Patient dynamics, staff burnout, and consultation-liaison psychiatry.

Many factors contribute to hospital staff burnout. One recent development is the increasing severity of illness and consequent high intensity of services required to treat patients under the prospective payment system. Aggressive case management diverts from hospital admission any but the sickest patients. Associated with increasing severity of illness is an emotionally disturbed patient population for whom acute psychiatric admission is inappropriate. This includes large numbers of chemically dependent individuals with severe personality disorders. Such individuals, frequently exhibiting disruptive behavior, [1] place a strain on staff-patient relations that often results in patient advocacy complaints and lawsuits.

Consultation-liaison psychiatry, a subspecialty that deals with both patient and staff issues, has existed since the post-World War II era, when it became apparent that medical care must be provided to the whole patient, not just an internal organ. Research in community psychiatry around the same time demonstrated that the therapeutic milieu, including the behavior and attitudes of staff, has a profound impact on patients and staff. [2,3] The consultation-liaison psychiatrist is generally a full-time, hospital-based professional who interfaces between the department of psychiatry and other hospital departments and should report to either the hospital vice president of clinical affairs or the chairman of the department of psychiatry. One of the traditional tasks of consultation-liaison psychiatry has been to help staff care more effectively for difficult patients. Experience suggests that this reduces staff stress and, by improving the staff's interaction with patients, may prevent potential legal complications.

The consultation-liaison psychiatry literature is replete with examples of how psychiatrists assist professional staff in coping. Kirstein [4] describes an educational program that assisted hospital employees in dealing with stress, a key ingredient of which was an attempt to deal with morale issues among the hospital staff. Krueger [5] describes how a psychiatrist might go about helping a medical student deal with a serious loss, namely the suicide of a patient. In a paper dealing with nurses' group process meetings. Mohl [6] writes about first-hand experience with how nurses can be helped to recognize covert group norms that affect the therapeutic milieu on medical/surgical units in order to deal effectively with chronic conflict, poor communication, and turnover among staff and to be able to emotionally let go of patients. He describes the chronic anger, helplessness, and poor nurse retention in such environments and the resistance encountered by the psychiatrist who tried to help.

From a different viewpoint comes an article by Blix and Brack [7] that discusses the role of the consultation-liaison psychiatrist in helping pediatric nursing staff deal with the stress of recognizing that they had failed to identify a parent's dangerously pathological behavior toward her child because the staff had liked her too much. The issue here is that staff members become emotionally over-involved with patients (and, in this case, parents), leading to disappointment, frustration, stress, and, ultimately, burnout. A similar type of problem and intervention is described in a paper by Billowitz and Schubert [8] in which a burn surgeon's reaction to a patient led to emotional difficulties. Weiner et al. [9] point out that the pressure for beds places tremendous stress upon staff and that an important role fulfilled by the consultation-liaison service is to assist in transferring nonacute patients to more appropriate settings.

Definition and Approach o

Consultation-Liaison Psychiatry

Almost all general psychiatrists perform consultations to assist other physicians in managing patients who might have emotional problems. These "patient-oriented" consultations are generally reimbursed by third-party payers. There is significant evidence that consultations decrease the length of stay of medically ill patients. [10-12] Consultation-liaison psychiatrists offer additional services, however, that are not usually reimbursed by insurers but that create indirect savings that are worth many times a single consultation fee. Liaison work with staff enables the consultation-liaison psychiatrist to contribute to the patients's care ("patient-oriented" consultation) or to facilitate the staff's ability to cope with system problems ("staff-oriented" consultation). Consultation-liaison psychiatry is not just a "high-tech" service for university hospital settings but is rapidly being added to the administrative armamentarium of community hospitals all over the United States.

Definition of Burnout

Burnout is the result of severe, protracted stress for which the individual's usual coping skills have become ineffective. It includes, in varying proportions, such symptoms as depression, anxiety, apathy, fatigue, anger, inefficiency, difficulty concentrating, cynicism, impoverished interpersonal relationships, alcohol and substance abuse, physical symptoms and illness, absenteeism, and high staff turnover. [13,14] In a general hospital in which there is no ongoing program to reduce staff stress and burnout, financial incentives are often ineffective in promoting staff retention. [15] Staff members who remain are often apathetic, angry, and inef-ficient and create many hidden costs for the hospital, such as absenteeism and turnover. When angry staff members relate unprofessionally to patients, patient advocacy and legal costs may be incurred.

Patient Dynamics and Staff Burnout

Many "normal" individuals regress during serious illness. Often, unable to cope with their loved ones' illnesses, patients' families regress as well. When patients and family members regress, they become clinging, demanding, depressive, and/or abusive to staff. These individuals use "primitive" or "immature" defense (coping) mechanisms. While these behaviors are extremely troublesome to staff, the patients exhibiting them are not usually fully aware of the reasons for their own behavior. Examples include manipulation, splitting (e.g., pitting one staff member or shift against another), projecting (e.g., the patient feels helpless and counterattacks by blaming staff for his or her condition), devaluing (severely criticizing staff in an unreasonable manner), and idealizing (overvaluing certain staff members to an unreasonable degree).

Projective identification is a defense whereby the patient projects bad internal feelings onto the staff, and staff members, failing to recognize the patient's unconscious dynamics, react in such a manner that they unwittingly feed into the patient's bad internal feelings. By overvaluing certain staff members, the patient amasses allies to pit against the devalued staff. Thus, different shifts may come into conflict over how to manage the patient, e.g. one shift feeling that the patient is helpless and needs much support and another shift feeling that the patient is manipulative and needs limit setting. Frequently, manipulative patients will pit unsuspecting family members against staff or hire attorneys with whom to torment the staff. All this is extremely stressful for staff members who must spend nearly their entire shifts working with these patients. Wurzberger and Levy [16] describe how disruptive to a unit a "hateful" patient can be and show how psychiatrists can work with staff members to help them cope. Gabbard [17] describes in depth how one might conceptualize the behavior of such patients, and how it may affect hospital staff, and general principles of patient management.

Role of the Consultant-Liaison

Psychiatrist

While the consultation-liaison psychiatrist provides patient care, he or she can also serve a variety of either functions. For example, he or she can provide undergraduate and resident psychiatrict education (consultation-liaison psychiatrists are particularly experienced in the interface between medicine and psychiatry), consult to administration regarding psychiatric aspects of overall patient care, serve as a liaison person between psychiatry and the rest of the hospital, and provide patient-oriented and staff-oriented consultations to the hospital staff.

The consultant role is a key ingredient in creating a comprehensive, ongoing program for the prevention of hospital staff burnout. Staff-oriented consultations focus upon the staff's emotional stress resulting from hospitalwide or unit-centered system dysfunctions. This permits airing of views and helps staff members to better understand how they might cope with problems that may be beyond their control.

Patient-oriented consultations arise when staff members experience serious stress when working with particular patients. The typical consultation consists of four parts:

* Education/reassurance provided by the psychiatrist for the staff about the dynamics of the particular case, including relevant psychological defense mechanisms.

* Open discussion with the staff about staff members' feelings, needs, and expectations relevant to the case.

* Administrative consultation with head nurse, hospital security, hospital attorney, attending doctor, and psychiatrist to ascertain what options are available and to address risk management.

* Treatment planning meeting with staff, head nurse, attending doctor, and psychiatrist to devise and implement a psychodynamics-oriented treatment plan that addresses the particular patient's needs.

Feeling less helpless reduces the risk of burnout. When staff members remain helpless in the face of adversity, they tend to feel abandoned by hospital administration, eventually becoming resentful and apathetic. This leads to alienation, impoverished relationship between administration and staff, high staff turnover, insufficient staff availability, and the need for large investments in staff recruitment. The consultation-liaison psychiatrist can serve as an important facilitator of a process designed to reverse this trend.

References

[1] Dans, P., and others. "Intravenous Drug Abuse and One Academic Health Center." JAMA 263(23):3173-6, June 20, 1990.

[2] Smith, H., and Levinson, D. "The Major Aims and Organizational Characteristics of Mental Hospitals." In Dean, A., and others. The Social Setting of Mental Health. New York, N.Y.: Basic Books, 1976, pp. 152-9.

[3] Kraft, A. "The Therapeutic Community." In Dean, A., and others. The Social Setting of Mental Health. New York, N.Y." Basic Books, 1976, pp. 162-72.

[4] Kirstein, L. A Health Care Program for Hospital Staff." General Hospital Psychiatry 1(2):134-8, July 1979.

[5] Krueger, D. "Patient Suicide: Model for Medical Students Teaching and Mourning. General Hospital Psychiatry 1(3):228-33, Sept. 1979.

[6] Mohl, P. "Group Process Interpretations in Liaison Psychiatry Nurse Groups." General Hospital Psychiatry 2(2):104-11, June 1980.

[7] Blix, S., and Brack. G. "The Effects of a Suspected Case of Munchausen's Syndrome by Proxy on a Pediatric Nursing Staff." General Hospital Psychiatry 10(6):402-9, Nov. 1988.

[8] Billowitz, A., and Schubert, D. "Reverse Liaison Rounds with a Burn Unit Case. General Hospital Psychiatry 10(1):67-73, Jan. 1988.

[9] Weiner, M., and others. "A Very Modest Proposal for 1990s C/L Psychiatry." General Hospital Psychiatry 11(4):231-4, July 1989.

[10] Ackerman, A., and others. "The Impact of Coexisting Depression and Timing of Psychiatric Consultations on Medical Patients' Length of Stay." Hospital and Community Psychiatry, 39(2):173-6, Feb. 1988.

[11] Hales, R. "The Benefits of a Psychiatric Consultation-Liaison Service in a General Hospital." General Hospital Psychiatry, 7(3):214-8, July 1985.

[12] Levitan, S., and Kornfeld, D. "Clinical and Cost Benefits of Liaison Psychiatry. American Journal of Psychiatry, 138(6):790-3, June 1981.

[13] Clark, C. "Burnout: Assessment and Intervention." Journal of Nursing Administration 10(9):39-43, Sept. 1980.

[14] Constable, J., and Russell, D. "The Effect of Social Support and the Work Environment upon Burnout among Nurses." Journal of Human Stress 12(1):20-6, Spring 1986.

[15] Sussman, D. "Nurses Wary of Recruitment Bonus Trend." HealthWeek 4(12):1,40, June 25, 1990.

[16] Wurzberger, B. and Levy, N. B. A "Hateful Epileptic" Patient in the Burn Unit." General Hospital Psychiatry, 12(3): 198-204, May 1990.

[17] Gabbard, G. "Splitting in Hospital treatment. American Journal of Psychiatry 146(4):444-51, April 1989.

Michael L. Zarr, MD, ABQAURP, is Director, Consultation-Liaison Psychiatry, Hurley Medical Center, Flint, Mich. He is a member of the College's Forum on Computers and Information Technology.