Burnout has a significant impact on the individual in terms of their physical and psychological well-being. The negative flow-on effects on the organization’s productivity and workforce, in general, are also important to recognize. In the healthcare sector, burnout of clinicians can impact the quality of care and patient safety outcomes. It is important and necessary to understand the contributing systemic, organizational, and individual-specific factors to develop a holistic response to prevent burnout. An integrated approach should be aimed at the systems level, which requires continual monitoring and assessment of resilience and workloads; at the organizational level, identifying factors unique to the organization type and setting; and at the individual level, focused on their well-being.
The impact of burnout on individuals and their families, organizational productivity, and others who are impacted by an individual experiencing burnout is significant [1]. Healthcare delivery can be impacted by clinicians experiencing burnout. This can result in poor patient care, increased length of stay and re-admissions [2], and increases the occurrence of errors, omissions, and mishaps [3]. Emotional exhaustion reported by nurses is consistently negatively associated with patient safety and is considered a significant predictor of increased patient mortality [4]. Their perception of providing quality care is also closely correlated with the degree of burnout they reported at the time of providing care [5, 6].
High levels of self-reported burnout are consistently related to decreased levels of productivity, the intent to leave the organization, and a noticeably reduced sense of emotional and professional commitment to the organization [7]. In addition to higher rates of absenteeism, presentism, and turnover, the physical and psychological toll of burnout has been linked to depression, substance use, and suicidal ideation in physicians and residents. It is also seen as a predictor of heart disease, chronic pain, gastrointestinal distress, depression, and mortality [8].
External and organization-specific factors are often implicated in burnout. Changed expectations and an increase in work demands (and therefore stress) without an appropriate increase in resources and support are often reasons why burnout occurs. A change in leadership and direction or a sudden unanticipated change in the work environment can precipitate symptoms of burnout. For example, a change in organizational structure and reporting relationships that result in previously held autonomy and independence being diluted, changes in work rules, attitudes, and behaviors, and contradictory instructions and communication are common reasons for burnout to occur in an environment in which the person previously may not have experienced work stress.
However, the question of why the same workforce-related stress impacts people differently requires further exploration. Internal and individual-specific factors may be equally significant in determining why selected people experience burnout and why some people are affected more than others. An individual’s psychological construct, their expectations of themselves and their workplace, their perception of their place and position in the changing organizational environment, and their perceived sense of loss of position, autonomy, or opportunity are often important determinants of whether or not the person would be at risk of burnout. An individual’s way of coping, attitudinal and personality attributes, and other individual-specific personal and environmental characteristics that contribute to their specific experience of burnout are important to consider. Such individual-specific characteristics may also make specific individuals more vulnerable to this experience [9].
Therefore, understanding both external and internal contributors to burnout is necessary to develop interventions that are likely to be effective for an individual. That is also the reason why any intervention has to be individualized.
Conversely, non-specific general recommendations and hope for improvement in the work environment, a general drive to reduce workplace stress, and an increase in relaxation and exercise can be quite deceptive and even counterproductive as these serve to distance the person from the stressor without necessarily influencing the external or internal factors that may be contributing to burnout. Non-specific recommendations are also often the reason for the prolongation of the period of living in distress for the individual. Instead, the focus should be on developing specific psychiatric, psychological, and social interventions with a clear understanding of the individual’s needs and expectations and an analysis of the environment (external psychosocial and internal psychodynamic) to ensure interventions are appropriate and effective.
Burnout is reported in diverse organizational settings [10]. It is suggested that burnout may be more common in professions that involve interaction with people, such as physicians, nurses, social workers, and teachers [11]. Healthcare workers are suggested to be at higher risk of burnout in comparison to other stressful public service jobs [12, 13]. The Medscape National Physician Burnout & Suicide Report reported a burnout rate of about 43% in 2020, 46% in 2015, and 39.8% in 2013 [14]. There is a suggestion that perioperative clinicians may be at higher risk [15, 16].
Several hypotheses exist about why some health professionals may be at a lower or higher risk of burnout [17]. It is proposed that burnout is a consequence of working in a high-stress environment, and those with high ideals are particularly prone to experiencing it [18]. Perhaps this is because, with the emotional exhaustion setting in, the capacity of the individual to fulfill those ideals becomes compromised, which further increases their internal distress. For caring professionals, an inability to continue to be compassionate, care, and give can become particularly distressing. For those with a high desire for personal accomplishment, such a feeling of incapacitation is particularly threatening and anxiety-provoking.
Personality traits play a role in how an individual deals with stress but also in their perception of their circumstances. This influences how they approach their work responsibilities and perceive their workload. It has been suggested that as far as experiencing burnout is concerned, an individual’s approach to work has a greater impact than that of the working environment [19]. Some research supports the association between Type-D personality traits (those who experience ongoing feelings of worry, sadness, irritability, pessimistic outlook, have negative self-talk, have a tendency to avoid social situations, experience a lack of self-confidence and have a fear of rejection) with job stress and job satisfaction, placing them at greater risk of self-reporting burnout, compassion fatigue, and compassion satisfaction [20]. Furthermore, learned characteristics, including resilience, hardiness, moral distress and injury, and secondary trauma, have been associated with clinician burnout [21]. A study on medical students showed students with a positive attribution style who attributed their successes to internal factors such as ability and effort and attributed their failures to lack of effort are less likely to self-report burnout. It appears attributing success and failure to factors that individuals control reduces the likelihood of burnout and improves self-efficiency [22].
Research has shown a strong correlation between the number of hours worked per week, a female gender, and being an inexperienced clinician, with higher levels of self-reported burnout [18, 21, 23]. Yet these cohorts have historically also been reported to have higher rates of mental health concerns than their counterparts.
The most effective and longer-lasting outcomes to build resilience and reduce burnout result from a multi-level response by addressing identified risks at systemic, organizational, and individual levels [23, 24, 25].
4.1 System-level interventions
To enable the health system to be resilient, a recognition of the increasing complexity of healthcare delivery systems and the risk of cumulative stresses on the workforce is necessary to ensure appropriate support can be instituted. An important aspect of building system resilience is anticipating future challenges and having contingency arrangements to manage anticipated change. An imbalanced focus on improvement, innovation, and agility without a realization of effective change management, including support and adjustment that must be factored in to manage both predictable and unpredictable changes, is often a recipe for a well-intentioned leadership precipitating burnout [26].
Workload demands that exceed human limits, fatigue from a demanding work environment, and increasing patient complexities with limited time to rest and recover are known to be risk factors for burnout [24]. Understaffing, increased workload, or working additional hours have also been associated with higher burnout levels [21]. These risk factors are also indicators of an underperforming health system and organization, which impact clinicians’ ability to fulfill their capability and capacity. Cultural workplace risk factors include an inadequate opportunity for quality social interactions and a lack of team building and conflict resolution systems and processes.
Inadequate extrinsic motivators such as financial, institutional, or social rewards in the workplace and a lack of recognition from stakeholders contribute to feelings of inefficacy. Unfairness, the perception of inequity to employees from an organization and leadership, an absence of direction, and unclear expectations also play a role in burnout culture [18, 24].
For healthcare organizations, there is a need to prioritize clinician well-being. Governance and management systems must ensure clinician participation to set priorities and solve problems. Clinician burnout and well-being indicators should be developed and monitored, including identified stressors that are commonly associated with burnout, such as excessive work hours, loss of autonomy, and lack of independence in clinical decision-making [27]. Addressing new and emerging stressors that are inherent in clinical care delivery systems, such as the clerical burden of the electronic health record and workflow design, noise from repeated alerts and reminders, etc., must be actively managed.
Clinician well-being survey results must be regularly reviewed. Healthcare administrators and clinical leaders should use data sources to identify outbreaks of burnout and monitor other mental health indicators to detect emerging risks before they result in significant harm. Priority must be given to designing effective and sustainable treatments for the identified problems that are uncovered [27].
4.2 Organizational-level interventions
Irrespective of the type of organization, employee satisfaction and welfare remain important determinants of the success of an organization [28– 31]. In healthcare settings, examples of organizational issues that are thought to contribute to burnout include funding model changes, the increasing burden of electronic medical records, dysfunctional administration, and system-wide communication issues [18]. The burden on clinicians relating to changes in the model of care, innovation, funding reprioritization, and a change in the direction of the health system is also thought to contribute to burnout [32]. Burnout tends to increase if support to individual clinicians does not include access to specific tools and training on understanding and addressing burnout and building resilience [33].
Organizations must have leadership that is committed to ensuring a healthy working environment. In healthcare delivery systems, organizations that have a focus on maintaining high standards of quality and safety, those that create conducive working environments that prioritize the safety of healthcare recipients and providers, promote teamwork and collaboration, and have effective communication systems, are associated with clinicians reporting lower burnout rates [21]. Effective management and leadership and organizations with leadership development pathways, including communication and emotional competence process training, are likely to be better at putting necessary systems and support in place to ensure that individual workers have appropriate support and that organizational systems are in place to achieve a high level of employee satisfaction.
4.3 Individual-specific interventions
It has been proposed that building resilience in healthcare workers can help decrease rates of burnout [34, 35]. Indeed, many strategies to avoid and treat burnout in healthcare focus on building the resilience of clinicians. Yet, research shows little improvement in the reduction of burnout amongst clinicians from implementing a successful `resilience-building strategy.’ The focus should shift instead to improving clinician satisfaction and embedding well-being strategies in the day-to-day work life of a clinician.
In fact, the focus on clinician well-being should start early in a clinician’s career with appropriate input from mentors that incorporate strategies to identify and manage stress. Aligning individual values with that of the organization creates a mutual culture of wellness and engagement. It also prevents dissonance in the achievement of healthcare delivery goals and ambitions. It has been proposed that time spent developing good relationships with colleagues and patients and prioritizing time to reflect and pursue interests outside the workplace are also important [23].
A supportive culture, strategies to improve workplace mental health, and interventions focus on developing positive coping strategies, autonomy and self-efficacy, skills-based competence, confidence, connection and engagement, self-worth, and personal values are likely to be helpful [23]. Supporting the self-determination of clinicians and each clinician’s drive to deliver care can help clinicians overcome burnout. Empowering clinicians to be accountable for clinical decisions and clinical performance and being responsible for their mental health and well-being are necessary protections to have in place to prevent burnout. Ensuring that clinicians have the necessary information and support to adapt to change in organization systems is also likely to be protective.
Understanding the needs and expectations of different clinician cohorts is essential to ensure necessary supports are in place to support clinician cohorts with specific needs. For example, Baby Boomers (born 1946–1964) and Generation X (born 1965–1980) have started using digital technology as adults, whereas Millennials (born 1981–1996) or Generation Z (born 1997–2012) have grown up with access to the resources on the internet. They have grown up with exponential growth in digital technology. Younger generations are more comfortable with the use of social media, adjusting to changing environments, and also have a better ability to multi-task [36]. On the other hand, millennials may not benefit from traditional resilience strategies. Their drive for immediate gratification and a preference, as well as preparedness to look for a working environment that meets their needs and expectations, is protective for them as they are likely to be more decisive when dissatisfaction and burnout are setting in. Therefore, labeling them as ‘snowflakes’ or encouraging them to be more resilient may become another stressor for them. Millennials may best respond to strategies that target the simplification of complex, contradictory, and confrontational work and personal environments [37].
It is important to recognize that for caring professionals (who work in health, education, religious, spiritual, and similar sectors), it is extremely difficult to accept that tiredness and exhaustion are setting in and might prevent them from providing further care. Acceptance that previous strength and energy have been depleted can itself be challenging and even threatening. It has been proposed that self-care, professional fulfillment and spirituality are ways to avoid burnout [38]. However, the notion of choosing to care for oneself over others is not always an easy option, nor often perceived as a permitted option.
For clinicians, a need to focus on self-care can come from acknowledging limitations that they may have encountered. Accepting unanticipated errors and omissions that may have occurred or judgments that may in retrospect appear not to be the best ones can lead to the realization that their performance is sub-optimal or has declined. Setting new rules and boundaries for the future, taking a break from the norm and taking the time to recover and rest, looking after health and basic physiological and psychological needs, and making new or different career decisions, including choosing to walk away from the chosen career path to regain composure and do a reset, may sometimes be required. Self-care has to be an active determination to prioritize one’s needs, reconsider commitments and expectations, and re-balance priorities, commitments, and goals [39].
The phenomenon of burnout is characterized by exhaustion due to work-related stress. Symptoms can range from a perceived sense of overwork to anxiety, depersonalization, depression, and complete emotional shutdown. Rates of burnout are high in caring professions, including healthcare workers. Self-reported rates of burnout in clinicians seem to be high.
An interplay of organizational, system-related, and individual-specific characteristics determines who experiences burnout and in what situation. Addressing these factors is essential to prevent burnout. Organizations and health services must prioritize clinicians’ well-being and provide support to build a positive workplace culture.
