Work–Life BALANCE: How Some Case Managers Do It!

Abstract

Estimates of the health care workforce place the number with burnout symptoms as high as 60%. Case management—whichever discipline you practice in—is a stressful job, fraught with compassion fatigue and physical, mental, and spiritual signs of burnout. If not careful, those feelings can spill into one's entire life. A small convenience sample was used to determine how some case managers find their work–life balance.

Estimates of the health care workforce place the number with burnout symptoms as high as 60%. Case management—whichever discipline you practice in—is a stressful job, fraught with compassion fatigue and physical, mental, and spiritual signs of burnout. If not careful, those feelings can spill into one's entire life. But these numbers also apportion that at least 40% are still engaged and healthy; this translates into better quality of care and compassion for our patients/clients.

So how do these health care workers keep their equilibrium when their colleagues are floundering? There are some important elements of resilience that relate to work–life balance: Most important may be incorporating “balance points” in one's life. Often, this is a hobby or a passion for something far removed from the typical work we do in case management ... and it seems to provide a “secret sauce” for a more symmetrical life. Within the Care Management department at Mayo Clinic Hospital, Arizona, I have witnessed incredible talent among the staff in such varied activities as opera singing, classical guitar, cello, and artistic quilting.

Seeking to understand what some colleagues do to balance various parts of their life, possibly preventing burnout and compassion fatigue, a “convenience” survey with two simple questions were sent via REDCap to 138 multidisciplinary staff members, including nurses, social workers, chaplains, and case management assistants. The two simple questions were as follows:

1. What do you do outside work, which provides a balance to the daily triumphs and challenges of your work–life in case management?
2. Does this activity enhance your life at work? If so, how?

This Editorial warrants two operational definitions: burnout and compassion fatigue.

• Burnout: American psychologist Herbert Freudenberger coined the term “burnout” in the 1970s. He used it to describe the consequences of severe stress and high ideals in “helping” professions (such as case management). There is no clear definition of what burnout really is. As a result, the lack of definition makes it impossible to say how common burnout really is (Anonymous, ²⁰¹⁷).
• Compassion fatigue: The formal caregiver's reduced capacity or interest in being empathic, bearing the suffering of clients. It is the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced or suffered by a person. It has been attributed to the “cost of caring” (^{Figley, 1995}).

Statistics

The last Role and Function Study, conducted by the Commission for Case Management Certification, cited this breakdown of where health care workers practice (^{Tahan, Watson, & Sminkey, 2015}); however, it does not reveal levels of fatigue in these settings:

• 28.94%: Health insurance plans
• 22.76%: Hospitals
• 11.6%: Workers' compensation
• 7.3%: Independent care/case management
• 5.48%: Ambulatory/outpatient care
• 2%: Acute rehabilitation
• 3.64%: Veterans health or other government agencies
• 2.28%: Home care
• 1%: Skilled care facility

General statistics mentioning compassion fatigue and/or burnout were difficult to find, specifically on case managers. Although the incidence of burnout is at an alarming rate across all health care disciplines (including nursing, mental health, physicians, and social workers), these statistics cite general health care workforce, nurses, and social workers as the best disciplines to use vicariously:

• 30%–45% of social workers leave their jobs within 2 years, with turnover rates 215% higher than other roles (^{Public Consulting Group, 2018}).
• 43% of new nurses leave their jobs within 3 years; turnover for a bedside RN resulted in the average hospital losing up to $8.1 million annually (Streamline Verify, ²⁰¹⁶).
• A 2013 survey of 508 employees working for 243 health care employers found that 60% reported job burnout and 34% planned to look for a different job (^{Bodenheimer & Sinsky, 2014}).
• Thirty-four percent of hospital nurses and 37% of nursing home nurses report burnout compared with 22% of nurses working in other settings (^{Bodenheimer & Sinsky, 2014}).

In our little case management survey, of the 138 surveys sent out, 32 staff members replied (approximately a 24% response rate) (see Table 1):

1. Some common themes for work–life balance includes:
• Faith
• Meditation/mindfulness
• Exercise
• Nature/animals
• Family, friends
2. Four of the 32 who responded deemed their out-of-work activities as “not really” or just “somewhat” helpful in balancing out their work–life.

TABLE 1 - Work-Life Balance: How Some Case Managers Do It

	What Do You Do Outside Work, Which Provides a Balance to the Daily Triumphs and Challenges of Your Work–Life in Case Management?	Does This Activity Enhance Your Life at Work? If so, How?
1	I bowl in a league once a week, and I bead jewelry—I also design my own patterns. I also spend time with family and friends away from the health care setting.	Dealing with life & death can be very exhausting. My hobbies and activities outside of work give me meaning and purpose and joy. I laugh and enjoy the beauty of life with people that I love.
2	I make key chains/planner charms. I plan in my planner, gratitude journal, walk my dog, exercise and make time for friends and family.	I think it does. I especially believe that gratitude journaling helps because it helps me stay mindful and appreciate all that I do have in my life.
3	Sew. Walk. Play with grandchildren. Nightly glass of wine.	Relaxation. Improved mood. Decreases blood pressure. Promotes restful sleep.
4	Exercise and making wreaths.	Helps to release stress and tension.
5	Spend time with family and friends. Go to Broadway shows, restaurants, Ballet, etc.	Doing activities that are completely different from work and enjoyable give me a sense of satisfaction and therefore feel no stress or resentment about the time I spend at work. Having plans for future activities gives me something to look forward to while at work.
6	I have a passion as a reseller (clothes and accessories) and an online boutique owner. I also love taking on older dogs or dogs who are difficult to home.	Yes, I find my other interests fulfill a more creative/entrepreneurial side.
7	Play the Native American flute. Walk my dog and take long hikes on area hills and mountains.	Yes, it rejuvenates me and allows me to focus at work.
8	First and foremost get adequate sleep!! I have a strong faith life that grounds me to my importance in the world. I love riding my horses, playing with my animals, and gardening etc. all done with my family. I love to travel and take regular vacations just my husband and myself without the pressures of children. Lastly, I do try and workout and eat well.	My faith life allows for meditation and practice of gratitude and forgiveness, very important in a stressful job. The value of understanding that I am just a dot within the whole is also very important (humility)
9	Work in my garden. Currently, I have garlic, tomatoes, chilies, mango, and pineapple. I also like to plant a variety of colorful flowers like sunflower, snapdragon, cosmos, marigolds, and petunias throughout the yard in pots, logs, barrels, and in a flower bed.	Yes, it takes away the stress and helps me to relax. Gardening makes me happy so when I go back to work I'm in a good mood.
10	I really like to spend my time at home with my husband and my fur babies, including two cats and two dogs. At home, I like to go outside and swim in the pool. I also like to sing, but keep that within the confines of my home, as well.	No, it doesn't really enhance my life at work, I find. I just pine away wanting to return home.
11	Involved in serving with High School Ministries and helping them with outreach projects. Hiking on weekends, trying to get up before work and walk/run.	(no response)
12	Spend quality time with my adorable kitties—pet therapy.	It puts me in a calming frame of mind to start the day. No matter how bad the day is, I know they will come running to greet me when I arrive home. The bad day vanishes when I see their cute faces. They just can't wait to get on my lap for some attention.
13	I enjoy listening to music, reading, sewing, walking, and meeting up with friends/family.	Walking is really great for a stressful day and helps the body to “let go”! Music helps slow the heart rate as you visualize your best place to be. Then you don't allow this to impact home life or bring the stress back to work.
14	Music is something I often turn to mostly. Outside of work I often crochet, sew, or do little home projects involving planting.	I choose to do these home activities for my creativity. Sure it works out for me both at home and at work. I usually just shut down my work mode after leaving at the end of the day and refuse to mix work issues with home.
15	I love music and I love to sing. I sing on the way to work and on the way home from work. I usually listen to music during the work day as well. Singing along with my favorite songs really gives me a sense of peace and happiness.	I would say it does. Music is a very big part of my life. I could not live without it and the fact that I listen to music on the way to work, during work, and after work, really helps with my mood, which, in turn, adds to my job enjoyment.
16	Gym-work out at least 3–4 times a week.	Yes, in that it manages my stress in a healthy way and helps keep my head clear.
17	Sleep, spend time with friends, and shop.	Yes, It gives me a healthy break from work to think about things other than work.
18	My faith in God. I spend time each day reading the Bible and in meditation/prayer. God gives me strength & solace to face each and every day. God gives my life purpose and meaning and I look to the future (whatever it holds) with confidence & peace.	Yes, as all I do is as unto the Lord. When at work I give my best and I ask God to bless it & to allow all I do to minister to those I come in contact with.
19	Exercise and animals.	Not really. Just keeps me sane
20	Hobby and taking classes related to my hobby.	It gives me something totally non-work-related to think about and focus on; an opportunity to clear my brain from work-related issues—hands-on and creative
21	Yoga, aviation aerobatics with an instructor.	Yoga provides concentration, balance. Aviation is my passion; “born to fly, forced to work.”
22	Spend time with children and/or grandchildren doing activities—attending their sporting activities, going places of fun, going out to eat; spend time with friends; go up into the mountains and hike; go shopping.	It refocuses me on what is really important in life and helps put things in better perspective.
23	Workout 3–4×/week; happy hour and dinner with friends; attend church on Sunday mornings and go to the movies.	The activities help to manage my stress and allow me to decompress after a stressful day or week at work.
24	Bike ride, hiking, swimming, eating out. I'm also an avid moviegoer.	Yes. Having interests and activities that bring joy help to alleviate stress and break up the routine of working.
25	Hiking, swimming, socializing with friends.	Somewhat. It allows me to practice mindfulness and participate in physical activity.
26	I cycle and hike on the weekends. I try to leave on time and not forget that I have a family at home.	I feel refreshed when I return to work after the weekend. It is always a balancing act when trying to do the best job you can do and also trying to put your family first.
27	Exercise (riding a bicycle, yoga, weights) with my wife. Listening to, writing, and playing music (I play guitar). Reading fiction or watching fictional movies/TV shows for a break.	Yes, I think anything that changes my focus to something other than work improves my work–life balance, which enhances my life at work by refueling my emotional energy. (I am a Chaplain, not a Case Manager)
28	Music: Harp, piano.	Yes, I use a totally different side of the brain than at work.
29	Garden participate in the arts spend time w/family & friends.	No
30	I have a very strong social life—many happy hour/meals with friends. I also make time to be outside and take day trips. I exercise 3–4 times a week. I practice mindfulness and meditation. I'm starting to give to charity through a donation of proceeds from a side business. I'm starting to explore more hobbies and try new things.	By staying connected to my personal relationships, it energies me and fulfills me. By living life fully, being grateful, finding the positives and recognizing that which I can control and that which I can contribute. It's important to have a work–life balance and find your purpose in more ways than your career ... it's all about relationships.
31	I am a writer. I have written a children's book and it is copyrighted. I am in the process of finding an illustrator to bring it to life so I can publish it. In the meantime, I am teaching myself to play acoustic guitar and piano. I truly have a love and passion for the arts!	Absolutely! It helps me “think outside the box” or professionally stated, to “critically think.” God did not create us to be one-dimensional beings. We must incorporate extracurricular activities into our daily lives so that we become and remain balanced individuals. Being balanced is the key to having a fulfilled life. One who is fulfilled will never burn out!
32	Spend time with my family, exercise, read, and watch TV shows with my husband.	Provides a good balance when things get stressful.

How Some Case Managers Find Their Balance

Other than a few editorial changes, these are the exact words of the staff. In the Preface in my first case management book (^{Powell, 1996}), I wrote:

Case management is an important area of (healthcare), both for its contribution to humanity and because case managers play a key role in impacting the healthcare crisis ... case management is an exciting challenge ... and (case managers) are in a unique position to be recognized for their contribution to healthcare. It is my hope that this book will help develop case managers who have peak job satisfaction and who will be recognized as shining lights, pulling the fragmented pieces of healthcare together.

This stands as true today as it did more than 20 years ago. But since 1996, health care has changed dramatically and evolved at a critically fast pace, with the costs often being at the expense of the health care providers' equilibrium.

As the theme of the National Case Management Week implies (Moving Patients to Wellness), we must first move ourselves to wellness. So, I offer this convenience study as a first step, giving ideas of how some in our profession are creating a more balanced life with important self-care strategies—strategies that often culminate in having more energy to “be there” for our patients. I welcome you to take this small study and figure out the “next steps” to help the caregivers stay sound.