Podcast: Burnout in nursing and midwifery explored with Sharee Johnson

Episode: 40
Guests: Sharee Johnson
Duration: 57:29
Tags: burnout prevention and recovery
Soundcloud: Listen to Episode 40

Registered psychologist, coach and author Sharee Johnson talks burnout in this podcast episode with new co-host Celeste Pinney. Sharee shares the wisdom of many years of experience working with doctors who have lived through burnout. Sharee offers insights and practical strategies for nurses and midwives to improve health and wellbeing and prevent or recover from burnout.

Sharee explains the importance of understanding burnout as both an individual and organisational experience:

The very first, and most important thing, that everybody needs to hear is that burnout is not a mental illness, it's not something wrong with the individual. It's a mismatch or a relationship difficulty, if you like, between the individual and their workplace…

When we're thinking about burnout, we do want to think about individual responsibility. It is about how you cope, how you ask for what you need, and how you develop support networks around yourself. We often talk in the work we do about having an internal scaffold and an external scaffold, both of which help hold you up, if you like. But we need to think about those individual skills of asking for help, regulating ourselves, being able to manage our mind effectively, having enough sleep, all of these things.

(But) even if we do all of those things beautifully, if the workplace is toxic or dysfunctional, then it won't matter how skilled we are as individuals, the workplace is still problematic. So we need to use a both/and lens when we're talking about burnout.

Listen to find out more about how you can identify if and why you may be experiencing symptoms of burnout, how to get the right support, and how we can gradually begin to create habits to shift our state and find our way back to wellbeing.

If you’re dealing with burnout, Nurse & Midwife Support is here to support you: 1800 667 877 or by email.

Sharee is a registered Psychologist, Executive Coach, Author and Meditation Teacher. She is the founder of Coaching for Doctors, Australia's first coaching practice dedicated solely to doctor development and in 2021 published her international bestselling book The Thriving Doctor - How to be more balanced and fulfilled, working as a doctor.

Sharee spends her days deep in coaching conversations with individual doctors and groups of doctors seeking to understand their goals, aspirations and challenges. She believes that healthcare systems can be much more effective for patients when caregivers are well. And that caregivers can have more longevity and joy in their work when they have well developed inter and intrapersonal skills. She is wholeheartedly invested in healthcare that values and prioritises human partnerships.

Celeste Pinney [0:09] Welcome to the Nurse & Midwife Support Podcast: Your Health Matters. I'm Celeste Pinney, your podcast host. I'm the Stakeholder Engagement Coordinator with Nurse & Midwife Support, and I'm a registered midwife. Nurse & Midwife Support is the national support service for nurses, midwives and students. Our service is anonymous, confidential and free and you can call us anytime you need support on 1800 667 877, or contact us via our website at nmsupport.org.au. 

I'd like to begin today by acknowledging the traditional custodians of the land on which each of us meet and pay my respect to First Nations elders past and present. I extend that respect to Aboriginal and Torres Strait Islander people listening today. 

Today's podcast is about the important and sensitive subject of burnout. The last few years have brought unparalleled rates of stress in the nursing and midwifery profession. Although we are no longer in the grip of the pandemic and lockdowns have ended, we're still hearing that nurses and midwives are feeling fatigued, overwhelmed, anxious and depressed. There seems to be a sharp focus on the topic of burnout at the moment, which is a good thing in that it can help to bring more awareness to this condition that we hear nurses and midwives are experiencing. 

A number of studies over the years have shown that burnout has always been a problem for nurses and midwives. A more recent study by Latrobe University found that around 75% of midwives are experiencing burnout, which is quite a high rate. In that regard, it's vitally important that we provide information and support to people to help support their wellbeing. We talk about ways in which people can implement positive coping strategies to help nurses and midwives avoid burnout and other chronic health conditions. 

To do that, today we have an exciting guest on our podcast, Sharee Johnson, joining us to talk about the very important topic of burnout. Sharee has practised as a psychologist for the last 30 years, and is an executive coach, author, and meditation teacher. She's the founder of Coaching for Doctors, Australia's first coaching practice dedicated solely to doctor development, and in 2021 published her international best-selling book, 'The Thriving Doctor: How to be more balanced and fulfilled working in medicine'. 

Sharee has spent the last eight years deep in conversation with doctors, individually and in groups, seeking to understand their experience of work, and their goals for their own futures and the future of the health system. Sharee has also developed a wellbeing program for health professionals, including nurses and midwives, named 'Respond'. We'll put some information about that in the show notes. So welcome, today. Sharee.

Sharee Johnson [2:41] Thank you so much, Celeste. It's really a pleasure to be here. I'm looking forward to our conversation.

Celeste Pinney [2:46] Yes, absolutely. Me too. Thanks so much for being here today. We look forward to hearing about your experience working with health professionals and burnout. We'd love to hear your insight and wisdom about some practical ways that people can help prevent and manage burnout. We'd love to hear a little bit about the work that you do. Would you please share that with us?

Sharee Johnson [3:06] Of course, yes. As you said, I'm a psychologist, and I'm an executive coach, founder of our coaching practice Coaching for Doctors. I've been working as a psychologist for about three decades. I worked initially in welfare with families and individuals, then I had my own counselling practice for a number of years. So I have pretty deep, long experience in grief, trauma, relationships, anxiety, depression, those kinds of things. But I always had an interest in work and the impact of work on people. 

For those who have read my book, you'll know that my husband died in 2011 of cancer after a four year journey. During that time, I was really struck [by] being on the other side of healthcare, which often happens to us as health professionals. We get some new insights when we're either patients ourselves or with somebody close to us who's a patient.

I was struck by the variation that we met in healthcare professionals. Not just doctors, but all healthcare professionals, complementary and mainstream Western carers. I was very struck by the impact that had on us as patients in terms of whether the doctor, the nurse, the psychologist or the physio, whoever it was, whether they were engaged and present with us, or whether they were distracted and in a hurry, no time to answer our questions or be with us in the experience. 

So I just left that experience after a bit of recovery, after Tim left us. [I was] really left feeling I'm a meditation teacher, a psychologist, a coach, there must be some way that I can help these healthcare professionals when clearly many of them are not okay. So I did some more particular training around being a coach, I started asking lots of healthcare professionals ... particularly doctors, because at that time I saw them as the gatekeepers and the decision makers for a lot of what was happening in healthcare, and I probably still think that's true. I'm not sure that's the best model but I think that is the model that we have at the moment. I started asking them about what training they had around interpersonal communication, how they managed their own emotional regulation, and found that there were some pretty big gaps in the training. 

This is a huge problem for patients. We know that doctors who are well have better health outcomes, and the patients have better health experiences. But it's also an issue around sustainability around team leadership, about connection with teams. We saw a lot of nurses in our four years working with cancer, who were propping up or supporting the doctors in many ways. The doctor would come in and have two or three minutes with the patient, but we'd sometimes have hours, particularly during chemotherapy and those kinds of things, with the nursing staff. 

My early iterations into this was to try and hold a couple of conferences in 2015 and 2017, where we invited all healthcare professionals and the community. We had a great response from the community, they wanted to come and do learning with healthcare professionals, but the healthcare professionals were fairly reluctant to be learning in the same room with patients. Again, there has been some shift in that since 2015/2017. But those experiences showed me that doctors in particular wanted to do training around what we call intra and interpersonal skills. So intra skills: how do I manage my own self, my own thinking, rumination and distress, my emotions. And interpersonal: my collaborations and communication with colleagues, patients, and patient families? 

We started thinking about how can we help doctors do those two things? As you've already said, that led to us developing a program called 'Recalibrate,' which is a deep immersion program we've been delivering for six years with doctors. 'Respond' that we built in the first year of the pandemic, because many other healthcare professionals were asking us to help in that very early stage of the pandemic, we were all so frightened about what it meant and how we were going to keep our family safe, and still do our work and so on. Then the book, 'The Thriving Doctor,' in 2021. Now in 2023, trying to develop a lot of other coaches to be able to work with healthcare professionals.

A lot of the processes and the practices that we would use in coaching in a corporate space apply. The way we're doing coaching, in large part, is very similar. But there are very specific differences in healthcare that perhaps don't exist in other industries, we want to see some specific development in the coaching community so that they're better equipped and better able to help healthcare professionals do their work in what is inherently a fairly difficult system. Sometimes we might even say, a fairly dysfunctional system.

Celeste Pinney [7:43] Wow. Thanks so much for sharing that story, and such important work that you're doing there. Really interesting that it was born out of your own very, I imagine, personal and intimate experience with your husband and seeing how he was impacted by the health of health professionals and how that translates into patient care. So yeah, great to hear.

Sharee Johnson [8:03] It was a very clear reality that when a health professional was with us who wasn't present, who couldn't engage with us effectively, that we would spend a lot of time and energy then debriefing from that, talking about that, expressing our frustration and wondering how we were going to get hold of them again, to talk some more. When the health professional was well, engaged, present and had time and space for us, that might have still only been five minutes. But there was a different feeling in the room. We didn't spend any time on that, we could just get on with the healing and family connection work that was so important at that time for us.

I think that translates over into the work that nurses and midwives do. Nurses and midwives want to be able to give that really good quality patient care, but sometimes are unable to because they're challenged with their workload, and some may be experiencing burnout. 

Celeste Pinney [8:03] You touched on the book that you've written. Could you tell us a little bit more about that book, why you've written a book and how you've hoped that the book would help doctors?

Sharee Johnson [8:22] I think I wrote the book because we were in pandemic and locked down, Celeste, in large! It was a "How can I still make use of this time?" but it was also very much about reach. I've coached hundreds of doctors now in small groups and individually. There are lots of strategies that we're using over and over again, they're kind of tried and tested now. So whilst coaching one-on-one is a very individually contextualised process--that's, I think, why it is so powerful--there are still these consistent themes. After working with enough people, I guess they were very evident to me and it just felt like a way to share. 

The reality is, as a coach, I can only ever in my life see a certain number of doctors or people, whoever happens to be my client. So writing the book just gave a bit more reach and helped people have access to some of those strategies. There are many doctors in their mid and late career who have asked me if I could share some of the things that I've learned with the junior doctors, and have expressed a wish that they would have known some of these things earlier in their career. We've tried a number of times to create something for the junior doctors, but the reality is they're so time-poor that it's very difficult for them to come in an ongoing way to any program that we offer. 

So the book was another way of helping them in a sort of self-paced learning way, to tap into some of what we were learning and sharing. And in an amazing turn of events we've had contact now from doctors in many, many countries. The book is currently being translated into Korean for Korean doctors, by a group of Korean doctors and dentists in one of the universities there, who said that the book resonated with them. 

When you put something like that into the world, like a book, you don't really know what will happen to it. But it's been very surprising and humbling for me to see how much these tools, skills and strategies have resonated in many, many places that I couldn't have imagined. I think yes, there is a lot in the book that's relevant to nurses and midwives. Of course, the stories are all about doctors, because that's where I live, in the world of doctors, but the skills, the strategies, the tools, the mindful presence, the ability to improve your emotional vocab, all those kinds of things are relevant to all adults, and certainly to healthcare professionals.

Celeste Pinney [11:26] Yeah, absolutely. We'd love to, as the conversation goes on, hear a little bit more about some of the content of the book and the strategies that you found to be useful and achievable for people who might be experiencing burnout or who want to prevent burnout from happening to them. 

We do hear, at Nurse & Midwife Support, that a lot of nurses, midwives, and even our students are experiencing burnout. Could you maybe just talk a little bit about what advice you might have for listeners who are experiencing burnout? 

Sharee Johnson [11:54] The very first, and most important thing, that everybody needs to hear is that burnout is not a mental illness, it's not something wrong with the individual. It's a mismatch or a relationship difficulty, if you like, between the individual and their workplace. The definition we mostly use about burnout is that it's around workplace, poorly managed. 

Christina Maslach and her colleague, Michael Leiter, are the lead researchers in the burnout space, they have a new book out in 2022, called 'The Burnout Challenge,' which I encourage people to look at, particularly if you have a leadership role or have any capacity to change the workplace conditions, please have a look at that book. They've identified six workplace conditions that need to be considered around burnout, which are: sustainable workload. Enough choice and control, or what we might call autonomy. Enough recognition and reward, feeling that someone's grateful or recognize that you're there doing the work you're doing. Having a supportive work community, feeling connected to some of the other people at work, and the Gallup organisation has found that having a best friend at work is significant in terms of people's wellbeing. A sense of fairness, that what's happening for you is also happening for others. So we could think about the gender pay gap, for instance, as one of the issues that is a burnout risk in organisations. And a sense of meaningful work, or feeling that your work is aligned with your values. 

When we're thinking about burnout, we do want to think about individual responsibility. It is about how you cope, how you ask for what you need, and how you develop support networks around yourself. We often talk in the work we do about having an internal scaffold and an external scaffold, both of which help hold you up, if you like. But we need to think about those individual skills of asking for help, regulating ourselves, being able to manage our mind effectively, having enough sleep, all of these things. 

Even if we do all of those things beautifully, if the workplace is toxic or dysfunctional, then it won't matter how skilled we are as individuals, the workplace is still problematic. So we need to use a both/and lens when we're talking about burnout. We want to talk about the individual, their experience; a burnt out individual will feel exhausted, and they'll be doing a lot of depersonalizing like, "It's the same old so-and-so, different day," and will have lost their sense of agency, their sense of efficacy. That's how we know a person's burnt out. But we don't want to only put our investment into that person's wellbeing or that person's skill. We need also to look at the job design, the workplace, at the same time. Both of those things.

Celeste Pinney [14:35] That's so important, I think, because sometimes there might be a tendency to think it's all about the workplace, or "I can't do anything to change this." I think a lot of people have that feeling of not being in control because they can't change staff deficits, workloads, or those external stressors that come in. I definitely think this is a great conversation and we hope that there'll be some management or people in more senior positions listening, so that they might be able to start to implement some of these changes. 

In terms of some of the things you listed, the symptoms of burnout like depersonalization or lack of autonomy, would you say that they are some of the more early signs of burnout? Because I know that burnout can exist on a sort of a continuum, and I'm curious to know what your experience is. I guess I want to help people start to identify when they're in early stages of burnout, so that they can be proactive, to try to intervene as much as possible, so it doesn't get worse.

Sharee Johnson [15:26] Some people will be aware of the acronym HALTS, and I always have an extended version of HALTS. Hungry, angry, lonely, late, tired, stressed or sick. All of these things will help a person feel depleted. The very first thing I would say is, if you are depleted in any of those ways, pay attention to them, attend to them. You mentioned the workforce shortage. Healthcare does not help in terms of the big, unwieldy system. If you are a nurse on a ward that usually needs to have three or four nurses on shift, and you're the only one there, well, it's all very nice for the psychologist to say go and get a drink of water, isn't it? It's not so easy to pull off. 

I always ask the people I'm working with, do you want to enable the system, or disable or disrupt the system? We do need to take some personal responsibility about what we're doing to enable or disable our circumstances. 

So in the first instance, looking at these HALTS. Am I hungry? Am I late, tired, stressed? How can I attend to any of those things? Even the very smallest thing of taking yourself to the bathroom, or having a bottle of water with you that you can take regular sips [from], which of course is very difficult with the PPE situation we've had in recent years. I'll share some other skills and techniques later on. But to answer your question about early signs, HALTS can be a very passing temporary state. I'm hungry, I have something to eat, I'm okay again and I can get back to work, focus and concentrate. 

When we're thinking about burnout, we're thinking about more pervasive kinds of things. For instance, the kind of exhaustion that tells you, "I really need a holiday. I need a break. I need to take a few shifts off." I do that, I have a week or a couple of weeks off. I come back and within the first, maybe even the first couple of hours or the first day, I feel exactly how I felt before I went on holidays. It hasn't really been appeased, it wasn't just that I needed a few nights of good sleep, there's something else going on. 

That's one way, if you take a break and you come back, and you think "I'm still no better than I was..." I think disconnection is a powerful alerter, if I can call it that. When we withdraw, when we don't want to engage in any of our usual things that would bring us joy. When we notice we're tuning out, we're not present. Or if somebody else says to us, "I don't think you were really listening in the meeting this morning," or "You seemed a bit distracted in the huddle." "You haven't actually seemed yourself all week." We actually make room to hear that message, because we can't see ourselves very well often. 

We're not taught how to be self-aware or how to listen, other than sometimes in the most superficial ways. Giving permission or allowing at least inside ourselves to say if a person that we trust--a family member or a colleague that we are friends with, that we have worked a long time with--if they make a comment like that, that we make a commitment to ourselves to hear it and to be curious about that. To not just straightaway say "No, no, I'm fine." Or if you do say on the outside, "No, no, I'm fine. All good," that we inside make a note to check that. To walk the dog after work, or to have a bath, or to go to bed early. And to just ask ourselves, "That was interesting that they said that to me today. How am I really?" I think we avoid that, we tend to brush stuff like that off, avoid it, keep going, keep busy. It's a disservice to ourselves to not pause and notice that. 

Another thing that happens when we disconnect is we tend to other people. We depersonalise them, we talk about "Oh, that's just another patient, just another day," or we refer to the diabetic in bed six. We revert to some of that, what we might call old medical language where we're minimising or discounting the other person's experience as a protective mechanism, as an armor for ourselves. Christina Maslach's research more recently says that if we're cynical or hostile, that's a good indicator. If we're more cynical in our view of what we can do or what others can do, or whether any change is possible, then that's a red flag for how we going,

Celeste Pinney [19:37] Yeah. I think it's great to talk about it because like you said, it's important to have self-awareness, but we're not taught that, that's not necessarily part of our education. So it's about how we can come into ourselves a little bit more and look at some of these potential symptoms and then from there, once we've identified that, we can seek help.

Once someone's seen some of those signs, their health might be declining and they might be headed towards burnout. What's a good way that they can access support? Is it better to speak to your GP, or to speak to a colleague, or just to speak to anybody that you trust, and then from there, try to get some professional support?

Sharee Johnson [20:15] I think that trust is the critical element. Some people find that really difficult, to find a person to trust. I think we probably go for the GP as the next step. But having somebody that you can trust I mean, it's a potential identity crisis, isn't it? If you feel like "I've lost the joy in my life. I don't have any energy for work. I'm trapped in this system, because my family's dependent on my wage. I've done all these years of training. Who am I? If I can't be a nurse, or I can't be a midwife anymore, what does that actually mean for my life? Who am I?" 

That's a significant identity crisis for a person, it's a very vulnerable place to be. It's not easy to say that out loud to somebody, and as adults who want to be autonomous and belong and feel safe, we have a lot of tactics to keep away from this place of having to disclose that we're not okay. There's a lot of anxiety and fear for people in saying out loud, "I need some help," or "I don't think I'm okay." 

In the ideal world, yes, somebody that we trust would be a great place to start. I often say to the people I work with that even if that's the dog, or the cat, or the horse, or if there's an animal in your life who is a good listener and won't say anything back, then it's a good place to try it out. Because it's not familiar to our mouth, or our way of thinking to say out loud for many of us, "I'm not okay. I need some help. I'm not delivering the kind of care I want to deliver. I'm really scared that I'm going to hurt somebody," or whatever it might be. If there is a person, then yes, that would be much better than your favorite animal. 

Another good place to start in terms of disclosure and practice. Many people get benefit out of writing in a journal. It's not for everybody, but that process of writing is very similar to that experience of telling somebody, it's a way of giving your experience a sensory element rather than just rumination inside your head. I think these questions of heart, what do I know in my heart to be true about myself, about who I want to be in the world? About how I want to serve? About how I want to be with the patients? Why did I become a nurse or a midwife in the first place? These kinds of "Who am I?" questions.

And then questions around, "Where should I put my energy?" and if you are burnt out, or you feel that you're on that slide to burnout, then the best energy--and I would actually argue every single day, even for a healthy, well, health professional--the best energy we spend is the energy we spend on ourselves. We can only provide sub-optimal care to somebody else, if we are sub-optimal. When we're really well, healthy, energised, connected and present, then we might have some chance of providing optimal care. 

I think telling somebody that you trust, say it out loud, practising in a journal or on a pet ... it doesn't have to be a medical person that you're telling, it can be anybody. Certainly, once you've established that, and you have got used to the idea that you might need a bit of help, talking to your doctor. If it's earlier on in the process, then I think reinstating some of your good habits is probably a good place to start. You used to go to the gym, and you always felt good when you did, tell somebody that's what you're going to do. Find your gym buddy, be public about it, because you're much more likely to follow through. If you recognize that you're very sleep deprived, give yourself a month to go to bed early, and have the people in your family help you to set some external structures up that will make you start to change your behaviour.

Celeste Pinney [23:55] I think it's great that you speak to that reaching out for help. When I think of that, I think about vulnerability, and probably a lot of people have heard of Brené Brown and her becoming very popular in terms of talking about the importance of being able to be vulnerable. I think it's something that probably a lot of people struggle with, but particularly nurses and midwives, because we are trained to be strong, push through, keep going, and you're focusing on the other. So I think it's great that you talked about some ways that people can start to practise a little bit, build that muscle around, 'how can I start to speak about how I'm feeling and reach out for help'. That's really, really important. That's great to hear. 

We know that too much stress can detrimentally affect health and wellbeing, and you talk in your book about finding the sweet spot for stress. How can people recognize and stay within a healthy stress zone to ensure that they don't become chronically stressed and then further risk of burnout?

Sharee Johnson [24:48] Great question, Celeste. When I find the answer, I'll make a lot of money. I think that the sweet spot of stress is where we are at our peak performance. We know when we're at peak performance, we're in flow, we're connected to people, we smile, we feel energised, we have a full busy day at work, a big shift, lots of patients and we feel good about it. We leave feeling like we've contributed, that we have helped people that we have lived a values-driven life that day. 

I think that most people know when they're in flow, or when they're at peak performance or optimum performance, whichever words you like. It feels good, it fills us up, it doesn't matter whether we're more introverted or more extroverted. When we're doing something that requires our energy, and we feel encouraged, uplifted and energised by it, then I think you've found the sweet spot. 

The stress curve is not a bell curve. It's got a slow gradual move up on the left hand side to the peak, and then it's a bit skewed to the right, the arousal curve, and then it's got this sort of slower downward gradient, and then we've [inaudible] until the peak, which is skewed a bit to the right of the graph. It'll start slowly coming down the other side when we're exhausted or not going so well. Then we fall off a cliff, literally, we get to the panic zone and the curve just drops almost straight down. 

So when we're in peak performance, we start to feel a bit exhausted or it's a bit too much or we're a little bit overwhelmed, that's when we're starting on the curve down. That's the time to know about interrupting. At that point, we can change our response, we can change our expectations, we can change the environment, we can ask for help. There are actually lots of things we can do. 

But it's about having that insight, you said some beautiful phrase before about turning inward or staying with ourselves, can't remember the exact words you used. But if we can have enough insight, enough self-awareness, to have a sense of 'this is not the same as what it was when I was in that peak experience,' then we can learn to interrupt that. Changing our response by saying things like, "Okay, I think I need a break. Now, I need to tell somebody I'm not focusing like I was. I noticed my attention is not as good." 

I love that analogy of the checkout in a supermarket where they put the sign up and they close the register. Somebody else does it for them, usually. The supervisor comes along, puts the sign up. If you're there, bad luck, you've got to go in another line. Often they do open another line and encourage you to come over there, but there's a system around the person that's helping them to take their break. It's saying, here's the line, we're drawing it in the sand, and you can now step away. 

I think we can all help that happen by being more vocal, sharing more, telling each other, we can change our expectations. I can have a different expectation that when I go to work, I'm going to be exhausted when I come home. Or I'm not going to be exhausted, I'm going to insist that I take a toilet break, and I'm going to leave the floor, or I'm going to leave, go outside. 

I love telling the story of working with an emergency doctor who said she could never leave the floor on a 12 hour shift. I was quite incredulous about this. What about a drink? What about the toilet? She said, no, if it's busy, she can't do any of those things. So then I started thinking about how dehydrated these doctors were in the emergency room, who were treating very sick people very quickly, and they were becoming completely dehydrated over the whole day. In the course of that conversation, I [asked] her, could she ever go outside and stand in the sunlight for two minutes, which she duly scoffed at. 

A month later, she came back and she said, "You'll never guess what I'm doing! Any chance I see, I'm on the lookout now for these spaces, these gaps. I'm going outside and standing in the sun." She was on the ground floor of her hospital, and it was making a huge difference for her. That small act had opened her mind to what else might be possible in terms of her day.

I think a lot of what we do when we're stressed is we have a habitual expectation that we haven't checked for a long time. We treat it as if it's true, and it is true, because it's part of what we look for as well. It's part of what we're practising. This opportunity to start to check our own expectations and say "What if..." To be curious, to wonder, "What if I did something different? What if I just paused between every patient, put my two feet on the floor, and took one long exhalation that would take me 10 seconds or 15 seconds? I wonder how I would feel if I did that, and I made that a habit?"

This idea of the sweet spot of stress, there's work to do on both sides, if you like. There's work to do around, 'what do I call a stressor? How do I respond to the stressor? What do I call stress? How do I experience stress? How can I identify it when it's becoming too much, so that I can pull back? What are the skills I need at that moment, so that I can step out, take a rest, or move back into that peak spot?'

Celeste Pinney [29:53] I think it's great that you talk about habits, because I think people can habitually get into habits managing stress that aren't necessarily good for them, that don't take them out of that stress response. I'd like to think of small things often, I think is sort of what you're talking about there? Where it's not about “I have to do an hour of meditation a day, or I have to go to the gym for an hour every day”, which can feel overwhelming or too much for people. But how can I just take a minute here, or a minute there, or five minutes of mindfulness, or even five minutes of exercise, so that we're still building that in. Hopefully, over time, we can build it up so we're gradually having more of that, but we're not just having our body switched into the 'on' mode all the time, so that we're chronically in a state of fight and flight.

Sharee Johnson [30:35] I totally agree, Celeste. Absolutely. I would even say 30 seconds, or one breath, as I said. We talk about mindfulness as a formal practice and we sit and meditate, or go to yoga or whatever, and also as an informal practice. You can actually make anything that you're doing your mindful practice. You can be peeling the carrots for dinner, and put your whole mind on that act of peeling the carrot, and that's your mindful practice. You can walk along the hall, focusing on every step and keeping your attention on your feet as you walk, instead of all the hundreds of things that you have to do that day, for the length of the hall, and that's your mindful practice. 

Each time we do these things, we are training our mind, our attention, to be where we want it to be. We can't interrupt our habitual activities and processes if we never pay attention to them. It's exactly the same as a person who's using an ill-advised coping strategy like drinking, smoking, taking drugs or being obsessive about food in some way, or any of these coping mechanisms that do us harm in the short and the long term. We don't change those things until we notice them as a problem, and very often other people think they're a problem before we do. We justify and explain, say it's not that bad and carry on because it requires less effort to keep following a habit that is established. 

It does require some effort to notice it, to own it, to admit that it's not really the way we want to live, and to then start unlearning that habit and replacing it with another habit. That all takes a lot of effort. If we break it down to very tiny, small things--and many people in the world have read James Clear's book 'Atomic Habits', or some people might have read BJ Fogg's book, 'Tiny Habits'--all the research is saying [is] break it down to its smallest thing and do a little bit, often. It's our neuroplasticity. Our new pathways in our brain come from regular repetition. 

So, you know, I want to get strong. Let's say I want to build strong shoulders and strong arms. Two push-ups a day, even two push-ups a day, two or three times a day as I get going, is much better than me the first day trying to do ten push-ups and feeling discouraged, weak, like I'm never gonna get there, and sore for the next two days. A little bit, often, is definitely key. It's the same for mindfulness, for meditation, for self-awareness.

Celeste Pinney [33:01] In terms of mindfulness ... we hear a lot about mindfulness these days. I'm curious what you know, in terms of the research around mindfulness as it relates to burnout and helping people overcome burnout. What is actually happening in the body, in the brain, when we're doing mindfulness? I guess that's my first question, but I also wanted to say that I think it's great that you said people can do mindfulness at any time, because I think a lot of people are busy. They think, "Well, I just don't have the time to set aside for ten minutes of mindfulness." So then they don't do it at all, they just completely put it into the too-hard basket. But it's good to know that you can just do it as you're going about your day. I like that concept.

Sharee Johnson [33:38] I think there's lots of ways people can start. If you're sitting down to dinner, can you make the first [bite] really mindful, where you taste, smell, appreciate and chew slowly, and then just eat your meal how you always usually do. Do that first mouthful every time. Or if you're setting off in your car, don't put the radio on and don't think about what time you need to arrive, how much traffic and whatever. Just feel the seat, feel the steering wheel, feel the pedals, be fully present in the car until you reach the first red light, for instance, or the first corner. 

We can practise mindfulness in anything that we're doing. Please don't close your eyes and try and do mindful meditation while you're driving or [using] heavy machinery! But you can make the patient, or colleague in a meeting be the centre of your mindful practice. Set yourself the challenge that for the first patient of the day, I want to be truly present. I want to feel what it feels like to not think about anything else, except what the patient is saying to me. Just be completely in that moment for the first patient of the day, and when I'm hooking up the drip or when I'm checking their vitals or whatever it is, I'm fully engaged and fully present in that experience. 

All I would say to people is try it out a few times. Run your own experiment, and see what happens. Don't fall for that critical mind that will say very readily, "I'm not very good at this. This is stupid. I don't know what I'm supposed to be doing." Ignore all that, and choose anyway. Mindfulness is about choice. It's about choosing where you put your attention, choosing what you're aware of. 

Try it out, run an experiment a few times, whether it's the car example, or walking up the hall, or being present to the patient, and just try and notice what happens to your energy. Do you feel different in some way? It's not so much a head exercise, as a 'What's happening in my body?' Do you feel more connected to the patient? Do you feel like, as you walked along the hall, you were able to slow down your breathing a little bit or slow down your heart rate?

One of the very powerful pieces of research for mindfulness shows that a mindful practice can help people's heart rate variability, one of our measures for wellbeing. We know that when we breathe in, our heart rate speeds up a little bit. When we breathe out, our heart rate slows down a little bit. So can we extend those exhalations more often during the day? Can we have a long exhalation every time we go to sit on the toilet, or every time we close a door, or open a door? Can we take one long, slow exhalation? Nobody even has to know you're doing it. But every time you do it, you're inviting your parasympathetic nervous system back into balance, or a little bit more like balance with your sympathetic nervous system. 

The more you do it, the more front of mind it is, and the more awake, aware and alert you become. One caveat or a little warning is, that if you've never done anything like this before, it can feel very uncomfortable at the beginning. Just like every other skill that you've learned as a novice. When you were first putting in a cannula, you probably felt self-conscious, unsure and uneasy, and a whole lot of different feelings and thoughts went through your mind. It's exactly the same when you're learning to bring your physiological system back into balance in the ways that I'm talking about. 

If you're a novice, there's lots of thoughts and feelings that might happen, and lots of things that might make you feel a bit nervous, or a bit like it's not worth the effort. But just as you can learn all the nursing skills that you have, you can learn these skills too, with a bit of practice.

Celeste Pinney [37:03] Yeah, that's good for people to know that about mindfulness, as I think not everyone knows those details. So it's great to hear your experience of that, and some of the research around that. I'm curious to know ... mindfulness is a big piece, in terms of helping people keep healthy and well, prevent burnout, and sort of activate the parasympathetic nervous system, and unhook from maybe some unhealthy coping strategies. Do you think these sorts of practices help people who might have maybe more prolonged or chronic unhealthy coping strategies like addictions? We know that nurses and midwives have begun having more problems with alcohol as a result of stresses placed upon them through the pandemic. Do these sorts of practices help with people who might have addictions as a result of burnout?

Sharee Johnson [37:45] Yes, the research is really good. For people that want to look at an app that is related to mindfulness and comes out of addiction work, you could look at Jud Brewers app, I can't think just right now what it's called, but his name is Jud, J-U-D, Brewer. The thing I would say is that if you have an addiction, or if you're worried that you might have an addiction, please get some professional help. It's a hard set of habits for most people to unlearn, or break, or re-establish away from that habit of substance use, by yourself. 

I do want to encourage people to get some professional help, take that first step of saying, "Can you help me?" with someone you trust, or with a professional. Ring Lifeline, if that's the most useful place to start. I love telling health professionals about Lifeline because I think we mostly think it's for the 'other people'. Because we work shift work, and we are exposed to a lot of grief and trauma, it's inherent in the work that we do, Lifeline is such a good resource, because it's there all the time. In the middle of the night, on the weekend, after shifts. So please remember this for you as well. 

But yes, certainly the mindfulness skills can help people with those kinds of conditions. It's sometimes more difficult at the beginning, because it's very hard to turn inward and listen to your own mind, that might then take the opportunity to ramp up and tell you how it knows what will help you, and you're trying to move away from that habit. Get some professional help, start small, be self-compassionate. 

Another skill that we spend a lot of time talking to health professionals about, is that we're excellent at looking at other people, caring for other people, and bringing compassion to the bedside. But oftentimes health professionals will say to me, "Oh yes, I've got plenty of compassion at work. I'm fine at work. I've got none left when I get home for my family." That feels wrong, that feels bad, that can bring people into the territory of moral injury, because they feel like they've given all of their good stuff to other people, and haven't left anything for people they actually love. 

So a little bit of self-compassion [is needed]. Essentially, that means be mindful, be aware of what's happening, what you're doing internally. Recognize that you are human, just like all the other people. That you have a common set of experiences, emotionally, in that regard. And be kind. Bring the kindness to yourself that you would bring to anybody else. Bring the kindness that you would bring to your best friend or your child, to yourself.

Celeste Pinney [40:05] I think that self-compassion does take some practice, but people can begin bringing that into their lives, especially if there's some unhealthy coping strategies, like addiction. There's a lot of shame around addiction, and it can be difficult because of that shame for people to reach out. It sounds like mindfulness and self-compassion can help to open the door a little bit to people being able to speak about how they feel, and seek some further help.

Sharee Johnson [40:34] It's an important word that you've said on this list, in terms of shame. There's so much shame in medicine. I don't know if it's more or less in nursing and midwifery, to doctors [experiences]. But this culture of holding it together, being strong, it's imperative that we care for the other people, so we have to look like we've got it together. 

Actually, many, many patients will describe a very different experience to that, that they felt held at arm's length. Yet we were taught that, not so long ago, to keep patients at arm's length, psychologists too. So I think that patients actually report that when the doctor looked them in the eye, or the nurse held their hand, or somebody sat down in the chair and stayed with them for a few minutes, that in some ways, that's the best therapy, or the best healing that they had in the healthcare system. I think that compassion is undervalued. If we ask that question of "What matters most?" of ourselves, very few of us are going to say "It matters most that I kept myself together and strong and separate from the other people."

Celeste Pinney [41:34] It's about connection, isn't it? Connecting with your patients and connecting with other people, which sounds like it can be hard when you're in burnout. 

That brings me to my next question ... you mention in your book the PERMA model, which is a model that was created by a psychologist named Martin Seligman. That model stands for Positive emotions, Engagement, Relationships, Meaning and Accomplishment. My understanding is that this is a framework for happiness and wellbeing. 

I know that there is a bit of a spectrum in terms of wellbeing with burned out on one end, and flourishing on the other. You touch on some of the things that people might be able to do to help move that needle towards having more thriving and flourishing in their lives. But can you tell us a little bit more about the PERMA model, why you decided to include that in your book, and how that's related to burnout?

Sharee Johnson [42:24] I think that PERMA model is, as you said, Professor Martin Seligman's work and many, many people since him [have used it], it's the foundation of positive psychology. Positive psychology is central to coaching, as well. Coaching is a very strengths-focused process where we're looking for what's working, what's going well. 

Martin Seligman was the first psychologist to say, "I don't want to do all this work in pathology. I know that we're all concerned about what's going wrong for humans, and we want to understand depression, anxiety, and so on. But I'm curious to know what the well people are doing. What's happening for the people that don't have mental illness? What are they doing? Can we find out more about that, and have more of that?" 

Essentially, positive psychology has concluded that these things that are part of the PERMA model, which I will talk a bit more to in a minute ... people who are well have all of those going on in their life. They don't have the same quantities, it's not the same recipe, like everybody has 20% of each. People have different mixtures, but they all have these things going on in their life.

Martin Seligman has moved away from saying that positive psychology is about happiness, it's more about wellbeing. In fact, he says that the work of positive psychology is to work out how people can flourish. His definition for flourishing is that the person has positive mental health and overall wellbeing. I think probably flourishing, thriving, wellbeing, they're all trying to get at the same thing.

In terms of happiness, the longest study in the world, at Harvard, into happiness says that relationships are the key for happiness. We don't need lots and lots of them, but we probably do need three or four intimate relationships, people that we can trust, to be really well or to be really happy, is that piece of research. PERMA is saying that positive emotions are really around, 'How can we generate, are we good at generating positive emotions? Are we good at doing things, thinking things, feeling things, keeping our attention on things that generate joy, love, compassion, excitement, enthusiasm, contentedness’. I think it's easy to understand that we feel more well when we're generating those kinds of emotions. 

People who have wellbeing, intentionally look for opportunities to create those kinds of emotions. They're engaged, they have that experience that we talked earlier about; a flow, being fully in the activities that they choose to be involved [in]. They're careful about where they put their energy, and then where they put their energy, they commit to it. 

I remember when Tim was having his chemotherapy, a doctor said to us, "If you're going to have chemotherapy, fully embrace it." Nobody really [embraces] chemotherapy obviously, but once you make that decision, embrace it. Be committed to it. Have this sense that you're doing something to help yourself, be well, to recover. 

I've spoken about relationships already, people who are very well connected, they understand that the importance of being a social animal means that we need to be socially connected. I always like to talk to health professionals about having medical connections and non-medical connections. Have people outside of your work culture that you can trust as well, that you're connected to because they can be pretty inward-looking, healthcare [professionals], at times, it doesn't reference a lot of the rest of the world when we're inside that little bubble. 

Meaning; so, belonging and serving something bigger than ourselves. Again, I think when we're burned out, we get very narrow in our focus. We're in a tunnel, it's very black and white, our thinking becomes very rigid, we're not very creative. The opposite is true [of] a person who's flourishing, having wellbeing. They have a sense of meaning in their life, they feel like what they're doing contributes, and adds value to the collective. It's much bigger than themselves, they're happy to be of service.

And then, accomplishment. Sometimes we call accomplishment 'autonomy,' but it's this sense of having progress in the activities we're involved in. Our progress can be mentoring somebody else, uplifting others. It doesn't have to be that we ourselves are the center of attention, and winning all the awards. But it is a sense of progress in our cause, or our chosen activity. The more recent work in positive psychology has said we need to add a 'H' onto PERMA, which is Health. The things that come under that are the things you'd expect: sleep, nutrition and movement, and also a sense of optimism. I think that goes well with positive emotions. This sense of being able to be optimistic about the future, even in the face of difficulties and challenges. That we hold a sense of, 'I've got the resources,' or 'I'll be able to find the resources. I've got a sense of agency, still, in my life.'

Celeste Pinney [46:58] Yeah, fantastic. That's such a good summary of some of those important components of how people can create wellness in their lives. I think a lot of people probably know about some of those things, but it's really a good reminder. Even if we are in burnout or heading towards burnout, it's good that we can start looking at, proactively, 'What are the things that I can focus on that are good for me?' rather than, 'I think we can dwell on that you're anxious or depressed.' It's easy to get stuck in that cyclical negative thinking about how bad things are, but what are the things that we can do to improve our health and wellbeing.

Like you said, some of the foundational things which we talk a lot about are exercise, nutrition, sleep. I'm curious to know ... people who are really busy, nurses and midwives, who are juggling a lot ... they go to work, they might have family commitments, maybe they're caring for elderly parents, they have other obligations. They feel like they just don't have the time for say, any exercise, or even sleep or rest might kind of go on the backburner. How do you work with people who are in those positions who feel like they can't engage in those types of helpful activities?

Sharee Johnson [48:03] I think you're describing the tyranny of modern life, Celeste. This is all too familiar, having been a single parent of three kids, working full-time, and so on. I think it's back to what we were talking about before, which is start small and do whatever you can do. We can bring a lot of what we can do to our existing activities. 

A large part about mindset is in the lens that we want to put up. If you're looking at the world in the dark with a torch, you can only see what's in that torchlight, in that beam. When we're in burnout, we have that very narrow view. That's all we can see, that life is hard. What's the point? I can't make any difference anyway. Nobody cares about me. I'm taken for granted. All of that stuff. 

When we put all the lights on, of course, we can see much more. We can see many more opportunities, we can see different kinds of work. We can see other values, we can see our family is important to us. But while we're looking through that small torchlight, we need to do whatever we can do to start. That might simply be to tell somebody, "I don't see what the point is. I can't be fagged anymore." That small sentence might be enough to give somebody we trust permission to ask us a bit more, to tell them a bit more. Maybe they even say, "Let's go for a walk. Let's go and get a cup of tea," or, "This can wait." It's kind of, start wherever you can start. 

For those of us helping others in burnout situations, I think it's about being very patient. Having the courage to wait, to keep showing up, to keep saying, "Are you okay? No, how are you really?" I know when I've worked with people with debilitating psychological problems, like bipolar disorder that's flaring, or things that can be a big [inaudible] on people ... and they tell stories about things like 'My sister rang every single day for two years. Every single day, she asked me, "Would I like to come out for a cup of tea?" And every day I said no ... until one day I said yes." It is kind of that 'hang in there' with people.

It's no good taking a horse to water if the horse won't drink. It's important to be with each other, to be patient, to help each other build courage. It's not easy to be vulnerable. I think, let's be frank and honest: to be in burnout, or to be completely overwhelmed so that you can't go to work, is a horrible position to be in. Nobody wants to be in that position. Anybody in that position wants to get out of there, ideally, so meet them where they are. If you're that person, in that situation, I think name what you've got, is the beginning. To say, "I'm really in trouble. What I can do is get up today and get dressed and sit in the sun. Give myself a rest, and be compassionate about that. It's actually all I can do. I'm proud of myself that I did that."

Celeste Pinney [50:54] The simple things. I think it's great to hear, because there might be people listening who have a friend, a family member, a colleague, or someone they care about who is in burnout and [hear] how they can be of support. I think just showing up and showing people that you're there, even if they don't take up the offer of support is absolutely critical, and really gold. Hopefully, that will really help that person.

I'm curious to know, in your experience, when people are in sort of more extreme levels of burnout, or more full-blown burnout, is it possible to come back from that? I guess I want to give that message of hope to people out there, from what I've read, that is possible. I'm just curious to know your experience with that.

Sharee Johnson [51:30] I think it is possible. It's like so many other things. The further along the track you are, the harder the work is and the longer the work will take. Definitely, to my mind anyway, it's better to get in early. But yes, I think it's certainly possible. The reality is when people are recovering from burnout and doing the work from finding themselves in that place, they may not want to come back to where/how they got into this position. 

It's a bit like people who are made redundant sometimes. First of all, a lot of grief, trauma, distress. Work around identity, place in the world, values and so on. Then there's work around 'Well, okay. Now I'm in this place. I've learned all the things I've learned about this experience. What is it that I really want to do? Who do I really want to be?' It's not necessarily that we're doing that work so that we can go back to where we were, like post-pandemic, none of us can actually ever go back to pre-pandemic, we know different things now. That idea of 'new normal,' I guess. 

One of the things I didn't say about stress before was that when we are completely feeling like we have no efficacy, there's nothing we can do, that's the place of hopelessness and helplessness where people often give up. It's also where people feel suicidal, and lots of tragic things can happen. Being able to find even the tiniest thing that you feel in control of is incredibly powerful. 

Like being able to say, "Okay, I can't actually change anything here in this workplace. I've got to the point where I accept I've tried really hard, made lots of suggestions, nothing's happened. What I can control is my ability to take a breath right now and to ground myself in this moment, and to be present to the patient when I'm with the patient. I'm not going to expect anything else of myself, or the organisation. As I regroup and reground myself, all I'm going to do is practise feeling my feet on the floor, taking some long exhalations every day at work. I'm going to regroup, feel my own self again. Maybe the next step will be that I'm going to tell somebody. I'm going to tell my partner, or I'm going to tell my sister, or somebody like that what's happening. Then I'm going to make an actual set of decisions about what I do next. I don't know what they are yet, because I just don't have the capacity for that. But I can make a commitment to myself that I will find a way to look after myself, and to make some new decisions."

Sometimes even just that commitment to self can be enough for a person to feel like they've regained some sense of control or some sense of self in the mess, if you like, and that's enough to feel like a turnaround. There's obviously a lot of work to do after that, but that first moment, that first sense of, "Okay, I can control this bit. I can control that I am going to do whatever I need to do to get back into a sense of control about my own life." That can be very grounding.

Celeste Pinney [54:24] Yeah, I love that. That's so important, and so good to hear that, because people can feel like they don't have that sense of impact, or a sense of control over their lives when they're at work. To know that there are things that you can do to start bringing back that sense of control and autonomy, and to know that people do have choices. They don't have to stay stuck even though it might feel like that's the only way of being, so that's great to hear. 

Well, that's great, Sharee. Thank you so much for your time today. I guess just before we finish up, are there any other key messages or anything else that you think would be important for our listeners to hear before we wrap up?

Sharee Johnson [55:04] I want to just reiterate, you mentioned about our program 'Respond' at the beginning, Celeste. Respond is an on-demand online program. It's all from me, I'm in all the videos. If people feel like the way I talk, or they've looked at my book, and I think that these things are useful for them, it's a very cost-effective available thing. I can't remember the price, but it's less than $200. It's online, it goes for 12 months. If people feel like they'd like to take a deeper dive into some of these things, and really learn some of these skills and have a place to reflect on them, it's a terrific resource for people. 

I hope one day that people might even use it in their teams and talk about it together. Initially we did promote it as something that organisations could purchase and share with their whole teams. It's built so that, for instance, ten people could be doing Module One together and talking about it at work. For me, that's the future dream, I guess, that these kinds of conversations are just part of the ordinary conversation that we have in healthcare. That we've shifted the culture so much that we just naturally, and all the time, are talking to each other, to the patients, about how we can look after our emotions, how we can manage our minds, how we can help each other, and that that's our new normal. 

So that's there for people to look at, if they want to. If people want to hear or see more of what I'm talking about, I'm on LinkedIn, and Instagram, and there's a lot of stuff on our website coachingfordoctors.net.au. We're just trying to resource people, all that stuff there is for free, so please take advantage of those things. 

Thank you all very, very much for the work that you're doing. I think it's extraordinary work that you're doing, under very, very difficult circumstances.

Celeste Pinney [56:43] No, thanks for that Sharee, that sounds like a great program. I think it's great that we've had this conversation so we can start opening up that conversation of burnout and hopefully bringing that more into the workplace for people to talk about how they're feeling, and if that's something they're experiencing. 

Of course, we're always here at Nurse & Midwife Support. We have a great team here who can help you if you are struggling with any kind of health problem. Please feel free to contact us at any time. You can phone us, or you can go onto our website as well. 

Thanks so much, Sharee. Great to talk to you and really appreciate your time.

Sharee Johnson [57:13] Thanks so much for having me, Celeste, and for the work that you're doing as well.

Celeste Pinney [57:16] Thanks, Sharee.