Fall 2023 - Vol. 18, No. 3 WHAT IS BURNOUT AND WHAT IS ITS IMPACT?
Burnout is a term used to describe exhaustion due to chronic workplace stress. The term was first coined by Herbert Freudenberger in 1974 to describe medical professionals, including doctors and nurses. More specifically, burnout has been defined as a syndrome involving physical depletion, feelings of helplessness, negative self-concept, and negative attitudes toward work, life, and others.¹ It has variously been described as a decrease in energy, engagement, and sense of personal accomplishment, as well as an increase in depersonalization.²

Burnout is a prevalent issue throughout the health care field and impacts job performance, absenteeism, and empathy for patients.³ In a 2023 survey of 9,100 physicians, 53% of respondents reported feeling burned out — an increase over the 42% in a similar survey in 2018.⁴ Numerous studies have been conducted to help identify, measure, and combat burnout in health care; a PubMed search of articles about burnout yields more than 26,000 hits, with nearly half — more than 12,000 — published since the start of the SARS-CoV-2 pandemic.⁵

Most recently, the pandemic has worsened this issue, showing us the impact of burnout on the health care workforce when the demand for health care is increased and resources are inadequate. To be specific, moral distress, described as the burden of being unable to provide the care one knows to be right,⁶ and compassion fatigue, a special type of burnout caused by the stress of helping individuals during or after traumatic life events,⁷ have contributed to the risk for burnout among health care workers in the past three years.⁸ Burnout, however, is not easily measurable, which may lead to disagreement regarding its impact.⁹

The negative consequences of burnout may be countered by specific interventions. The hope is that these interventions will yield a better quality of life, performance at work, and overall happiness for those providing health care. Reducing the potential for burnout and augmenting its impact on those working in health care will likely impact the lives of health care workers, as well as the communities they serve.

WHO IS AT RISK AND WHAT RISKS ARE THERE?
An environment of low control and high job demand can create the most pathogenic work environment; physicians, advanced practice clinicians, and staff in smaller solo practices less commonly report burnout, while those in health system-owned practices and Federally Qualified Health Centers are more likely to report burnout, which suggests practice-level autonomy is a critical determinant of risk.¹⁰ Stressed employees may be more likely to take sick days and allow personal problems to permeate their workplace.

Physiological disturbances may appear when burnout is present in a health care employee. One study revealed higher levels of cortisol in health worker hair samples that correlated with higher scores on burnout surveys.¹¹ While the current research does not reveal consistent conclusions, high levels of burnout may affect hormone levels, particularly cortisol and adrenaline, which can affect various bodily functions and contribute to physical symptoms such as fatigue, muscle tension, and sleep disturbances.^12,13

The immune system can be weakened if chronic stress makes an individual more susceptible to illnesses. Chronic stress can contribute to long-term problems such as inflammation of the circulatory system, which can lead to an irregular heartbeat, heart failure, or coronary artery disease.¹² Brain structure and function may also be impaired.

The emotional and physiological symptoms of burnout can lead to alterations in the size and activity of certain regions of the brain.¹⁴ Chronic stress may also affect the musculoskeletal system (tense muscles, migraines, back pain), the respiratory system (exacerbating pre-existing respiratory diseases), and many other essential systems of the body.¹⁵ Burnout may cause serious physiological demand on and changes to homeostasis in the body.

Workplace stress also affects the businesses where we work. High levels of stress in a workplace environment contribute to missing more days of work, which can cost businesses financially and productively. In fact, U.S. businesses lose up to $300 billion annually because of chronic workplace stress.¹⁶ When struggling with burnout, the quality of care that clinicians provide may be severely impacted.¹⁷ In a meta-analysis including 82 studies and 210,669 health care providers, a negative relationship was found between burnout and quality of care; this translates into more risk for patients.¹⁸ It is thus critical for health care organizations to prioritize and address burnout within their workforce, or the consequences may be severe.¹⁹

HOW TO IDENTIFY AND MEASURE BURNOUT
To address burnout, we must first be able to identify and measure it. The Maslach Burnout Inventory is a proprietary form available for purchase which suggests three domains that can be measured: emotional exhaustion, depersonalization, and personal accomplishment.²⁰ Emotional exhaustion occurs when a great amount of stress accumulates in one’s life, leading to breakdown and feelings of being drained. Emotional exhaustion is one of the most central and fundamental aspects of burnout. Depersonalization, a common symptom of anxiety disorder, can lead to negative attitudes and a lack of desire to fulfill duties. Accomplishment is a measure of one’s professional efficacy. Pooling measures of how one scores in each of these domains suggest where on the spectrum from Burnout to Engagement one falls.²¹ Thus, individuals may be/ have:

• Burnout: Negative scores on exhaustion, cynicism, and professional efficacy.
• Overextended: Strong negative score on exhaustion only.
• Ineffective: Strong negative score on professional efficacy only.
• Disengaged: Strong negative score on cynicism only.
• Engagement: Strong positive scores on exhaustion, cynicism, and professional efficacy.

COMBATING AND PREVENTING BURNOUT
Health care leaders not only need to understand how to identify the degree and range of burnout but must understand and implement effective mitigation strategies to aid their struggling employees. Some of these mechanisms may include: setting clear and well-defined boundaries, requiring scheduled breaks, finding ways to reduce the workload, and facilitating various destressing techniques, such as deep breathing, mindfulness, and time management.²¹ Identifying one’s own personal accomplishment may also augment burnout, as there is an inverse relationship between scores of personal accomplishment and burnout: as the risk for one increases, the other decreases.

In addition, engaging in regular physical activity has proven to be an effective intervention for reducing stress and preventing burnout.²² Exercise stimulates BDNF (brain-derived neurotrophic factor), which is essential for maintaining brain health.²³ Helping health care workers prioritize their own physical and emotional well-being by encouraging them to engage in activities that promote self-care, such as exercise, meditation, and hobbies, may help to reduce the risks of burnout.

Reinforcing support systems can help maintain and stabilize mental health. A support system, such as a colleague, supervisor, or mental health professional, can be of benefit by alleviating feelings of isolation and providing a safe space to talk about and process challenging experiences.²⁴

Further, in a study measuring the connection between emotional intelligence (EI) and burnout, high EI was found to be negatively correlated with burnout.²⁵ Emotional intelligence is often described as the ability to control emotions in oneself and understand those emotions experienced by other people, to distinguish emotions from each other, and to apply this information to guide one’s own thinking and action.²⁵ Low EI has been shown to be a predictive tool of burnout, while high EI has been linked to higher job performance. Studies demonstrate that EI can be improved.²⁶ Thus, developing a higher EI is an effective way to help mitigate burnout.²⁷ By accurately recognizing and processing emotions and understanding the reasons behind them, workers will be better equipped to work through feelings of burnout and avoid negative effects on health and job performance.

Sleep hygiene is an instrumental aspect of preventing burnout. Health care workers are known for working long hours and are susceptible to missing sleep, which can lead to immune system changes and have a long-lasting impact on mental and physical health.²⁸ The exact reasons why we sleep are still not completely understood, but many believe it is a way for the body to conserve energy, maintain homeostasis of the nervous system, process affective information, and preserve other necessary functions of the body. We must ensure health care workers can get the sleep they require to provide the highest possible care for their patients and for themselves.

System wise, we are encouraged by a Wellness Committee dedication to augmenting burnout, and at the policy level more is being done. In 2022, the Dr. Lorna Breen Health Care Provider Protection Act became law.²⁹ This act, inspired by a physician who took her life as a result of her own emotional distress suffered while caring for patients during the SARS-CoV-2 global pandemic, establishes grants and requires other activities to improve mental and behavioral health among health care providers.²⁹ Hopefully, this will lead to further interventions to augment the burdens those in this workforce endure as they try to help their patients.

CONCLUSION
Stress and burnout are common issues faced by health care workers and can have serious consequences on the individual, the organization, and their patients. Targeting and reducing burnout in health care workers by incorporating mechanisms to properly deal with the issues will greatly impact the health care system and the care workers are able to provide. Mental illness is becoming increasingly recognized and discussed, so it is imperative to find ways to help people cope with these conditions.

It is important to note that burnout is a complex issue, and no single solution will work for everyone. We must address burnout in a holistic and personalized way, considering the unique needs and circumstances of each individual health care worker.

REFERENCES
1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
2. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav. 1981;2:99-113.
3. Dyrbye LN, Shanafelt TD, Johnson PO, et al. A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses. BMC Nurs. 2019;18:57.
4. Kane L. “I cry but no one cares”: physician burnout and depression report 2023. Medscape. January 27, 2023. Accessed August 3, 2023. https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058#2
5. Keywork search: “burnout.” National Library of Medicine. Accessed August 3, 2023. https://pubmed.ncbi.nlm.nih.gov/?term=burnout
6. Jameton A. Nursing Practice: The Ethical Issues. Prentice-Hall; 1984.
7. Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. Psycholo Trauma. 1995;7(3):1-2.
8. Williams RD, Brundage JA, Williams EB. Moral injury in times of COVID-19. J Health Serv Psychol. 2020;46(2):65-69.
9. Institute for Quality and Efficiency in Health Care. Depression: what is burnout? InformedHealth.org. Updated June 18, 2020. Accessed August 14, 2023. https://www.ncbi.nlm.nih.gov/books/NBK279286/#
10. Edwards ST, Marino M, Balasubramanian BA, et al. Burnout among physicians, advanced practice clinicians and staff in smaller primary care practices. J Gen Intern Med. 2018;33(12):2138-2146.
11. Ibar C, Fortuna F, Gonzalez D, et al. Evaluation of stress, burnout and hair cortisol levels in health workers at a university hospital during COVID-19 pandemic. Psychoneuroendocrinology. 2021;128:105213.
12. Pariante CM. Chronic stress, cortisol dysregulation, and adrenal fatigue. Front Horm Res. 2015;43:47-58.
13. Sjörs Dahlman A, Jonsdottir IH, Hansson C. The hypothalamopituitary-adrenal axis and the autonomic nervous system in burnout. Handb Clin Neurol. 2021;182:83-94.
14. Kanai R, Rees G. The relationship between work-related stress and brain structure: a systematic review. Front Hum Neurosci. 2012;6:1-10.
15. Stress Effects on the Body. American Psychological Association. Updated March 8, 2023. Accessed August 14, 2023. https://www.apa.org/topics/stress/body
16. Workplace Stress. American Institute of Stress. 2022. Accessed August 14, 2023. https://www.stress.org/workplace-stress
17. Dyrbye LN, West CP, Sotile W, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(2):443-451.
18. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. J Gen Intern Med. 2017;32(4):475-482.
19. Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors related to physician burnout and its consequences: a review. Behav Sci (Basel). 2018;8(11):98.
20. Maslach C, Leiter MP. How to measure burnout accurately and ethically. Harvard Business Review. March 19, 2021. Accessed August 14, 2023. https://hbr.org/2021/03/how-to-measure-burnout-accurately-and-ethically
21. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to promote resident well-being: a systematic review. Ann Intern Med. 2016;164(2):187-197.
22. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-809.
23. Ratey J. Spark: The Revolutionary New Science of Exercise and the Brain. Little, Brown and Company; 2008.
24. Shanafelt TD, Boone S, Tan L, et al. Interventional programs aimed at reducing physician burnout: a systematic review. Mayo Clin Proc. 2015;90(9):1600-1613.
25. Landry L. Why emotional intelligence is important in leadership. Harvard Business School Online. April 3, 2019. Accessed August 14, 2023. https://online.hbs.edu/blog/post/emotional-intelligence-in-leadership
26. Pool LD, Qualter P. Improving emotional intelligence and emotional self-efficacy through a teaching intervention for university students. Learn Individ Differ. 2012;22(3):306-312.
27. Gong Z, Chen Y, Wang Y. The influence of emotional intelligence on job burnout and job performance: mediating effect of psychological capital. Front Psychol. 2019;10:2707.
28. Garbarino S, Lanteri P, Bragazzi NL, Magnavita N, Scoditti E. Role of sleep deprivation in immune-related disease risk and outcomes. Commun Biol. 2021;4(1):1304.
29. H.R.1667 — Dr. Lorna Breen Health Care Provider Protection Act. Congress.gov. Accessed August 14. 2023. https://www.congress.gov/bill/117th-congress/house-bill/1667/text