An episode of “Changing the Conversation” podcast
Kathlynn Northrup-Snyder and host Ali Hall discuss addressing burnout with Motivational Interviewing.
May 8, 2023
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Ali Hall, Host (00:05): Hello and welcome to Changing the Conversation. I’m your host today, Ali Hall. I work as an independent trainer and consultant in motivational interviewing, and I’m a member of the Motivational Interviewing Network of Trainers or MINT. I’m joining you today from San Francisco, California. Our topic is MI and burnout, and my guest today is Dr. Kathlynn Northrop-Snyder, a good colleague from the MINT, specializing in health promotion behavior change, a career public health nurse and faculty from Oregon Health and Sciences University, calling in today from Washington State. Thanks, Kathlynn for joining us today.
Kathlynn Northrop-Snyder, Guest (00:43): Hi, Ali. I am so very excited to be here.
Ali (00:46): And this is an exciting conversation. In preparing to talk with you today, I learned that more than 76% of employees experience burnout on the job at least sometimes. 28% say they’re burned out very often or always at work. And not to even get into sort of the economic outfall from that, but in any case, it is serious and pervasive. Let’s back up a second, what is burnout?
Kathlynn (01:14): So there’s different definitions. I like the one from the World Health Organization that says it’s basically a poorly managed chronic workplace stress, and it’s often characterized by energy depletion or exhaustion, discontent and disconnection from the job, and it reduces professional efficacy. Bill Miller and Vivek Murthy, our US Surgeon General, also I like how they tied it into the concept of loneliness and a disconnection.
Ali (01:44): Well, that’s fantastic and really helpful definitions. I think we have always suspected that MI would have some potential to prevent and ameliorate burnout, but you have a particular reason to believe that that’s true. Please say more about that.
Kathlynn (01:59): Yes, I think the workplace has a lot to do with it. I know myself, I ended up experiencing burnout. And so a visual of that, there’s a lot of really good metaphors related to the idea of you need to get a bucket of water and fill it up every day if you can, and then as you dip out of it to take care of others, you need to remember that you’ve got to fill that bucket back up. Otherwise, you get down into sort of the mud and the icky stuff at the bottom. I was one of those people who dipped out and forgot to fill up, and I got down to the mud. I emptied the bucket, I ended up emptying the well supply and pretty much everywhere I could look around and see was dry as a desert. It was just my whole body was empty and all the pieces related to it, the fatigue and everything else, were painful, because I’m a doer, and the Energizer Bunny batteries were completely gone.
(03:01): And it took a long, long time to recover from that. So that’s my personal reason. And then I think the rest of the options are just related to motivational interviewing and the idea that it’s such an awesome connector for people. It’s helped me in my connectivity with people and certainly the community has helped fill my bucket.
Ali (03:26): So there are ways that we can recharge through the collaborative and autonomy supportive framework of talking with people in MI that we can in fact re-energize because not only do our batteries get depleted, but even the backup supply ends up running down, or our spare battery ends up running down.
Kathlynn (03:45): Absolutely, yeah. And other than the visual I gave you, it’s really, really hard to describe that emptiness almost, that happens, and that inability to be able to just fill it back up for a really long time until you figure out some of the strategies for doing that. And for a healthcare caregiver, that’s a tough one, because that’s our nature is to give. And when you have no more to give it’s really hard.
Ali (04:15): What I’m imagining is, particularly for healthcare providers who feel the need to be compassionate all day, to give to others, to care for others, that this idea that everything’s always kind of going in one direction, in an outgoing direction, that maybe there’s even a fear or an apprehension about MI, about connecting more with others and thinking of that even as a source for refueling ourselves.
Kathlynn (04:41): I agree. I hear that all the time from providers when I’m teaching them motivational interviewing. It’s been fascinating because I have heard providers say by taking the time to use MI I actually save time because I’m having better breakthroughs with the clients that I’m working with and it’s worth it. And there are a couple of doctors in a local Oregon area are known as the superstars and all the patients want to go see them because the patients feel understood, and the provider is re-energized by that loop that’s created with that connectivity. So yeah, there’s definitely a need, I think, for it, it’s just, I guess, trusting the system and seeing what happens.
Ali (05:28): So it really is mutually reinforcing then to express empathy, to express compassion, to express collaboration, and that connectedness is actually something that helps us rather than drains us. But say more about your study and some of the powerful things that participants said.
Kathlynn (05:47): I was able to, because of my teaching, I taught online for a long time in both the School of Nursing and the School of Public Health, so I had this wonderfully rich qualitative data from a variety of healthcare professionals, most of them fairly seasoned. They were about midpoint in their career and their age groups. It was fun because I did a search for MI and then the different words for burnout. People use moral dilemma, compassion fatigue and moral distress. And so looking at those, then I tied that together and started looking at what did they have to say? And it was fascinating because in the large part, really what spoke to me in the qualitative data, was the idea that it’s about the spirit, what you just mentioned, very much so.
(06:37): When they learned that empathic understanding and realized that non-judgment and acceptance meant that they had a better relationship with their client, and then on top of that being able to emphasize their client’s autonomy, it opened so many doors for them. I’ve heard people say it just takes a weight off of their shoulders that somehow they can control their patient’s story. And when they realize that, no, all they have to do is try to understand it, it made all the difference.
Ali (07:07): So something powerful and liberating about taking the burden off of our shoulders to solve everything around us and making decisions for people, all of that of course is impossible. And when we start to express autonomy support and work with others in a collaborative way, it sounds like not only does it help with burnout that we might be experiencing, but we actually get better outcomes and we make better use of our time with others.
Kathlynn (07:30): Exactly. Now, I do want to hold a candle up to the other part, and I think this comes back to the bigger picture of the workplace issues that create burnout. But I did understand one nurse was saying as hard as we work, we’re putting out all this energy, and then MI does take some brain energy. And there was that concern that that would be one more thing that would be difficult to give energy toward. So I want to just recognize and accept that, yeah, it does take some brain energy, especially as your first learning. With that said, though, I do want to recognize that the vast majority of the healthcare workers that I taught in class only had a very brief intro to MI, so the skillset of MI was still very beginner and probably rocky. The spirit in MI though, I think that’s the clincher. I think that’s the part that really makes all the difference.
Ali (08:29): So if providers can learn to express MI spirit more effectively, that in and of itself may begin to change the flow of things.
Kathlynn (08:36): Exactly. So if it’s okay, I want to share a quote from one of the folks who had had actually a larger experience with motivational interviewing in their own career. This person said, “My level of burnout has ebbed and flowed over the years. When it has been at its worst has been when I’ve been less committed to the use of MI techniques, becoming too aligned with the client’s success or my definition of that success for them. And getting back to MI helps alleviate some stress because it often results in the client’s reporting improvements because we’re back to their goal identification and their recognition of the issue, not mine.”
Ali (09:17): That’s fantastic. It really reminds me of Bill Miller’s often used metaphor, dancing rather than wrestling.
Kathlynn (09:24): Exactly, exactly. I’m going to also, I guess, link it, if you will, to the concepts of diversity, equity, inclusion, and belonging and justice. I did a little bit of research that tied MI to some social justice issues. When we take the time to hear someone else’s story as opposed to making assumptions about that story, which we know so little about, and of course taking the time not to have any judgements about anyone, there’s that connection, and it doesn’t matter who you are or what you bring, that connection fills in that information.
(10:04): And again, another quote, if it’s okay, was a provider who had that experience where they said, “When I’ve taken the time to listen and ask questions and almost every time, once I have more of the context of the behavior that I had been baffled by, all of a sudden it makes so much sense. So I try to remember that while I may have a quicker session without using MI and sharing all the education I think the client needs, if I haven’t taken the time to understand my client’s context, their barriers and strengths, I’ve just really wasted both of our time.”
Ali (10:40): That’s really powerful. So really coming from a position of cultural humility and being interested and curious about the perspective the other brings in that may be different from different privileges, say, that we might be centered in, we’re really hearing what the person’s experience is that may also help us tailor some ideas that we have for them and help the other person use the ideas that they already have inside.
Kathlynn (11:03): Exactly. And we have to remember that we can’t dance our song, we have to dance with someone, and the song may be something we’ve never heard before and so we just have to go with it. And of course, we have our skillsets, we have our education, we have our experience, that all comes to it and will influence how we choose to dance. But it’s still a new song and it’s still someone else we’re dancing with. It makes such a huge difference. I think for me, what drew me to MI in the first place, and this is because I am a public health nurse, when I would go visit people in their homes, I couldn’t stomp in and say, “Okay, I’m here to tell you exactly what to do.” They would just basically show me the door.
(11:51): So I had to deal with cats and dogs and other people as I’m trying to do my assessments, and temperatures, sometimes at 80 degrees in some of the elderly homes that I would visit, and you roll with it. You learn how to work with that person and those needs. And so MI spoke to me because it gave me some more conversational tools, but the spirit was already there because I had to be present and ask and work with the person in their own environment to make any forward movement and to build that relationship.
Ali (12:25): And sure, a relationship certainly isn’t built by showing up to someone’s doorstep, barging on into their living room and rearranging their furniture for them. I mean, you’ve really got to value their expertise and bring that forward and appreciate and be interested and curious. Reminds me too of the beginner’s mind that we talk a lot about in MI.
Kathlynn (12:44): Yes, I agree, and I think it’s really important that we always approach with that. I think there’s another piece which helps with that non-judgment piece. Another person had mentioned that they had been really familiar with MI saying that, “My knowledge of MI is beyond novice, but my application of MI is still squarely in the novice category and it was really humbling to put myself through a rigorous and goal setting process and try to achieve behavior change.” This is because in the course I required everyone to work with a couple of goals throughout the course and basically use their experience of that to address things like the stages of change and the other theories we used.
(13:31): So this person had that experience. So what they said is, “By putting myself through that rigorous goal setting process and trying to achieve behavior change, this is the same type of change that I encourage, admonish and sometimes try to extract from my patients. How gratifying though to approach patients from a more authentic, empathetic place when it comes to encouraging goal setting and health promotion.” So by having that lived experience helped to remind this person that, exactly, I don’t always understand that other person’s experience. I thought I did, but nope, it was something quite different.
Ali (14:08): And it really reminds us of the difference between knowing and being able to do, and great, it sounds like a particularly practical application course. I think it would be difficult at this point for any provider in human services to not have at least heard about motivational interviewing. To assume that one knows a lot about it is one thing, but the ability to do, as you say, is another. I’m wondering, since this is such a powerful approach and we know that it transforms providers’ lives, those who we serve, what are some ways organizations can support individuals to use MI effectively and hence reduce burnout?
Kathlynn (14:49): It’s tough in today’s healthcare world with so many staff shortages. One of the studies that I read was done by Dallâ Ora and she specifically looked at the idea of what were all the issues that affected burnout in the workplace, and in this case it was focusing on nursing. So issues related to workload everyone’s aware of since we do have staffing shortages, but also that there’s a lot of flexibility in the schedule, which makes it hard for us to turn into a time of expectation for when we’re there, when we’re not there, being present and then clocking out. There’s also problems with how many patients, too, in this case nurses, those ratios. There’s also a disconnect with value sometimes, what is the provider’s value isn’t always mirrored in the workplace’s values. And of course definitely an increase in demand for the providers to be 100% present all the time for a higher level of clients.
(15:49): Then there’s of course just basically poor relationships within the workplace and difficulty then as an overall picture of that work-life balance. So I think the big picture is we focused a lot on ratios, we focused a lot on work, but as an example, if we think about this idea of loneliness that Dr. Murthy brings up, it’s this bigger story of when I started nursing way back in the dark ages, [laughter], there was this sense of being able to have a patient for a period of time and build that relationship which allows you then to create change. Now, I don’t think that there’s a nurse that receives the same patient more than two shifts in a row, if that even. And so it’s a harder struggle. So part of it, I think, is the workplace recognizing that there is value in that connectivity for both the patient and the staff, the providers.
(16:46): I think the rest of it though is how do we structure our workplace? And if you will, if motivational interviewing was brought in as the communication style from admin all the way down to janitors, think what a difference that would make. Where each person coming, whether it’s a support visit, where the supervisor’s having to say, “Hey, you keep turning up late,” if that was motivational interviewing in a conversational style, to having bigger meetings and exploring what does everybody really need? And it’s such a different way of looking at the world that isn’t always used because we keep looking at bottom line and it’s hurting everything and hurting everybody.
Ali (17:38): It almost sounds like if we do really look at the bottom line, we might start to realize that a little bit of time spent here results in a really tremendous outcome on the other side. So maybe some structural or organizational changes that key thinkers can work on to generate more opportunities to learn MI in the setting to value the expression of MI spirit, no matter who’s having a conversation with who. Maybe even a role for brief motivational conversation. What do you think about that?
Kathlynn (18:07): I absolutely agree. What my particular study looked at certainly wasn’t just the skillset, it was really about the spirit of coming in and not making judgements about your coworkers or about the admin or other people. So part of it’s just simply being there and being present, I think. And a silly side note to that, I really love the show New Amsterdam, and it’s because of exactly that. Our hero comes in and saves the hospital not through doing all the great usual things and making the stockholders money, [laughter], or keeping the bottom line as tight as possible for profit reasons. No, he starts looking at the bigger picture of so what is it that you need? What will make it easier? And coming up with amazing creative solutions that make a difference not just in the hospital, but also in the local community. And that’s really where we’re at.
(19:04): If you will, one final quote that’s sort of similar to that big picture was this one person seemed to capture that spirit, that context, if you will, saying that, “Rather than just focusing on the skills but instead focusing on the spirit with dealing with the ethics and, if you will, difficult to manage patients, and let’s add other situations like at work, when I reflect on cross-cultural effectiveness of MI I think that it’s really effective related to the partnership, the acceptance, the compassion, and the evocation, both in spirit and technique.” Because regardless of culture, we all want to be respected, accepted, heard, and empowered. And I think that’s the issue, is we need to reconnect. We need to go back to a time when we took the time to hear each other.
(19:56): That’s what I think our communities of healthcare need to remember. That doesn’t mean just for our patients, yes, huge, please do it, it also means for working with each other, no matter a flat hierarchy, a top-down hierarchy, it doesn’t matter. We all connect. We’re all human, and we have to work through all of that and find that connection and, as you said, dance together.
Ali (20:19): So connection is, at very minimum, the starting place for healing. Kathlynn, thank you so much for joining us today. A timely topic, not likely to go away, so we appreciate your contributions not just to this, but for everything that you do to make the world a better place.
Kathlynn (20:36): Aw, that’s sweet. Thank you. I really appreciate being here, and thank you for letting me talk about one of my passions, MI.
Ali (20:44): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (20:48): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode is produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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