Burnout: causes and preventions
NeuroNotes#4 : long-form with references
This article is a deeper dive into our blog on burnout. If you’re looking for the blog, it’s available here:
Burnout is a serious issue, especially in healthcare. Technology will be part of the solution, for instance, by helping to identify shift patterns that increase the risk of burnout or notifying surgeons when they are more likely to make mistakes.
Unfortunately, large institutions often lack the structure and personnel to make changes, even if technology is lighting the way. This leads to a greater risk to the health of employees and more cases of burnout
This needs to change; indeed, burnout is often seen as an ‘outcome’ of being a nurse (Dall’Ora et al., 2020). However, there are other tactics that nurses and doctors, along with everyone else, can employ to reduce the likelihood and severity of burnout.
Background
The term “burnout” has seen a recent resurgence in popularity due to the stresses of the COVID-19 pandemic. There is empirical evidence to suggest that the pandemic was a trigger for this resurgence, not just in popularity, but in the condition itself (Edú-Valsania et al., 2022).
(numbers taken from a search for burnout articles on sciencedirect.com on 03 01 23)
A 2019 study estimated that the organisational cost of physician burnout in the United States alone was $4.6 billion, or an annual cost of $7,600 per physician employed (Han et al., 2019). This was deemed a conservative estimate, not accounting for the effects of poor patient care, lower patient satisfaction, and resulting malpractice suits (Williams et al., 2007; Balch et al., 2011).
What is burnout?
Burnout is the result of chronic stressors in a job that trigger a psychological response (Rossi et al., 2006; Bayes et al., 2021). According to the multidimensional model of burnout (Maslach, 1998), this is expressed as extreme exhaustion, a lack of engagement in the job role, and a feeling of poor ability or failure to be successful in the role. The two main components, repeated in other analyses, are emotional exhaustion and depersonalisation (Lee & Ashforth, 1996; Lin et al., 2021).
What are the outcomes of burnout?
Burnout causes both behavioural and physical changes. Behavioural change is most often cited. Burnout has long been linked to employees quitting their jobs (e.g., Madigan & Kim, 2021), but the process to that point is long and costly, both for the individual and the company. As burnout builds, employees will significantly reduce their productivity at work and their personal lives will suffer.
A 2016 study of physicians found a significant reduction in overall work effort (Shanafelt et al., 2016). Zhang and Feng (2011), in a study motivated by the rise in the number of physicians leaving their roles due to job dissatisfaction, identified emotional exhaustion and occupational burnout as factors affecting physician turnover.
Burnout also affects those in the person's social circle. Even students' academic achievements have been found to be affected by teachers with burnout (Madigan & Kim, 2021). Notably, although grades were affected, the students' well-being wasn't found to be affected. This may be due to the student-teacher professional division; there are few opportunities for a teacher's personal feelings to interfere with those of the students. This could also be why a high prevalence of burnout often goes undetected in the workforce. Burnout affects worker output, but relationships with others are not noticeably affected.
Physical change is less often researched, but there is growing evidence that burnout can change the structure of the brain and result in anything from decreased immune responses to cardiovascular disease and premature death (Bayes et al., 2021).
Who does burnout affect?
Early research focused on professional care providers such as doctors and nurses (Maslach, 1986). The recent global pandemic also increased the prevalence of burnout among healthcare professionals (Gualano et al., 2021).
Anyone can suffer from burnout. It has also been demonstrated that there is a differentiation between burnout and disorders such as anxiety and depression (Schaufeli et al., 2001), indicating that many people may think that they are suffering from one condition when they should be seeking treatment for something different.
Due to the prevalence of burnout relating to occupation, several scales have been introduced to allow its assessment. The Oldenburg Burnout Inventory and the Copenhagen Burnout Inventory have been found to be robust (Shoman et al., 2021). However, the reliability of many of these scales is in question, confounding the problem of misdiagnosed burnout. Further updating and testing of these scales are required.
Those later in their careers tend to suffer less from burnout, most likely because they have moved away from stressful roles. There are age differences between men and women as to when they suffer burnout (men do so at a younger age), however, the mixed evidence points to lingering inequality in the workplace leading to different career progression paths and therefore influencing the age that burnout occurs (LaFaver et al., 2018; Marchand et al., 2018; Rožman et al., 2019).
“Workaholics” are particularly susceptible to burnout. These are people who have a compulsive need to work excessively hard (Schaufeli et al., 2009), making them subject to burnout even in situations that would not normally present a risk. Although appropriate recovery periods can in theory mitigate their path to burnout (Sonnentag & Zijlstra, 2006), as the definition of a workaholic is that they have a compulsive need to work, this is rarely achieved. Consistent studies identify being a workaholic as a root cause of burnout (e.g., Burke 2008; Taris et al., 2005).
As well as burnout being prevalent in the medical profession, as noted above, teacher burnout and parental burnout is also prevalent. Particularly among parents with younger children, it can lead to a breakdown in parent-child relationships (Le Vigouroux et al., 2022).
What triggers burnout?
A sudden change in the environment at work will cause disorganisation and poor management as new circumstances are adapted to (the COVID-19 pandemic being a classic example). Workers who were comfortable in a role begin to question their ability just as their managers are simultaneously adapting. Adequate support systems and ways of working are no longer available and workers’ psychological resources are exhausted (Edú-Valsania et al., 2022).
However, burnout is more often triggered as a result of a combination of many factors. These include workload and environment, individual differences in areas such as self-esteem and empathy, and perceived social support (Jurado et al., 2018; Altmann & Roth, 2020).
From a psychological perspective, Schaufeli et al. (2009) identified role conflict as the pivotal factor around which conditions such as burnout and workaholism rotate. The perceived roles that a person sees themselves fulfilling are critical to their identity and how they interact with their environment. For instance, someone may see themselves as a combination of a loving partner, a dedicated parent, a valuable employee, and someone with a successful career. This person has spent 15 years maintaining an adequate balance in their daily activities so that they feel they are fulfilling all of these roles. Something disrupts this balance: a new manager; a change of location; a new technology. At this point, they begin to fail at fulfilling the perceived roles that they have held as their identity up to that point. This can cause burnout as the individual struggles to regain balance.
How can organisations prevent burnout in their worker population?
There is evidence that approaches should be taken to combat burnout on both an individual and organisational level. Given the figures noted above, there is a clear business case to reduce the possibility of burnout in organisations.
On an individual level, interventions such as mindfulness, stress management, and small-group discussions have been shown to reduce burnout (West et al., 2016). A focus on individual progression, group engagement, and avoiding neglect of the individual directly targets coping strategies that have been shown to increase burnout (Montero-Marin et al., 2014).
On an organisational level, a reduction in required hours on duty has been effective (West et al., 2016). Amongst physicians, high emotional exhaustion, a symptom of burnout, has been shown to be decreased by 14% using this measure. Employee-led mentorship programmes, extracurricular activities, reductions in paperwork, increased autonomy, and a supportive and regular evaluation system have been found to work in medical settings (Fares et al., 2016; LaFaver et al., 2018).
Robust studies in this area are still lacking, and further study is needed (West et al., 2016). However, these solutions frequently have additive positive effects on the worker population, both in their personal lives and in their contributions to the organisation. As such, a positive outcome from a focus on burnout is an overall improvement in employee health and well-being, even for those who are not susceptible to burnout.
How can the individual prevent burnout?
A link has been found between the emotional coping strategies an individual uses and the prevalence of burnout (Bartkowiak et al., 2021; ). As always, the connection is complicated due to individual differences and also the wide range of coping mechanisms people adopt (Shin et al., 2014). Coping strategies such as talking (either to friends or a therapist), meditation, and reframing have been found to be effective in reducing and treating burnout.
In health and safety, there is a term called the “root cause” of an accident. Someone may slip on oil and think that the best course of action to prevent that from happening again is to put up a sign insisting that oil (the direct cause of the accident) is not spilt. A contributing cause may be that there was no blue-roll available to clean up the spill. However, the root cause may be that there isn’t a reliable supplier of blue-roll so there is never enough stock. Someone slipping on oil resulting in a reliable supplier for blue-roll is a far better outcome than erecting a sign that isn’t read. Tackling the root cause is often the better course of action.
We can look at burnout in the same way. It has been identified that physicians are required to keep increasingly exhaustive records about their time with patients, and this adds significantly to their daily burden without significantly increasing their patients’ outcomes (Patel et al., 2018). Rather than attempting to reduce physician hours in a workforce that is already understaffed, reducing the amount of administration would increase the amount of time physicians spend concentrating on their patients. This will improve patient outcomes and, in turn, job satisfaction, reducing the likelihood of burnout. Asking why admin tasks are required and how they can be suitably replaced is a simple but effective form of burnout management.
If a job role is seen to be at risk of causing burnout, it must be managed in a way that allows the person fulfilling that role adequate time for rest. This may be through long periods away from the role (such as in oil rig work) or rotation to a different role at regular intervals. Appropriate recovery periods have been found to directly reduce burnout, and their absence is a direct cause of burnout (Sonnentag & Zijlstra, 2006).
A positive takeaway from much of the research is that burnout risk decreases in older populations. As noted above, this may be due to many variables, but the message is clear for the younger population: things will get better (Hybels et al., 2020).
Conclusion
Burnout is a serious issue, especially in healthcare, caused by chronic stressors in a job that trigger a psychological response. It has been linked to employees quitting their jobs, reduced productivity, and physical changes such as decreased immune responses and cardiovascular disease. It is most prevalent in professional care providers, workaholics, and those with a sudden change in their environment. To prevent burnout, organisations should take approaches to combat it on both an individual and organisational level.
There is a moral imperative for organisations to take action to reduce the chance of burnout in their employees. There is specific evidence that indicates they have the ability to do so using both individual and structural interventions.
Burnout can affect anyone. If an individual is experiencing a lack of job satisfaction and engagement in a role that used to give great satisfaction, burnout may be the cause. As well as seeking help from a medical professional, simple actions such as taking a break from the role or discussing issues with friends are actions that everyone can take before burnout and its negative outcomes become a possibility.
This article was a deeper dive into our blog on burnout. If you’re looking for the blog, it’s available here:
References
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