Guest Blog: Granting Ourselves Permission – Why Is It So Hard? by Dr Samantha Anthony

Self-care and regular breaks are essential for our well being at work, but is the lack of “permission” at the heart of why we don’t achieve these most basic of human needs?

The importance of self-care remains in the spotlight, as the covid pandemic has continued to impact upon healthcare professionals everywhere. But this has been a topic at large for far longer, yet somehow has been shadowed in the background of the continued dedication to the
daily grind.

We are familiar with the need for regular breaks, to recharge, replenish, and reset, so we can continue working in optimal ways, for our own good, and for the patients we care for. But why does finding, and taking, opportunities to support our own sustenance and longevity in the profession seem repeatedly challenging, despite the continual encouragement to look after ourselves?

There are numerous barriers, but often overlooked, and more obscured, is that of permission.

In 2016, I was burning out. As a lucky cancer survivor 10 years earlier, I had plunged myself back to work, albeit slowly staged, just 2 months after my life-changing stem-cell transplant, and this was my need, to restore my purpose which was so deeply rooted in my identity as a doctor, and also somehow wanting to prove to my cancer that I could be again what I had been before it. Eventually the impact of work, and life, and health, were colliding, and had sparked a flame that was slowly and silently engulfing me. And whilst I could see and feel the risks getting closer, I felt paralysed and unable to remove myself from this danger in order to survive, recover, and restore my balance once more, and to continue working in a healthier way.

It was only when my husband had a timely job offer abroad for a year, that this became my valid and self-justifiable reason to step aside and take a career break, which in turn prevented me from breaking instead. Initially reluctant, as this imminent change required speedy planning, this break was ultimately life-changing and career-saving, and was easier to enable than I had feared. I have often asked myself why I resisted addressing my needs for so long, and on reflection I see that I was unable to grant myself the permission to do so, as though it was selfish, retracting from the care that I was there to give others. My career break was wholly opportunistic, but it gave me space, perspective, recovery, and a renewed energy for the job I had always loved, and I had no insight of this until I emerged from the embers. And knowing what I know now, I would have given myself the permission far sooner.

We all have an in-built need for permission-from ourselves, or from others. We often seek approval, reassurance, acceptance, support, justification, and validation for our actions, and may lack awareness of this obstacle to our own needs. The duties and time pressures in this 24-7 caring profession, can leave us starved in more ways than one. So understanding and overcoming our barriers to permission, which may be intrinsic or extrinsic, would better enable us to recognise, and respond, to our needs. Unattended to, chronic self-neglect can leave us malnourished, exhausted, resentful, disillusioned, and more likely to leave the profession, with significant impact on mental health. And the suicide rates in healthcare professionals is simply unacceptable-taking one’s life when dedicated to saving life cannot be a statistic any longer.

Intrinsic factors which may hinder permission to self-prioritise might include personality, gender, culture, and past experiences which may drive self-persecuting feelings such as guilt, perfectionism, self criticism, fear of error or judgement, worthlessness, and exhaustion. Emotional challenges, and the inability to prioritise when in the epicentre of chaos may also influence. And all are ironically more likely in the absence of regular self-care.

Extrinsic factors may include available support networks, personal and financial responsibilities, and time constraints. But institutional factors are at large. The culture and expectations within the profession, training, work volume, targets, and rigid job plans, all contribute. And the need to deliver and perform; there are potentially significant consequences of making a mistake, although we are more likely to err if not caring for ourselves. Over-working colleagues, feeling unsupported or undervalued, working in isolation, or in teams where leadership or team dynamics are suboptimal, lack of scheduled breaks, or protected areas to take them, and fear of burdening colleagues may also impact.

Many of these are outside of our control, and we don’t always reflect on how the footprints of our personal traits, individual journeys, and circumstances contribute, but all may affect our confidence, self-awareness, communication, willingness to unburden, or to express or respond to our needs. In our professional roles, we act in our patients’ best interests with ease, our strong duty of care and responsibility propelling us to make health-critical decisions with vigour for those whose health, and life, depends on us.

But we stop short when giving ourselves the same duty of care, taking responsibility for our own wellbeing, and being forthright about what we need. Our powerful override button enables us to ignore our needs despite the alarms that our bodies sound out. Somehow we continue to function, albeit less well. We often wait for permission from others, breaks so often opportunistic, and seldom of our own volition. The more we ignore, the more we lose insight, further marginalising our needs. But as we repeatedly hover on the edge of overwhelm and burnout, it’s vital that we become our own advocates, granting self-permission for purposeful pauses regardless of the external barriers in our way, whilst these must of course also be addressed.

The lack of scheduled, or “permitted” respite in our less structured jobs has wrongly made this “way of life” accepted, and whilst urgent patient needs will understandably prevent or delay some of our immediate needs, we must work together to work better. The idea that we are less important than the people we care for is slowly diminishing, the Hippocratic Oath having recently advocated that we address our own wellbeing. But we are a long way from establishing acceptable changes in workplace culture throughout the NHS. Wellbeing facilities and support for staff initiated during the pandemic have been positive, but finding the time and permission to access them, remains challenging.

Eliminating the unspoken need for permission can happen now: instituting staff wellbeing within departments, for some mindfulness time, physical activity, nutrition breaks, team debriefing, or one-on-one time through mentoring or buddying to enable regular reflection, offloading, and adjusting, beyond the single annual appraisal, can and should be a part of how we work every day. Corporations have long introduced such things, resulting in happy, healthy, valued and thriving employees. Small changes in the NHS, at little cost, can reach all. And self-care education should begin at medical school, if not far earlier in life. Gratefully there are now organisations and charities dedicated to supporting the wellbeing of healthcare professionals, and never more than now have these been needed.

Time is scarce, so making time for self-care is imperative. Abolishing the barriers to permission, the taboos, outdated cultures, and expectations in the profession, creating ways and spaces to make self-care more accessible, introducing new ways of working, and supporting one another in doing so, will establish a thrive culture in medicine. We can’t just survive, we must live, and work, well. Surely we don’t need permission for that.

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