Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies

Abstract

Approximately, one in three physicians is experiencing burnout at any given time. This may not only interfere with own wellbeing but also with the quality of delivered care. This narrative review discusses several aspects of the burnout syndrome: prevalence, symptoms, etiopathogenesis, diagnosis, impact, and strategies on how to deal with the problem.

Full text

REVIEW
Burnout in Healthcare Workers: Prevalence,
Impact and Preventative Strategies
This article was published in the following Dove Press journal:
Local and Regional Anesthesia
Stefan De Hert
Department of Anesthesiology and
Perioperative Medicine, Ghent University
Hospital, Ghent University, Ghent,
Belgium
Abstract: Approximately, one in three physicians is experiencing burnout at any given time.
This may not only interfere with own wellbeing but also with the quality of delivered care.
This narrative review discusses several aspects of the burnout syndrome: prevalence, symp-
toms, etiopathogenesis, diagnosis, impact, and strategies on how to deal with the problem.
Keywords: burnout, healthcare worker, prevalence, impact, symptoms, prevention
Never overestimate the strength of the torchbearer’s arm, for even the strongest arms
grow weary.
AJ Darkholme, Rise of the Morningstar
Introduction
Burnout is a work-related stress syndrome resulting from chronic exposure to job
stress. The term was introduced in the early 1970s by psychoanalyst Freudenberger
and has subsequently been dened by Maslach et al as consisting of three qualita-
tive dimensions which are emotional exhaustion, cynicism and depersonalization,
reduced professional efcacy and personal accomplishment.
1–4
Burnout can occur
in any kind of profession.
5
Healthcare workers, and especially perioperative clinicians seem to be at parti-
cular risk for burnout.
6,7
This may have signicant negative personal (substance
abuse, broken relationships and even suicide),
8,9
but also important professional
consequences such as lower patient satisfaction,
10−12
impaired quality of care,
13,14
even up to medical errors,
15–18
potentially ending up in malpractice suits with
substantial costs for caregivers and hospitals.
19
Therefore, alertness for the phenomenon with prompt recognition together with
the development of adequate coping personal and organisational strategies is
essential in dealing with this important problem in contemporary healthcare. The
last 10 years have witnessed an increasing interest in the topic with an exponential
growth in the number of papers published on the topic (Figure 1).
Prevalence
Because of the absence of a generally accepted denition of the syndrome of
burnout, its multifactorial origin and the vagueness and subjectivity of the diag-
nostic criteria, it is difcult to get a clear and correct overview of the prevalence of
burnout in a general population. Estimations report values up to 20% of the
Correspondence: Stefan De Hert
Department of Anesthesiology and
Perioperative Medicine, Ghent University
Hospital, Ghent University, Corneel
Heymanslaan 10, Ghent B-9000, Belgium
Tel +32 9 332 32 81
Email stefan.dehert@ugent.be
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working population but the number is strongly dependent
on the cut-off values to dene severe burnout.
20
Interestingly, the results of a Finnish study, looking at
the relation between the level of burnout and socio-
demographic factors found only small differences between
the different population groups studied. There was
a slightly higher incidence with increased age and some
gender-specic features. For instance, in women burnout
was related to education and socio-economic status while
for men, a relation to marital status was observed.
21
The reported incidence of burnout varies worldwide.
For instance, in Europe, a difference is observed between
the European Union countries (10%) and the non-
European Union countries (17%). Within the European
Union countries, the incidence of burnout ranges from
4.3% in Finland to 20.6% in Slovenia and within the non-
European Union countries from 13% in Albania to 25% in
Turkey.
22
This study also indicated that burnout at the
country level seemed positively related to the workload.
Burnout in Physicians
Burnout has been shown to occur in all kinds of jobs.
However, the incidence seems to be higher in physicians.
In a study comparing incidences of burnout between US
physicians and a population control sample, Shanafelt et al
observed an incidence of symptoms of burnout of 37.9%
in physicians compared to 27.8% in the control population
(p < 0.001).
23
Physicians in specialties at the front line of
care access such as family medicine, general internal med-
icine, and emergency medicine seem to be at greatest risk.
The 2020 Medscape National Physician Burnout and
Suicide Report reported a burnout rate of about 43%,
24
which remains quite similar to the 46% reported in 2015
and 39.8% in 2013. While most studies agree on the fact
that there is no real gender effect in the incidence of
burnout,
25,26
the data from the Medscape National
Physician Report indicate that women physicians reported
more commonly symptoms of burnout (in 2015, 51%
female vs 43% male and in 2020, 48% female vs 37%
male).
24
Interestingly, there seem to be gender differences
in the presence of the different symptoms: exhaustion,
depersonalization, and lack of efcacy. A study in general
practitioners showed that exhaustion and fatigue occur
equally in both sexes. On the other hand, the feeling of
lack of efcacy seems more common in women. It seems
that male physicians are less likely to doubt the quality of
their work than women.
26
It is difcult to have an exact estimation of the inci-
dence of burnout in physicians. A recent systematic review
including 182 studies published between 1991 and 2018
and involving 109,628 individuals in 45 countries
observed a substantial variability in prevalence estimates
of burnout among physicians, ranging from 0% to 80.5%.
This appeared to be related to important differences in
denitions of the syndrome and of the assessment methods
applied. There were no relevant associations between
burnout and demographic factors.
27
1970 1980 1990 2000 2010 2015 2016 2017 2018 2019
0
500
1000
1500
2000
2500
1970 1980 1990 2000 2010 2015 2016 2017 2018 2019
0
500
1000
1500
2000
2500
027 145
311
578
985
1,171
1,330
1,680
2,145
Figure 1 Overview of the number of PubMed hits for the search term “burnout” between 1970 and 2019.
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Burnout in Anesthesiologists
The 2020 Medscape National Physician Burnout and
Suicide Report ranked the incidence of burnout on 29
medical specialities. The top three medical specialisms
for burnout are urology (54%), neurology (50%), and
nephrology (49%). The lowest incidence of burnout is
reported in general surgery (35%), psychiatry (35%), and
orthopedics (34%). Anesthesiology comes on the 16th
place with 41%, emergency medicine on place 14 with
43%, and critical care on place 10 with a reported inci-
dence of burnout of 44%.
24
During the last decade, several studies have been pub-
lished specically looking at burnout in the anesthesiology
community. A recent systematic review identied a total
of 167 papers on the topic, from which nally 17 were
included to assess the prevalence and initiating factors for
burnout.
28
From this study, it appeared that the occurrence
of burnout varied substantially among the different reports,
ranging from 10% to 59%. It seems to occur in all career
stages and is related to a stressful work situation. No
specic relationship was observed between burnout and
gender, or marital status. However, the authors underscore
that the small number of studies included together with the
large differences in their methodology and reporting
approach make reliable conclusions difcult and warrant
further research.
28
Symptoms
Burnout has been dened as a syndrome of emotional
exhaustion, depersonalization, and a sense of low personal
accomplishment that leads to decreased effectiveness at
work.
29
Burnout seems to occur mainly in professions
involving an interaction with people, such as physicians,
nurses, social workers, and teachers but meanwhile, the
syndrome has been described in other professions.
30
The symptomatology of burnout appears to be rather
complex as the syndrome seems to develop in several con-
secutive stages. Initially, Freudenberger described its devel-
opment in a 12-stage model
31
(Figure 2). Later on, this model
has been simplied, and currently, a 5-stage model is most
frequently used (Figure 3). This 5-stage model starts with the
honeymoon phase and is characterized by enthusiasm.
However, inevitably, after time this becomes associated
with experiencing the stresses of the job. If at this stage, no
positive coping strategies are implemented, the process of
burnout risks to become initiated. This is followed by a stage
of stagnation characterized by the onset of stress. This second
stage begins with an awareness of some days being more
difcult than others. Life becomes limited to work and taking
care of business, while family, social life and personal prio-
rities are neglected and suffer and common stress symptoms
appear, which affect the person emotionally, but also physi-
cally. Then a stage of chronic stress develops which leads to
compulsion
to
prove
working
harder
neglecting
own needs
displacement
of conflicts
revision
of values
denial of
emerging
problems
withdrawal
behavioral
changes
depersonalisation
emptiness
depression
BURNOUT
SYNDROME
Figure 2 12-stage model for the development of burnout as described by Freudenberger.
31
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frustration. Individuals get the feeling of failure and a sense
of powerlessness. Efforts do not visibly pay off and the
impression or fact of not receiving enough acknowledgement
leads to one feeling incompetent and inadequate. This then
leads to the stage of apathy, where despair and disillusion-
ment occur. People do not see a way out of the situation and
become resigned and indifferent. The nal stage is habitual
burnout. Symptoms of burnout cause a signicant physical or
emotional problem and ultimately these may prompt one to
look for help and intervention.
The list of symptoms is long and most of them are not
very specic (Figure 4). Symptoms are related to the
different stages of the syndrome and have been divided
into different clusters.
30
These include warning symptoms
in the early phase (increased commitment to goals and
exhaustion), followed by a phase of reduced commitment
(towards patients and clients, towards others in general,
towards work, towards increased demands), emotional
reactions and blaming (depression, aggression), nally
leading to reduction in cognitive performance, motivation,
creativity, and judgement, attening of emotional, social,
and intellectual life, psychosomatic reactions and despair.
Etiopathogenesis
The etiopathogenesis of burnout is multifactorial.
Different etiological factors are summarized in Figure 5.
These factors have been taken into account in the devel-
opment of the different psychological explanatory models
for the etiopathogenesis of burnout. The job demand-
control model focuses on the job task prole (job demand
vs control),
32
the effort-reward imbalance model focuses
on the work contract (effort vs reward),
33
and the organi-
zational injustice model focuses on organizational justice
(unfair procedures and their interactions).
34
Job Demand-Control Model
The job demand-control model was introduced by Karasek
in 1979 and focuses on the balance between the magnitude
of the demands (height of strain) and the level of control
(decision latitude) in a person’s work situation.
32
The
height of strain represents the requirements that are set at
work which may cause for stress. This includes all aspects
of the workload of a particular job such as work rate,
availability, time pressure, travel time, difculty of the
tasks, etc. The decision latitude refers to the possibilities
and freedom of an employee to organise and manage the
workload. Based on these concepts a diagram has been
proposed representing four different job situations, where
both the stress imposed by the work situation and the
personal attitude and engagement of the employee are
incorporated. These are the low- and high strain jobs and
the passive and active jobs (Figure 6).
The low strain job rectangle represents the combination
of a job without important demanding tasks but with where
the employee has some job decision latitude for instance
some freedom to decide on own schedules and targets. This
section represents a majority of the routine jobs. Persons in
this category may progressively get bored in their work
STAGE 1
HONEYMOON
enthusiasm
STAGE 2
ONSET of STRESS
stagnation
STAGE 3
CHRONIC STRESS
frustration
STAGE 4
BURNOUT
apathy
STAGE 5
HABITUAL BURNOUT
intervention
PHYSICAL EXHAUSTION
MENTAL and EMOTIONAL EXHAUSTION
Figure 3 Simplied 5-stage model for the development of burnout which is most frequently used.
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Figure 4 Symptoms in the different stages of burnout.
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situation. A high strain job, on the contrary, refers to very
demanding and/or complex jobs with little control about
working conditions and targets by the employee. As
a consequence, the risk of stress is very high.
Passive jobs are simple jobs but with very little
decision latitude, typically repetitive production jobs.
Such jobs present very little stress but also no substan-
tial challenge to the employees. Active jobs, on the
Figure 5 External (environmental) and internal (personality-related) etiological factors for burnout.
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other end, represent highly demanding jobs but where
the employees have a high level of decision
latitude.
In fact this model focuses on the balance between the
requirements of a job and the level of control the employee
has in his/her professional situation.
job demands
job
decision
latitude
low
high
low high
LOW STRAIN
JOBS
HIGH STRAIN
JOBS
PASSIVE
JOBS
ACTIVE
JOBS
risk for
psychological and
physical stress
motivation to
develop new
behavioral patterns
Figure 6 The job demand-control model, introduced by Karasek in 1979 focuses on the balance between the magnitude of the demands (height of strain) and the level of
control (decision latitude) in a person’s work situation.
32
Figure 7 The effort-reward imbalance model, proposed by Siegrist in 1996 denes threatening job conditions as a mismatch between high demand (high workload) and low
control over long-term rewards.
35
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Effort-Reward Imbalance Model
Another theoretical explanatory model for the etiopatho-
genesis for burnout is the effort-reward imbalance model.
It was proposed by Siegrist in 1996 and denes threaten-
ing job conditions as a mismatch between high demand
(high workload) and low control over long-term rewards.
35
An additional point in the model is the concept of over-
commitment to the job, which may negatively impact the
balance between effort and reward (Figure 7).
Organizational Injustice Model
A third model is the organizational injustice model. In
1987 Greenberg introduced the concept of organizational
justice. This refers to how an employee judges the beha-
vior of the organization.
36,37
There are four components of
organizational justice: distributive, procedural, interperso-
nal, and informational justice. Several models have been
proposed to explain the structure of organizational justice
perception including a two factor, a three factor, and a four
factor model. It is beyond the scope of this review to
discuss these. The interested reader is referred to specic
articles on the topic.
37–41
Other Proposed Models
Additional proposed models include the person-
environment t model, the job characteristics model, the
diathesis stress model, and the job demands resource
model.
42–45
The multitude of explanatory models proposed
indicates the complexity of the syndrome of burnout and
no single model is capable of incorporating all the aspects
of its etiopathogenesis. As a consequence, the different
potential causative factors need to be explored when deal-
ing with an individual case of burnout (Figure 5). An
integration model of personality-related and environment-
related etiological factors has been proposed by Fisher
46
and has been considered plausible and practicable.
30
In
this model, the precondition for the development of burn-
out is a complementary interplay of factors in the employ-
ee’s personality and environmental triggering factors.
47
Diagnosis
A health technology assessment report from 2010 commis-
sioned by the German Institute for Medical Documentation
and Information concluded that to date there is no standar-
dized and generally valid procedure to diagnose the burnout
syndrome.
48
A number of screening tools are now available.
The most frequently used is the Maslach Burnout Inventory
(MBI).
29
Others include the Tedium Measure (later
renamed the Burnout Measure),
49
the Shirom Melamed
Burnout Questionnaire (SMBQ), the Oldenburg Burnout
Inventory (OLBI), the Copenhagen Burnout Inventory
(CBI), and the School Burnout Inventory (SBI).
30,48
These
different questionnaires are adapted for the specic popula-
tion studied, in terms of language and culture and of specic
occupations. They all share a similar approach of looking at
burnout as a multi-dimensional construct consisting of the
main three components, emotional exhaustion, depersona-
lization, and reduced personal accomplishment (or dissatis-
faction with personal accomplishment). The problem is that
all value for the diagnosis of burnout, and when such a value
is used, it is determined arbitrarily. In addition, while the
dimension emotional exhaustion appears to be a constant
feature of burnout, this seems to be less the case for the
dimensions depersonalization and personal accomplish-
ment, which appear heterogeneous, thereby reducing the
signicance of the latter two dimensions.
30,48
Following its publication in 1981,
4
several new adapted
versions of the MBI were progressively developed to t
different groups and different settings.
29
There are currently
ve versions: Human Services Survey (MBI-HSS), Human
Services Survey for Medical Personnel (MBI-HSS (MP)),
Educators Survey (MBI-ES), General Survey (MBI-GS),
and General Survey for Students (MBI-GS (S)). The ques-
tionnaires look at the different dimensions of burnout. The
9-item emotional exhaustion (EE) scale measures feelings
of emotional overextension and exhaustion. The scale is
used in the MBI-HSS, MBI-HSS (MP), and MBI-ES ver-
sions. The MBI-GS and MBI-GS (S) use a shorter 5-item
version. The 5-item depersonalization scale assesses the
degree of impersonal response towards the recipients of
one’s care, treatment or service. This scale is used in the
MBI-HSS, MBI-HSS (MP) and the MBI-ES versions. An
8-item personal accomplishment scale measures feelings of
competence and achievement in one’s work and is used in
the MBI-HSS, MBI-HSS (MP), and MBI-ES versions. The
MBI-GS and MBI-GS (S) additionally score cynicism
(indifference towards one’s work) on a 5-item scale and
professional efcacy (feelings of competence and achieve-
ment) on a 6-item scale. All items are scored on a 7-level
frequency scale: never (0), a few times a year or less (1),
once a month or less (2), a few times a month (3), once
a week (4), a few times a week (5), and every day (6).
Currently, none of the assessment tools for burnout
provides instruments for differential diagnosis. In particu-
lar, the association between burnout and the chronic
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fatigue syndrome and burnout and depression is relevant,
as all entities share quite some common symptoms and
burnout is a risk factor for the development of
depression.
48
Burnout seems to be associated with musculoskeletal
diseases among women and with cardiovascular diseases
among men. These associations are not explained by socio-
demographic factors, health behavior, or depression.
49
Other studies have suggested that chronic burnout might
be a risk factor for the onset of type 2 diabetes,
50
and
hyperlipidemia.
51
The underlying neurobiological mechan-
isms for the physical effects of burnout are still unknown.
Several studies have investigated the association between
burnout and functioning of the hypothalamic-pituitary-
adrenal axis, but the results are not consistent and the
clinical implications of these ndings remain to be
established.
52
Currently, there is no hard evidence for the
clinical usefulness of any specic biomarker for burnout.
53
Impact
Consequences of burnout are decreased job satisfaction,
54
absenteeism,
55
turnover in personnel,
54,56
and cynicism.
15,57
These effects at work frequently have repercussions on per-
sonal life such as feeling unhappy, anxiety, depression, iso-
lation, substance abuse, frictional and broken relationships
and divorce.
58–66
Burnout in physicians may have more
serious professional implications than in other professions.
Indeed, physician burnout has been linked to suboptimal
patient care [8] resulting in lower patient satisfaction,
8−12
impaired quality of care.
13,14
This may eventually lead up
to medical errors,
15–18
with potential malpractice suits and
subsequent litigation, with substantial costs for caregivers
and hospitals as a consequence.
19
How to Deal with Burnout?
The complexity of the interaction between all the pre-
viously discussed external and internal factors in the
development of burnout underscores the importance of
a multifactorial approach in the prevention and the treat-
ment of the syndrome. This means that both the work
environment and the person’s own personality and attitude
towards the work situation need to be addressed. This
implies not only the implementation of measures at the
level of the professional employers and work environment
but also developing and implementing individual coping
strategies.
Approaches to treating burnout syndrome should be
guided by the severity of the symptoms. If these are
minor and slight, measures such as changing life habits
and optimizing work–life balance are recommended.
These measures concentrate on three important pillars:
relief from stressors, recuperation via relaxation and
sport, and “return to reality” in terms of abandoning the
ideas of perfection.
30
Various wellness strategies can be applied by physi-
cians in order to cope with the symptoms of
burnout.
6,15,67,68
A rst strategy focuses on relationships.
It refers to an understanding of the importance of spending
quality time with family, friends and signicant others.
This strategy also includes actively developing connec-
tions with colleagues, to share and reect with them on
emotional and existential aspects of being a physician.
A second element that seems to promote well-being in
some people is religious belief and/or spiritual practice.
This refers to a personal attentiveness to nurturing own
spiritual aspects.
68,69
It has been reported that up to 34%
of persons mentioned this aspect to be important and even
essential.
15,68
A third element deals with work attitudes.
This has two components. The rst one refers to nding
meaning and fulllment in work, the second one to
actively choosing and limiting the type of medical practice
such as working part-time, being involved in education
and/or research, managing schedule and discontinuing
unfullling aspects of practice. A fourth strategy consists
of self-care practices, in which an individual actively
cultivates personal interests and self-awareness in addition
to professional and family responsibilities. This also
implies actively seeking professional help in case of per-
sonal physical and psychological problems or illness.
Examples of such practices are, among others, exercise,
self-expression activities, adequate nutrition and sleep,
regular medical care, professional counseling, etc.
Finally, the fth component is adapting a specic life
philosophy. This is developing a philosophical approach
to life that is based on a positive outlook where one
identies own values and acts accordingly with emphasis
on the balance between personal and professional life. It is
likely that such strategies are also the designated tools to
be implemented in the prevention of the development to
burnout.
Although each individual is in the end responsible for
his/her own wellness, organizational and institutional
awareness, attention to and recognition of the problem can
play a crucial role in promoting physicians’ well-being.
6,70
Job characteristics and institutional factors that contribute
to wellbeing include promoting autonomy,
71–82
providing
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adequate ofce resources and support staff,
83,84
and facil-
itating a collegial work environment.
75,77
Giving physicians
the ability to inuence their work environment, to partici-
pate in organizational decisions that affect medical practice,
and to have more control over their time schedules seem to
have a substantial positive effect regardless of practice
type.
71–81
Efforts to minimize work-home interference by
providing exible scheduling, childcare adapted to irregular
work hours, etc., are also important for increasing the
employees’ well-being.
59,81,84
If the symptoms of burnout are severe, psychothera-
peutic interventions are recommended. There may also be
a place for antidepressants, preferably combined with
psychotherapy.
30
There are several therapies for the treat-
ment of burnout but all with unclear evidence. In 2012,
a health technology assessment analyzed the usage and
efcacy of different burnout therapies.
85
In this systematic
review, 17 papers were included. Thirteen of them (partly
in combination with other techniques) deal with the ef-
cacy of psychotherapy and psychosocial interventions for
the reduction of burnout. In the majority of the studies,
cognitive behaviour therapy seems to result in the
improvement of emotional exhaustion. However, evidence
is inconsistent for the efcacy of stress management and
music therapy. Two studies on the efcacy of Qigong
therapy do not deliver a distinct result and only one
study shows the efcacy of the roots of Rhodiola Rosea.
Physical therapy is examined separately in only one study
and does not show a better result than standard therapy.
Some authors report the effects of considerable natural
recovery.
Conclusion
Burnout has become an important problem and a challenge
for public health. Unfortunately, the syndrome still is not
clearly dened and there is no consensus on the
diagnosis.
86
There is an agreement that burnout in medicine is
harmful to the professional, the institution, and the patient.
Risk situations should be identied and preventive mea-
sures should be implemented early to avoid future harm.
87
Therefore, prospective, longitudinal studies are needed to
further explore the causes of burnout and identify the
specic instruments to measure physician’s well-being.
We are also in need of additional prospective studies to
identify individual and organizational interventions that
can promote wellness and evaluate its effect on productiv-
ity, patient care, and patient satisfaction. Of note, well-
being may depend on different variables and therefore
studies specically focusing on different subpopulations
are needed.
72,73,75,78,87–90
Staff working in critical care
settings may be particularly affected.
91
This situation
may aggravate when the ow of critically ill patients starts
to exceed available capacities, as is for instance the case
with the recent COVID-19 pandemic.
92
Also the efcacy of therapies for the treatment of
burnout syndrome is insufciently investigated. There is
evidence from meta-analyses that organisational issues
need to be addressed as well as individual ones,
93,94
but
the exact most effective strategies to apply in each indivi-
dual remain to be established. Further studies are needed
to evaluate the efcacy of the different therapeutic options.
Disclosure
The author reports no conicts of interest in this work.
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