of differences and withholding of judgement while listening to allow speakers to make their points while listening with an open mind. A response could be made after one has thought about what to say.
Rogerian coaches should aim to enhance an environment of congruence or genuineness; unconditional positive regard and acceptance; and accurate empathetic understanding while at the same time facilitating clients to learn and apply the same to their personal lives (Joseph, 2006). This approach to coaching was deemed relevant to the current study that aimed to explore a group coaching intervention for burnout amongst Generation Y medical doctors working in the public sector. They were given the opportunity to describe their experiences of the intervention while their objective levels of burnout before and after the intervention were measured.

Stress intervention models

Certain practices from two stress intervention models were incorporated into the group coaching intervention. These models are the Critical Incident Stress Debriefing (CISD) (Everly & Mitchell, 2010; Mitchell & Everly, 1996) and the Multiple Stressor Debriefing (MSD) models (Armstrong, Lund, McWright, & Tichenor, 1995). I adapted some aspects of these two models using other suggested intervention strategies for burnout in literature. Incorporating the two stress intervention models in the following sections seemed appropriate to promote validity of the group coaching intervention.
i. Critical Incident Stress Debriefing model
CISD is a structured group discussion designed to alleviate symptoms, assess follow-up requirements, and offer coping strategies (Davis, 2013; Everly & Mitchell, 2010). CISD has been implemented in various contexts and was beneficial in certain contexts. It is evolving as more focus is placed on multi-layered approaches as the need for psychological interventions is growing rapidly due to increasing pandemics, trauma, and other disasters (MacDonald, 2003). CISD has been applied to hospital staff by researchers such as Caine and Ter-Bagasarian (2003); Narayanasamy; Owens (2001) and Davis (2013). It has been used by Moola, Ehlers & Hattingh (2008); Pillay (2008) and Kusel (2016) in a South African context.
A critical incident is defined in the CISD model as an incident that happens outside the common experiences of a person, thereby challenging their ability to cope (Everly & Mitchell, 2000). This incident could lead to a crisis by overwhelming psychological defences and coping mechanisms (Everly & Mitchell, 2000). The Generation Y medical doctors are exposed to trauma and cases in difficult environments, which could be described as critical incidents. These incidents are likely to overwhelm them and cause traumatic and crisis reactions such as burnout (Liebenberg et al., 2018). The cases include incidents such deaths of patients, trauma cases, and diseases (Discovery Health; 2018; Hlatshaneni, 2019). The CISD model explains a crisis as a response to a situation where psychological balance is disrupted, usual coping mechanisms fail, and there is an indication of functional distress or impairment (Everly & Mitchell, 2000). Burnout based on this definition could be seen as some form of crisis that often leads to maladapted reactions that require some form of intervention (Discovery Health; 2018; Hlatshaneni, 2019; Liebenberg et al., 2018).
CISD is a short-term intervention where client’s sense of control is overwhelmed and could benefit from a brief, solution-focused intervention that may alleviate the increasing experience of distress and traumatic symptoms (Everly & Mitchell, 2010; Mitchell & Everly, 1996). This intervention is not psychotherapy but aims to alleviate the intensity of the challenge as well as acute signs of distress and dysfunction-reducing risk factors. CISD restores functioning through a higher level of care if needed by using psychological change mechanisms such as reframing, catharsis processing, cognitions modelling, and group dynamics (Everly & Mitchell, 2000).
CISD is a seven-stage solution that is a purposeful cognitive intervention with the following phases: introductory; fact exploration; cognitive or thought; reaction; symptom discussion; teaching and re-entry with the focus on the importance of coping strategies and recommendations for long-term counselling (Everly, 1995).
CISD works through early intervention, permits cognitive processing that precedes increased experience of symptoms, and aims to express emotions related to the trauma. Reformation of memories can happen by sharing verbally with others, which creates a sense of hope that they can overcome and shows how to overcome. It lastly emphasises cognitive affective integration that initiates holistic recovery (Everly, 1995). The group process in this type of intervention allows for dynamics such as cohesion, modelling, hope for self, demystification, peer support, and sense of care (Yalom, 1995), which are essential in certain health professions (Everly, 1995).
ii. Multiple Stressor Debriefing intervention
The second stress intervention model is the MSD that aims to discuss challenges at work in a group format (Armstrong et al., 1995). More research regarding the effectiveness of MSD is still required. MSDs are encouraged for all, including those with less prominent stress symptoms (Armstrong et al., 1995). It focuses on psycho-education in four phases: disclosure of events, feelings and reactions, coping strategies, and termination (Armstrong, O’Callahan, & Marmar, 1991; Armstrong et al., 1995). It has been researched and applied in the South African context (van Den Heever, 2013)
The participants in the MSD model are encouraged to share a number of experiences while the facilitator aims to support them while they process traumatic/stressful events, which leads to resolution and completion of the experience (Armstrong et al., 1995). The model does not imply that those exposed would finish processing their experiences immediately at the completion of the group sessions, but rather that it promotes ongoing processing even after the sessions (Armstrong et al., 1995). The authors further stated that MSD aims to normalise stress reactions and facilitates education on coping strategies. It aims to assist with transitioning to a home environment subsequent to a traumatic occurrence.
Armstrong et al. (1995) mentioned that debriefing is not psychotherapy nor an analysis of historical events in the initial phase, but rather a reflection of negative and positive aspects of a job. Precise instructions for participation need to be stated so expectations are clear (Armstrong et al., 1995). The members describe recent occurrences in their stressful or traumatic work. The second phase follows and focuses on exploring and describing feelings, thoughts, and reactions of negative and positive events written in the first phase (Armstrong et al., 1995).
Beneficial coping strategies and potential stress responses are discussed in the third phase and previously used coping strategies are identified (Armstrong et al., 1995). Facilitators assess potential maladaptive coping mechanisms such as self-medication using substances and reckless impulsive behaviours (Daniels & Scurfield, 1994). The last phase involves reflection of positives and lessons learned. This model could be used during an actual disaster experience (Armstrong et al., 1991).
iii. Adopted assumptions for current burnout coaching intervention
Burnout is ongoing and is not necessarily caused by one specific incidence or crisis; it is usually a consequence of overwhelming events at work that lead to occupational stress, which subsequently leads to burnout (Maslach & Leiter, 1997). I adapted some CISD techniques such as the suggested intervention process and the small homogeneous group. Further, as in the case of the CISD model, I structured the group coaching intervention for burnout amongst Generation Y medical doctors not as psychotherapy but more as psycho-educational therapy (Mitchell & Everly, 1996). The initial group coaching intervention was structured as 3 Phases. Phase I was the Pre- Coaching Intervention amongst Generation Y medical doctors and focused on finalization of the coaching intervention to be used in the study and selection of participants who met the final criteria being high levels of burnout based on the completed Maslach Burnout Inventory (MBI-GS).
Phase II was the Coaching Intervention for burnout amongst generation Y medical doctors. It initially comprised of the group coaching intervention process in three sessions (Session 2 to Session 4) for the selected potential 18 participants (in two groups of nine selected from Phase I). The identified Generation Y medical doctors who met the criteria were exposed to the burnout coaching intervention in this phase. Due to the process that unfolded as discussed in Chapter 5, Phase II sessions had to be adjusted, which changed from three focus group sessions to a single session of 4.5 hours with one group of ten participants. Phase III was Post Coaching Intervention Phase 6 months’ post Phase II. It comprised of one focus group session and completion of the MBI. Additionally, reflection on the experiences of the group coaching intervention for burnout amongst generation Y medical doctors.
The CISD and MSD processes are suggested for traumatic events where coping methods are overwhelmed and there is an exhibition of considerable distress, impairment or dysfunction (Mitchell & Everly, 1996). Burnout is seen as dysfunctional coping mechanism where there is distress, dysfunction or impairment due to occupational stress caused by numerous events.
I incorporated certain practices from the two stress intervention models, namely, CISD (Everly & Mitchell, 2010; Mitchell & Everly, 1996) and MSD (Armstrong et al., 1995), into the group coaching intervention to promote validity in the process. I also incorporated other suggested individual based intervention strategies for burnout in literature such as those suggested to build personal resilience (Discovery Health, 2018). These include exercises, rest, healthy nutrition, mindfulness and formation of new enjoyable hobbies (Discovery Health, 2018).
From the CISD model, I viewed the cases of Generation Y medical doctors in their difficult working environments as critical incidents that are likely to overwhelm them and cause traumatic and crisis reactions such as burnout (Everly & Mitchell, 2010). Burnout based on this definition could be seen as some form of crisis that often lead to maladapted reactions that require some form of intervention (Everly & Mitchell, 2010). CISD is a short-term solution that is focused on cognitive intervention (Everly & Mitchell, 2010) and so was the group coaching intervention for burnout amongst Generation Y medical doctors used in the current study.
The MSD model practices were also applied. For example, participants in the MSD model are encouraged to share their experiences and integrate them into their lives while the facilitator aims to assist them in processing the experiences, leading to resolution and completion of the experience (Armstrong et al., 1995). This was also the aim of the group coaching intervention for burnout amongst Generation Y medical doctors.
The MSD model does not conclude that members stop processing their experiences immediately at the end of the group sessions and therefore promotes ongoing processing even after the sessions (Armstrong et al., 1995). I also encouraged this as the coach in the coaching intervention for burnout amongst Generation Y medical doctors.
Some of CISD’s seven stages of intervention (Everly, 1995) as well as some of the four phases of MSD’s psycho-education (Armstrong et al., 1995) can be seen within the group coaching intervention.

TABLE OF CONTENTS
DECLARATION
ABSTRACT
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
LIST OF TABLES
ABBREVIATIONS
CHAPTER 1: SCIENTIFIC ORIENTATION TO THE STUDY
1.1 Introduction
1.2 Background and Motivation for the Research
1.3 Problem Statement
1.4 Aims of the Research Project
1.5 My Evolving Interest in the Research Project
1.6 Paradigm Perspective
1.7 Research Design
1.8 Findings
1.9 Conclusion
1.10 Contribution of the Study
1.11 Limitations
1.12 Recommendations for Future Research
1.13 Chapter Division
1.14 Chapter Summary
CHAPTER 2: DYNAMICS OF BURNOUT
2.1 Introduction
2.2 Conceptual Foundations of Burnout
2.3 Etiology of Burnout
2.4 Biographical Variables as Risk Factors for Burnout
2.5 Implications for Burnout Amongst Generation Y Medical Doctors
2.6 Burnout Manifestations
2.7 Critical Review of Burnout
2.8 Relevance of Burnout Interventions
2.9 Theoretical Integration
2.10 Chapter Summary
CHAPTER 3: COACHING INTERVENTION FOR BURNOUT
3.1 Introduction
3.2 Conceptual Foundation of Burnout Interventions
3.3 Coaching Intervention for Burnout Amongst Generation Y Medical Doctors
3.4 Conclusion
3.5 Chapter Summary
CHAPTER 4: RESEARCH METHODOLOGY AND DESIGN
4.1 Introduction
4.2 Research Approach
4.3 Research Strategy
4.4 Research Method
4.5 Strategies Employed to Ensure Quality Data
4.6 Reporting
4.7 Chapter Summary
CHAPTER 5: RESEARCH FINDINGS
5.1 Introduction
5.2 Coaching Intervention
5.3 Themes That Emerged About Burnout
5.4 Themes Relating to the Coaching Intervention
5.5 Integrated Discussion
5.6 Chapter Summary
CHAPTER 6: CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS
6.1 Introduction
6.2 Conclusions
6.3 Limitations
6.4 Recommendations
6.5 Chapter Summary
REFERENCE LIST
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