Burnout (psychology)

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Template:Otheruses4 Template:DiseaseDisorder infobox Burnout is a concept in industrial and organizational psychology for "an excessive stress reaction to one's occupational or professional environment. It is manifested by feelings of emotional and physical exhaustion coupled with a sense of frustration and failure".[1] Burnout has three dimensions[2]:

  • Emotional exhaustion
  • Depersonalization (cynicism)
  • Diminished personal accomplishment (inefficacy)

Subsequent research suggests the third dimension, personal accomplishment, better fits with the concept of professional engagement rather than with burnout.[3]

Burnout is due to loss of control at work, and also "burnout is mainly predicted by job demands but also by lack of job resources".

Burnout is now being studied in its reported antitheses, job satisfaction, job engagement and thriving. Thriving may protect against burnout[4][5]. Engagement is both negatively associated with burnout, but also unhealthy engagement may lead to burnout.[6]

Engagement may not simply be the opposite of burnout.

Prevalence

The prevalence of burnout in the general, employed population of the United States, aged is[7][8][9]:

  • General, employed U.S. population
    • (2010): aged 31-47 30%[7], aged 29-65 29%[8]
    • (2014): aged 31-65 28%[9]
    • (2017): aged 29-65 28%[10]
  • College graduates 2010: aged 31-47 36%[7]

Health care workers

As of 2017, 44% of physicians have have burnout[10]. Previously, in 2014, as many as 50% of physicians in practice may have burnout.[9] General practitioners seem to have low job control and the highest proportion of burnout cases[11].

Burnout is more common in larger practices suggesting that practice level autonomy may be important[12].

For physicians in training, rates of burnout (emotional exhaustion) for students, residents and fellows is about 50% while the rate is 36% in similarly aged college graduates.[7] Burnout in physicians in training is associated with perceived harassment[13]. In one survey of 24 American medical schools, harassment occurring at least one time was reported by 83% of students[13]. In this study, harassment was more commonly reported being perpetrated by residents[13]. The rates of burnout among students responding to the survey were[13]:

  • All students 34%
  • Those reporting recurrent harassment by faculty 57%
  • Those not reporting recurrent harassment by faculty 32%

According to the yearly survey of recent medical school graduates by the Association of American Medical Colleges, the following are reported [14]:

  • Occasional public embarrassment 20%
  • Occasional public humiliation 8%

Measurement

Several burnout inventories are available including the Maslach, Copenhagen, and Oldenburg[15].

Eckleberry-Hunt in 2017 raised the question that burnout is being over-reported by deeming burnout present if either emotional exhaustion or depersonalization are present.[16]


Maslach Burnout Inventory

The Maslach Burnout Inventory is the earliest and most well-studied measurement of burnout. Maslach and her colleague Jackson first identified the construct "burnout" in the 1970s, and developed a measure that weighs the effects of on three scales[2]:

  • Emotional exhaustion (nine items)
  • Depersonalization (five items)
  • Personal accomplishment (eight items)

An important question has been raised by Eckleberry-Hunt that we may be over-estimating rates of burnout due to the common two item survey deeming burnout if either emotional exhaustion or depersonaliztion are present when the original survey required both to be present[16].

2 item burnout Inventory

In this survey, abnormal is defined as symptoms weekly or more on either item.[17][18] The first item correlates with emotional exhaustion.

1. I feel burned out from my work[18] or How often do you feel burned out from your work?[17]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

2. I have become more callous toward people since I took this job[18] or How often do you feel you’ve become more callous toward people since you started your residency?[17]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

The two item format has been used in national surveys in 2011[8] and its follow-up survey in 2014[9].

Mini Z

The 10‑item Zero Burnout Program survey, or called the Mini Z[19], was adapted from earlier work by Rohland[20] and Schmoldt[21] and the Physician Worklife Survey[22]. The Mini Z is a single item (burnout is defined as answers c, d, or e) that correlates with the emotional exhaustion scale of the Maslach[20]:

1. Using your own definition of “burnout,” please circle one of the answers below:

a. I enjoy my work. I have no symptoms of burnout.

b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.

c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.

d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.

e. I feel completely burned out. I am at the point where I may need to seek help.

The Mini Z is promoted by the American Medical Association's Steps Forward campaign.[23]

The Mini Z may[24][25] report lower prevalence of burnout than when measured by the full Maslach Burnout Inventory (MBI). Olson found that the Mini-Z reports a prevalence 10% to 15% lower than the MBI.

This discrepancy may be related to an important question raised by Eckleberry-Hunt that we may be over-estimating rates of burnout due to the common two item survey deeming burnout if either emotional exhaustion or depersonaliztion are present when the original survey required both to be present[16].

Copenhagen Burnout Inventory

The Copenhagen Burnout Inventory is another scale and was developed in 2005.[26]

Physician Well-Being Index (PWBI)

The PWBI contains 7 items, one of which queries burnout in a yes/no response format. Its development[27] and application[28] have been reported.

Professional Quality of Life (ProQOL)

The ProQOL has three scales[29][30]:

  • Compassion satisfaction (CS)
  • Compassion fatigue (CF) which includes anger, exhaustion, frustration, or depression
    • Burnout (BO) which is "feelings of unhappiness, disconnectedness, and insensitivity to the work environment. It can include exhaustion, feelings of being overwhelmed, bogged down, being 'out‐of‐touch' "[29]
    • Secondary Traumatic Stress is being "preoccupied with thoughts of people one has helped"[29]

Norms are available[31].

Causes

Leiter and Maslach found the following antecedents from the Areas of Worklife Survey (AWS) using factor analysis:[32]

  • Workload
  • Fairness
  • Control
  • Community
  • Values
  • Rewards

Of these causes, workload is the strongest correlate of emotional exhaustion[32] but loss of control may be the initial factor. Perceived control or autonomy and fairness correlate with cynicism.[32][33]

These findings, specifically workload, are reflected in the job demands-resources model of burnout[37].

These findings are reflected in the Demand-Control theory of job stress. [38]

Moral distress and professional disonance

Moral distress[39] and professional disonance[40], as operationalized in research studies, is the report by healthcare personnel of participating in the provision of healthcare that the healthcare personnel perceives as inappropriate due to pressure from other health care professionals or administrators of families that the health care professional perceives as inappropriate due to being[39][41]

Leadership

Leadership tactics are associated with burnout[42][43][44][5][45][46]

Pandemic related burnout

Regarding COVID-19, on April 7, the Institute for Health Metrics and Evaluation (IHME) projects a 36,654 hospital bed and 16,323 ICU bed shortage on day of peak resource need (April, 15), and 3,130 COVID-19 deaths on the day of peak daily deaths (as of 4/7/2020) across the United States[47]. This poses a significant stress on the healthcare system. Strains on the healthcare system lead to increased practitioner stress and burnout, of which moral distress is a contributor. Moral distress occurs in high stress environments, like the ICU[48]. A qualitative literature review of moral distress in nurses found that moral distress can lead to emotional exhaustion and depersonalization toward patients, which are components of burn out[49].

Consequences

Burnout is negatively associated with Practice Adaptive Reserve, or the ability for an organization to learn[50].


Clinical outcomes

A systematic review suggested there may be a small association between burnout and the quality of patient care[51]

  • In intensive care units, physicians and nurses reported a signicant correlation between burnout and standardized mortality[52].
  • In hospital units in which nurses report high burnout, nosocomial infection rates are higher[53].


However, other studies have not found an association between burnout and clinical outcomes.

  • A study of general/vascular surgery residency programs, found an insignificant correlation[54].
  • Another study found no association[55]

Financial

Burnout may be associated with operating margins[56].

The cost of burnout is estimated to be $7600 per employed physician each year[57].

Prevention

Thriving[4][5] and engagement[58][3] are negatively correlated with, and thus may be protective, against burnout. However, unhealthy engagement may lead to burnout.[6]

Perceived control or autonomy and fairness correlate with cynicism.[32][33]

Resilience

Interventions, including those directed at physicians, have been reviwed.[59]

Reporting of workforce state to external stakeholders

Treatment

At the individual level

Religion may[60] or may not[61], protect against burnout. Spirituality may better associate with engagement than burnout[62].

Observations studies suggest the following tactics by individuals may help[60]:

  • Measured by the Spiritual Involvement and Beliefs Scale (SIBS)[63]:
    • Humility/personal application
  • Measured by the Coping Orientation to Problems Experienced (COPE) Inventory[64]:
    • Acceptance
    • Active coping (trying to correct the situation)
    • Positive reframing or reinterpretation
    • Mindfullness training[65]

Calling

Calling may protect against burnout[66][67].

Calling may be more important than extrinsic motivation such as income[68].

Calling can be measured with:

  • A single question, "For me, the practice of medicine is a calling"[67]
  • A scale with two dimensions, Calling and Vocation Questionnaire (CVQ)[69]:
    • Transcendent Summons (4 items) which includes "I believe that I have been called to my current line of work".
    • Purposeful Work (4 items)

Calling may not be as important as autonomy[70].

At the institutional level

Institutional and individual strategies to reduce burnout have been reviewed[59].

Physicians may not be aware that they are burned out and providing awareness may increase engagement with addressing burnout[71].

In the UK National Health Service's large Health Foundation's Safer Patients Initiative (SPI) reported[72]:

  • A borderline reduction in burnout (as measured by staff self-report of "Work related stress in previous 12 months")
  • An insignificant decrease in mortality
  • No change in patient satisfaction

A follow-up report from the SPI noted "compliance-oriented bureaucratised management...poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement"[73].

The Mayo Clinic reported a case study of promoting physician control, social connectedness, and excellence/meaningfullness[74].

See also

References

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