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Safeguards against burnout: Evaluate the emotional labor and compassion fatigue in dentistry

Oct. 18, 2016
The authors point out that burnout in dentistry is often based on an emotional toll that goes beyond just working too hard.

By Kandice Swarthout-Roan, MS, RDH, LPC-Intern, and Priya Singhvi, MS, LPC

Have you found yourself counting down the hours until it's time to go home? This is true for all of us from time to time, but what if it happens every day? Perhaps you find yourself wanting out of a perfectly stable work environment but can't seem to pinpoint the source of your despair. You're having difficulty being excited about going to work, you're irritable with coworkers, and your attitude toward patient care is increasingly diminishing.

If this sounds familiar, you might be suffering from compassion fatigue or burnout due to the unhealthy engagement of emotional labor. Many dental professionals suffer from occupational stressors with psychological and emotional consequences that can lead to burnout and poor work performance.1 Emotional labor and compassion fatigue can contribute to stress and burnout.

Emotional labor is the attitude or mood that professionals are required to put forward during a workday in order to acclimate to the culture of the practice or business.2 Compassion fatigue occurs when individuals spend a significant amount of time working with traumatized individuals.3

Dental professionals must also manage the reality of sometimes causing patients pain and discomfort in order to deliver services. In some cases, patients have a hyperelevated level of dental fear that must be carefully and professionally handled by a clinician in order to foster a positive environment.1 An accumulation of these emotional labor tasks can lead to decreased quality of life, which can have a universal impact on the profession.

Emotional labor

Emotional labor is maintaining expected emotional expression on the job, which is essential to performing work responsibilities, but might have unintentional consequences for the practitioner.1 As dental professionals, we strive daily to create a warm and friendly environment to make a frequently unpleasant situation tolerable. In some cases, putting forth a jovial attitude comes easily if a patient is friendly and familiar with the practice. Other times, patients display irrational behavior that can leave clinicians confused, frustrated, and exhausted.

Unexpected or unpredictable patient behavior can be the result of undisclosed traumas or disorders, such as childhood abuse, anxiety disorders, or substance abuse. Challenging appointments with patients experiencing these issues can leave dental professionals drained physically, mentally, and emotionally.4 The potential source of this behavior will be discussed more in this article.

When hygienists, assistants, or dentists call on emotional labor skills to get through an appointment, they engage in either surface acting or deep acting. Surface acting is feigning empathy for another person in order to conform to behavioral expectations.5 In other words, what is felt on the inside does not match the outward communication. There might be a change in facial expression or voice tone to project empathy, but inner thoughts do not match.

For example, when a patient expresses an exaggerated pain response, the hygienist might display a facial expression of concern, but real thoughts are insensitive. Surface acting may seem innocuous, but it is a detriment to clinicians. Studies show the effort to fake an outward expression is draining. Clinicians report feeling numb and removed from the situation, which later solicits poor customer reviews and leads to clinician burnout.1

Deep acting is the opposite of surface acting. Deep acting occurs when thoughts match external behaviors. It is sometimes difficult to use deep acting during times of stress. Remember the old adage, "Fake it 'til you make it"? In situations of surface acting, someone will fake positive thoughts about a patient until the positive thoughts become authentic. This is called reframing of negative thoughts. Repeated practice in reframing negative thoughts constructs new neural pathways in the brain, and over time these new pathways become a natural occurrence and deep acting becomes a natural behavior.6 Replacing surface acting with deep acting is important because research shows that surface acting is a core source of clinician burnout.1

Another way to activate deep acting is by practicing empathy. Empathy is the act of projecting oneself into the situation and feelings of another person. A simple way to practice empathy is to shift thinking about another person from that of judgment to curiosity. For example, instead of thinking, "Wow, I'm only putting a mirror in your mouth, what's wrong with you?" redirect to "I wonder what happened to this person that she reacts in such an extreme manner."

The mere sense of curiosity can change your entire attitude from surface acting to deep acting. If dentists, hygienists, and assistants can achieve this level of empathetic resonance with patients, it can have a profound impact on the relationship and dental practice as a whole. Empathy is very powerful when building relationships with patients. The strength of the relationship between patient and clinician is more powerful than any clinical intervention.4

Compassion fatigue

Compassion fatigue (CF) is defined as "the consequence of working with a significant number of traumatized individuals in combination with a strong empathetic orientation or a formal caregiver's reduced capacity and interest in being empathetic for a suffering individual."3 Compassion fatigue is the result of secondary trauma stress and burnout and is experienced by many health-care providers. Compassion fatigue is also a consequence of ongoing emotional labor (surface acting) and contributes to increased stress and decreased ability to show empathy. When health-care workers repeatedly deliver care to ill, traumatized, or suffering patients, they are likely to experience consequential stress called secondary trauma stress.7 They may experience secondary trauma when required to administer treatment that knowingly causes pain.

The consequences of emotional labor and compassion fatigue create personal strain outcomes, muscle tension, and thinking about patients after they leave.1 Signs and symptoms of compassion fatigue include reduced compassion for patients, nervousness, cynicism, pessimism, dreading work, decreased job satisfaction, and anger toward coworkers.7 Emotional conflict in surface acting might result in emotional exhaustion, making it difficult for clinicians to focus and show true compassion professionally and personally.8

Stress-Stress is a commonly used word in today's busy and chaotic society. You're probably aware of when stress influences daily life, but may not realize the long-term detriment or source of stress. Any profession can require emotional labor and increased stress. Dental professionals have the additional potential stressors of physical demands, hectic schedules, precise motor skill implementation, competent patient education, and intellectual aptitude. In addition to these pressures, dental clinicians perform a multitude of services in a short period of time while executing emotional labor to provide optimal care.1

Burnout-Burnout is described as a "defensive response to prolonged occupational exposure to demanding interpersonal situations that produce psychological strain and provide inadequate support." Psychophysiological symptoms of burnout include sleep disturbances, irritability, resistance to work, aggression, and mental and physical exhaustion.3 The daily grind of dental hygiene and the combination of interpersonal fatigue, emotional labor, and physical strain can easily lead to burnout if not attended to properly.

If we're unaware of the reactions to demands, and we overuse surface acting and acquire compassion fatigue, we're likely to experience burnout. Dental hygienists especially yield and constantly adjust to back-to-back appointments that create an environment for redundancy and burnout.1

Dental fear-As mentioned, a heightened response from a patient can leave a clinician feeling confused, frustrated, and exhausted. It can be very confusing when a patient cries, screams, shakes, or engages in another reactive behavior during a simple dental hygiene procedure. It's important for clinicians to be aware of the potential origins of dental fear in order to acknowledge the patient's experiences and reduce one's own stress.

Statistics show that one in five women is a survivor of childhood sexual trauma.9 Furthermore, and quite disturbing, is the fact that 70% of these women experienced oral penetration during their attacks.10 In addition, anxiety disorders and post-traumatic stress disorder (PTSD) are contributors to the ongoing cycle of dental fear.11 These traumatic experiences result in fragmented memories that live in emotional centers of the brain. These memories can be triggered by something as simple as a mirror or finger being placed into someone's mouth. The act of laying a patient back in the dental chair can also serve as a trigger that provokes intense fear and powerlessness, as it can activate the fragmented memories. From a patient's perspective, the person has no connection between the fragmented memory and the current activity. It feels as if what is currently taking place is a true threat to the person's well-being.12

For a clinician with no dental fear, these responses may seem insincere and activate surface acting that can lead to the hygienist feeling fatigued and the patient misunderstood and embarrassed. Redirecting negative thoughts to those of curiosity about the patient's situation can lead to a better experience for both hygienist and patient.

Coping with stress and burnout

Given the variety of patient personalities and the demands of a hectic schedule, how can dental professionals deal with these daily stressors of patient care without experiencing burnout? New research indicates how to guide thoughts and emotions rather than be coerced by them. The simple act of being aware of one's own thoughts and emotions is the first step in coping and balancing daily stress.13

Now that you know about emotional labor, identify your emotional labor style as either deep acting or surface acting. Take some time to consider how your emotional labor style affects your daily routine, patient care, and mood. If you're a surface actor and would like to become a better deep actor, take steps toward activating empathy through thoughts of curiosity instead of judgment. If you're already a deep actor, just being aware of how you engage with patients is helpful because when you're aware of the inner workings of your mind, you have the ability to move beyond reactive emotions.13 Being aware of your feelings gives you, as the clinician, the ability to slow down and consider your next move rather than engaging in fight, flight, or freeze behavior, or becoming so frustrated your mood and level of care are compromised.

Ongoing self-care in and out of the dental office is crucial to avoiding burnout. A few ways to engage in self-care during the workday include deep breathing exercises, drinking plenty of water, stopping long enough to have a meal, and taking momentary contemplative pauses to be aware of why you're feeling stressed. Any action that brings presence to each moment or reminds someone to connect with what they find most meaningful can be considered a contemplative practice.14

Self-care tips for coping with career stress

1. Deep breathing exercises
2. Drinking plenty of water
3. Stop work long enough to have a meal
4. Take momentary contemplative pauses

Contemplative practices are frequently described as mindfulness. Recent research on brain activity through MRI (magnetic resonance imaging) scans has given science a new perspective in changing the brain and how humans think and process incoming information after using mindfulness practices.6

Self-care such as exercise, diet, massages, meaningful relationships, fun activities, and good sleep habits are important to follow outside of the work environment. Participating in self-care is a crucial part of avoiding burnout and healing from past experiences that have already started the burnout process.

In summary, it's important to consider many aspects in order to avoid compassion fatigue, stress, and burnout. Patients' past life experiences, stress from causing someone physical pain, demands of a profession that requires high level of skill, and engaging in emotional labor for several consecutive hours on a daily basis are all factors that lead to burnout.

Making mindful decisions about self-care, engaging in contemplative practices, reframing judgmental thoughts into empathy, and taking time to check in with your emotions are all effective ways to reduce burnout and have a longer, happier career. RDH

Kandice Swarthout-Roan, MS, RDH, LPC-Intern, is a full-time dental hygiene educator at Collin College in McKinney, Texas. She practiced dental hygiene in private practice for 17 years before returning to school to obtain her master of science in counseling. Kandice is a licensed professional counselor-intern and works with clients on a multitude of mental health and life adjustment issues.

Priya Singhvi, MS, LPC, LMFT, is a full-time wellness educator and school counselor in Addison, Texas. She is a licensed professional counselor and licensed marriage and family therapist, and holds a master of science in counseling from SMU. Priya counsels couples, families, and individuals at Insights Collaborative Therapy Group. She also owns her own education business and public speaking platform called Meaningful Minds. She is currently pursuing her doctorate in family studies at Texas Woman's University.


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