|Year : 2010 | Volume
| Issue : 1 | Page : 35-37
Mid-career blues in healthcare workers: A physiological approach in ethical management
Department of Physiology, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
|Date of Web Publication||3-Aug-2010|
Associate Professor, Department of Physiology, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pakkala A. Mid-career blues in healthcare workers: A physiological approach in ethical management. J Mid-life Health 2010;1:35-7
| Introduction|| |
Mid-career blues are a state of mind resulting from occupational exposure to physiological and emotional stress, which manifests through a combination of negative attitudes. Any demanding profession carries with it this hazard. A professional sensing a lack of control over work, a lack of interest, and a sense of being unhappy signals the herald of this phase. It continues as a tendency to undervalue and discredit performance and a desire to get away from everything at work. Unhappy people spread unhappiness. Mid-career blues not only affect the individual, but also tend to bring down and demotivate others in the organization.
There is evidence that some forms of psychological well-being are related to subsequent in-role performance, although the evidence for a causal influence of work stressors on job performance is much weaker. There is also evidence for relationships between some job stressors or well-being and organizational citizenship behaviors. In general, research conducted at the individual level indicates only weak or provisional relationships. A small number of recent studies indicate stronger associations between average levels of well-being in an organization and organizational level . 
The stress factors in a healthcare professional range from personal to job related to organizational. Highest stressors included excessive workload, increasing overhead, departmental budget deficits, tenure and promotion, disputes with the dean, and loss of key faculty. Personal-professional life imbalance was identified as an important risk factor for emotional exhaustion. Withdrawal, irritability, and family disagreements are early warning indicators of burnout and emotional exhaustion.  All these result in progressive emotional exhaustion and behavioral symptoms of mid-career blues.
| Signs of Stress|| |
Mid-career blues adversely affect performance of an individual in the short run and may bring down the productivity levels in the health institution. The older adage that drive depends on an adequate level of stress is no longer held true. The signs of stress all have an additive and accumulative effect. Task performance tends to drop.
The signs of stress lead to the typical burnout in the form of chronic exhaustion, a cynical attitude to work, lack of commitment, irritability, and mental depression. Psychosomatic complaints are common in advanced stages.
| Role of Hormones in Mid-Career Blues with Relation to Menopause and Andropause|| |
Genomic actions are exerted by steroids such as estrogen, progesterone, DHP, testosterone, and DHT binding with intracellular receptors.  Alternatively, 3a,5a-THP and 3a-diol have nongenomic actions at GABA-a receptors.  All of these hormones can target the hippocampus and amygdale, brain areas involved in anxiety and depression.  This is critical to our growing population of peri- and postmenopausal women. The prevention and treatment of negative affect associated with menopause is becoming increasingly important. Gender/sex differences in the prevalence of neurodevelopmental and/or neuropsychiatric disorders indicate a role for steroid hormones.
Various data suggest that natural changes in endogenous estrogen levels may underlie women's increased susceptibility to affective disorders and lower estrogen as a result of aging can cause anxiety and depression in women. The hippocampus and the amygdale are rich in estrogen receptors, and both these areas are affected by aging resulting in anxiety and depression. Similar to estrogens, progestogens vary across hormonal cycles and can have neuroprotective effects. The levels of progestogens decrease during postmenopause, a period when anxiety and depression are most likely to occur. Progestogens may act in the hippocampus and amygdale to produce antianxiety and antidepressive effects. Progestogens and its metabolites alter function of hypothalamo-pituitary axis [HPA] and affective responding. 
Both young and aged men with lower circulating levels of androgens are more likely to be diagnosed with an anxiety or depressive disorder. , Aging is associated with a decline in endogenous androgen levels, which occurs concomitantly with increased anxiety and depression. 
| Physiological Strategies to Beat the Blues Away Before They Get You|| |
Strategies at the individual and organizational levels are needed to overcome this problem.
At the individual level, some of the following techniques are useful. Muscle relaxation, bio feedback, meditation, cognitive restructuring, and time management are among them . 
De Berry studied the following parameters: (1) state and trait anxiety, (2) self-report muscle tension, (3) hours to fall asleep, (4) number of nocturnal awakenings, and (5) headaches related to stress. Results indicate that with the exception of trait anxiety, the experimental group manifested significant improvements on the remaining five measures from baseline to end of training. For state anxiety, a significant improvement continued during the 10 weeks of home practice following the end of training. 
Ericksen et al. suggested that within the Cognitive Activation Theory of Stress (CATS), the stress response occurs whenever there is a discrepancy between what the organism is expecting, and what really exists. It affects the biochemistry of the brain, mobilizes resources, affects performance, and endocrine, vegetative, and immune systems. Initial positive feedback and feed-forward mechanisms are gradually changed by homeostatic mechanisms. Slower reactive hormones such as cortisol seem to dampen the initial response. The time course may depend on psychological mechanisms. Subjects with efficient coping show the fast- and short-lasting catecholamine response, whereas subjects with high-defense mechanisms (related to stimulus expectancies) may show more signs of prolonged activation. Noncoping individuals show a sustained general activation which may develop into somatic disease or illness. 
Schilling and Poppen studied behavioral relaxation training (BRT), a set of 10 overt behaviors directly taught by prompting and performance feedback, was compared with frontalis EMG biofeedback (BIO), progressive muscle relaxation (PMR), and a Music "attention focusing" (MUS) control, on five dependent measures of relaxation, in four groups of volunteers for a "stress-reduction" project. The dependent measures consisted of the Behavioral Relaxation Scale (BRS), frontalis EMG, finger temperature, skin conductance level, and self-report. BRS scores decreased in BRT, BIO, and PMR, but not in MUS groups. EMG decreased in the BRT and BIO groups, but not in PMR or MUS. BRT retained its improvements at 4- to 6-week follow-up. All groups reported similar improvements on the self-report scale. Temperature and skin conductance were not systematically related to training procedures. Significant correlations between BRS and EMG were obtained. 
Tsai and Crockett studied effects of relaxation training, combining imagery, and meditation on the stress level of Chinese nurses. The results supported the hypotheses that the relaxation training decreased the Chinese nurses' self-reported work stress as measured by NSC and increased the Chinese nurses' self-reported psychophysiologic health as measured by Chinese General Health Questionnaire (CGHQ). The significant difference on means of the CGHQ in post-test 1 at week 2 showed that the self-reported psychophysiologic health level responded to the relaxation training earlier than to the self-reported work stress level. In the relaxation treatment, duration of practice was an important factor of the effectiveness of the treatment on the dependent variable of NSC. It is suggested that even brief teaching of relaxation techniques may reduce work stress levels and promote a sense of psychophysiologic health in Chinese nurses who are employed in large teaching hospitals in Taiwan. 
Building on the strength of marital and family bonds, improving stress management skills and self-regulation, and improving efficiency and productivity can combine to assist the orthopedic surgery leader in preventing burnout and emotional exhaustion. 
Intervention at the organizational level is of more importance as it tends to have a generalized effect on all workers and attacks the very important cause of mid-career blues.  Some of the important strategies in this front are as follows.
Improvement in physical work environment
A clean and ambient work place with adequate provision for rest and recreation has to be provided. Ergonomically designed furniture and safe equipment for information technology are very essential. Easily accessible hygienic facilities which are sometimes not available should be accorded due priority.
Job redesign to eliminate stress
The nature of job is an important factor in causation of stress. Care should be exercised in design of specialized parts of a job. Adequate clerical support is essential for any specialist to concentrate effectively on his work. The tendency of jack-of-all-trades should be avoided.
Changes in workload and deadlines
A triage of work schedules is important for any organization as always resources tend to be scarce. Priority should be accorded to emergencies and realistic deadlines set for other work. This will prevent a lot of mental stress and agony at the work place.
Minimum bottlenecks are always good for a smooth chain of events. This also provides for autonomy at the level of healthcare workers, fixation of responsibilities of an individual and instills a sense of job satisfaction. The number of managers for a given number of "the managed" should always be less. The middle management level cadre in a hospital should place confidence in the lower level staff and not take the strategy of the "white man's burden."
Changes in work schedules
Flexible hours of work should be considered for the needy group. No group should be subjected to a continuous exposure of perceived difficult or busy work schedules. Rotation of work schedules is an important tool in the hands of the management for effective utilization of available human resources.
Management by objectives
Goal setting especially in the short run helps in managing things efficiently. The targets to be achieved should be realistic according to the prevailing conditions. No group of workers should be subjected to multiple targets at the same point of time as this is likely to result in inefficiency.
Employee participation in planning changes
Opinion of all employees must be sought whenever a change is planned. This instills a sense of ownership and also helps in eliciting a genuine feedback. Many a heartburn is prevented by getting employees a say in work-related matters.
Reorientation and continuing education
Workshops involving subject specialists help employees update their skills and knowledge. Better focus on career and newer areas always refresh the mind.
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