Coping with Burnout in the Healthcare Field
York University, Toronto, Canada
University of Toronto , Toronto, Canada
Academic Editor: Peta Stapleton
Received: July 27, 2023 | Accepted: October 09, 2023 | Published: October 13, 2023
OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 4, doi:10.21926/obm.icm.2304042
Recommended citation: Rokach A, Patel K. Coping with Burnout in the Healthcare Field. OBM Integrative and Complementary Medicine 2023; 8(4): 042; doi:10.21926/obm.icm.2304042.
© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
1. Coping with Burnout in the Healthcare Field
We will begin this review by describing burnout, which is not foreign to healthcare workers, and then examine the factors that contribute to it, and conclude by the ways that self-care and resilience may prevent or at least limit burnout. By healthcare workers we mean physicians, nurses, nurse’s assistants, social workers and psychologists, and other personnel who have direct contact with patients. Bridgeman et al.  pointed out that healthcare, in general, places numerous pressures on healthcare providers, including the challenges of clinical work, time constraints, competing demands, lack of control over scheduling, and conflicting roles and relationships with leadership.
Occupational stress has an adverse effect on one’s well-being, psychologically and emotionally. Stress was found to be positively correlated with anxiety, depression, and anger, which were expressed through increased absenteeism . Stress was found to be associated with cardiovascular illness, lowered immune functioning, and gastrointestinal problems, which in turn deplete personal resources, which negatively affect patient care [3,4]. The Canadian Medical Protective Association [CPMA]  noted that medical practice with its demands and requirements can enhance physicians’ stress. When addressing the stresses faced by physicians, it is noted that their witnessing suffering, fear, pain, tragedy, and death takes a toll on their wellbeing. In addition, there are increasing patient care demands which they attempt to fulfill, operating with limited resources, long work hours, and many times difficulties with balancing work-life dimensions. Further, loneliness may be experienced if self-care is not practiced .
Burnout. It is well established that healthcare work is quite stressful and the chronic work-related stress, emotional exhaustion, and loneliness may bring about burnout (see ). Freudenbenger  was the first to highlight burnout syndrome, defining it as a phenomenon which points to the emotional wear of a person, accompanied by a decrease in physical and psychological energy, which leads to reduced motivation at work. Later, it was clarified, that anxiety, distress, or pain, expressed behaviorally, emotionally, physically, socially and even spiritually were involved as well. . Schadenhofer et al.  noted that “according to the European Agency for Safety and Health at Work (EU-OSHA), hospitals represent a work environment with high job strain. Prolonged perceived occupational stress may result in symptoms of burnout, such as emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (PA)” (p. 1).
Burnout is a significant work-related challenge for healthcare professionals . Up to 67% of service providers reported high levels of stress, anxiety, and burnout [12,13]. A study which examined work experiences of 182 clinicians found that they tend to overextend themselves when attending to patients . Another example was a survey of 474 psychotherapists, which revealed that up to 61% of clinicians suffered clinical depression . Woo  explored rates of burnout in nurses worldwide. That was based on a systematic review on 113 studies, totaling 45,539 nurses worldwide in 49 countries across multiple specialties. It was found that up to 10% of the nurses throughout the world suffered burnout symptoms. Their burnout seems to be related to the central theme of nursing, which includes an emphasis on caring for patients .
A meta-analysis conducted by Salyers  examined relationships between provider burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and the quality (perceived quality, patient satisfaction) and safety of healthcare. Results indicated a small to medium-sized association and a lower quality of patient care and decreased safety. It was thus suggested that emotional exhaustion had the strongest association with quality of healthcare provided by physicians, psychologists, and therapists . Sipos et al.  investigated the prevalence of burnout among 205 nurses, oncologists, and radiographers during the COVID -19 pandemic. Their results suggest that males, who were oncologists, and who worked more than 50 hours per week suffered a negative impact on individual burnout. A study carried out in Hungary on radiographers by Sipos et al. , before the pandemic broke out, indicated that the younger generation [aged 20-30] were more interested in work relocation than the older ones, indicating their wish to lower stress and decrease the chances of burnout. Interpreting these results should be done while keeping in mind that about ¾ of the participants were females. However, generally it was demonstrated the effects of work-related stress on radiographers.
Bianchi et al.  defined burnout syndrome as a combination of emotional exhaustion, depersonalization, and reduced personal accomplishment caused by chronic occupational stress. The symptoms involve overwhelming fatigue and loss of motivation, a cynical view of one’s job, and a sense of ineffectiveness and failure. Clearly, burnout could interfere with provision of optimal care. Salyers  asserted that burnout may increase the possibility of the healthcare provider committing error which may lead to an adverse event, which may then lead to greater liability for healthcare organizations.
2. The Occupational Hazards of Being Part of the Healthcare Profession & Why Self-care Is Essential
2.1 Physical Isolation of Independent Workers
Practicing patient care, is best done in privacy, though this isolation may come with a price. In the hospital setting, clinicians may feel ‘together’; however, actually caring for patients is a solitary task. It is noted that being part of an inpatient team involve working with others, but most clinicians go it alone. Treatment offered by independent practitioners allows for very little interaction with people of the world that lies outside of the hospital or organization. Consequently, it is not unusual to find sleepy physicians on their long schedules. Emotional numbing, which they may also experience, may reduce their sharpness, which may negatively affect the attention which they pay to what their patients complain about .
2.2 Emotional Isolation
Most healthcare workers experience emotional isolation, despite working closely with various patients that seek their help (see Schadenhofer et al. ). Focusing specifically on patients and their suffering, healthcare workers may neglect attending to their emotions, needs, and concerns; personal feelings are hidden or even repressed in order for the worker to be able to provide competent treatment . Research indicated that up to 80% of clinicians reported struggling with anxiety, anger, and sexual attractions as part of their work. Feelings which they must address by themselves, and contain . Preti  who conducted a large-scale review of the literature, confirmed those statistics.
Patients may demonstrate depreciation by (mainly) verbally attacking their therapist, which may result in the clinician feeling demoralized and humiliated . The therapist’s duty to maintain patient confidentiality may become emotionally challenging and lonesome as the therapist attempts to work through the feelings emerging as a result of the adverse reaction from the patient (e.g., verbal/physical attack). The ethical requirements of confidentiality result in healthcare workers splitting off the emotional impact of their work from their personal life . In fact, Simpson et al.  observed that attempting to balance work-life issues, to be highly distressing in this group.
2.3 Vicarious Traumatization
Patients are seen when they are at their “worst” . As such, they experience and express various negative emotions which may be contagious and health care workers may consequently experience vicarious traumatization, which hampers their ability to be empathic and caring . In addition, healthcare professionals often provide their services to individuals who may have had traumatic experiences. Given their unique role of working with traumatized clients, healthcare professionals are at an increased risk of experiencing emotional distress as a result of their therapeutic work . The repeated exposure of listening to the painful stories and often traumatic events of the client’s experiences may lead to significant stress on the healthcare provider and lead to them becoming indirectly traumatized . This “cost of caring”  phenomenon has been coined as vicarious traumatization otherwise expressed as compassion fatigue . Consequences of vicarious traumatization on healthcare providers includes but is not limited to: emotional withdrawal from family and friends [32,33], sleep disturbances, anxiety, depression, feelings of inadequacy, maladaptive coping strategies such as drug use , impaired clinical judgment , decreased work productivity, and lower quality of service delivery , leading to increased burnout and poorer client outcomes .
2.4 Patient Behaviors
Most disconcerting behaviors of patients are those that concern patient safety and the possibility of self-harm, very distressed patients, or those pointing to complicated mental health issues . Aggressive behavior is a known phenomenon, and such stressful behavior may be expressed by patients. Aggression may be expressed verbally, physically, through stalking, or even an attempt to kill the healthcare provider . The healthcare worker may react to patient aggression with either a submissively or passive aggressively, and these naturally may harm the relationship . Literature has established that patients’ aggression is associated with healthcare workers’ intense anxiety, anger, and a fear of returning to work [39,40].
2.5 Moral Distress
Healthcare workers commonly experience heightened stress and they face a variety of ethical conflicts that can negatively affect their health and wellbeing. Moral distress in healthcare workers is noted when healthcare workers face moral adversity, when they are called to make moral judgements that are related to the ones they treat, and that the consequences of their action (or inaction) which negatively affects their moral integrity . Systemic failures have been identified  in safeguarding healthcare workers from developing moral distress, or not assisting them in successfully managing it. Moral distress was found to relate to the volume of care of patients, especially during the recent COVID-19 pandemic, and access to personal protective equipment . Working in such a stressful environment is positively correlated with moral injury .
2.6 The Clinician’s Life
There are life events may result in significant distress and to wit, up to 82% of clinicians have endured a significant distressing event in the past three years, such as dysfunctional marriages, serious illnesses, or death of a spouse or a child [27,43].
Female clinicians, by the mere fact that they appear pregnant, actually communicate what happens in their private lives . Locker-Forman  described how stressful her pregnancy was a clinician attending to children. She described working with a prepubescent male for a period of two years, prior to her pregnancy. “At times, he played in an extremely destructive way, throwing objects in the room… [and] while I never worried that he would intentionally hurt me, I was always aware of the possibility that he could lose control and harm me inadvertently” (p. 34–35).
Family emergencies or other unexpected events, may cause significant disruptions in the healthcare worker’s life and work. That highlights the clinician’s situation which needs to be monitored and balanced, if the professional is to survive in that capacity . Loneliness, enduring a spouse’s or a parent’s death, personal illnesses, and financial concerns experienced by healthcare workers, although relatively rare, may push some of them to engage in unethical sexual misconduct with patients [47,48].
3. Self-Care: How to Do It the Right Way
Celano and colleagues  maintained that it is essential that healthcare workers be provided with a whole-person care, i.e., mind, body, spirit, in order for them to remain and flourish in their place of work. It stands to reason that organizations, need to support the overall health and well-being of healthcare workers. Showing support for the spiritual health of healthcare workers is a measure of organizational care that goes beyond the typical support which is commonly expressed. Caring for healthcare workers by emphasizing meaning and purpose is a central feature of their overall well-being and self-care.
Self-care is the effort one exerts in taking care of oneself. Such an activity is an essential tool for enhancing clinician wellbeing and overall treatment efficacy . Initially, when it was conceptualized in the 1970s, self-care was seen as narcissistic and self-indulgent, all that despite the understanding that neglect of self-care may increase occupational stress related to caring for patients . Self-care is our therapeutic tool. Lasky  observed that our tools for self-care always remain available to us. Since caring for others is demanding, and may face us with occupational hazards, the first step in our self-care must include establishing realistic expectations that we are not super humans. It is important that we recognize the stresses. That recognition, by itself, could be therapeutic . The Buddhist nun Chodron  wrote a book entitled ‘Start Where You Are’, suggested that we start by showing empathy to ourselves alike, understanding that we need support and nurturance. As the Chinese tradition holds, difficulties are an opportunity to grow. Resiliency means that the practitioner, in this case, acts with the goal to correct the situation, and moreover prevent it from recurring . As practitioners, we may be emotionally broken and need to heal ourselves .
Norcross and VandenBos  highlighted the need to make self-care a priority. Self-care, unlike what we may have been used to believe, is not a narcissistic luxury but a human requisite, and an ethical imperative. We cannot rely on insurance companies or the organizations we belong to. Maybe our families will pitch in. But mostly, it must be us who will look after us.
Self-care needs to be individually tailored, and address such issues as a proper diet, enough and good quality sleep, regular exercise, and meaningful interactions with people . The CMPA  advised that putting the healthcare worker first is of utmost importance. Florio Pipas  eloquently stated that “Want to see change in your team, your organization, or beyond? Start by filling your own tank… Physicians should consider a critical shift in thinking — one that prioritizes caring for oneself as an effective means of caring for others”.
Self-reflection and mindfulness are essential for one’s own wellbeing, and when practiced regularly help center the healthcare worker, enhancing their ability to self- monitor their emotions, and introduce changes when such are needed .
The importance of sleep is becoming increasingly apparent to researchers. Many practitioners grew up believing that sleep is, in some way, a wasted idle time. Research, emphasizes the importance of sleep, during which brain waste is being carted away, and muscle and neurological renewal occurs  which is essential for memory consolidation and optimal cognitive performance. Workplace burnout affects sleep quality and is known to lead to insomnia . Healthy quality of sleep ensures improved emotional regulation and mental wellbeing . Recommendations and environmental modifications to promote high sleep quality includes: achieving regular sleep timing, sleeping in a dark and quite room at a comfortable temperature, and limiting electronic exposure prior to sleeping .
Massage therapy. Can significantly ease the hours of tension and stress that clinicians may experience when they tend to their clients [61,62]. A randomized clinical trial of 110 female university employees exploring the effects of massage vs. lavender aromatherapy on work-related stress and burnout, found that participants reported lower work-related and personal burnout following aromatherapy massage . Research on massage therapy indicates positive and valuable benefits in promoting a healthcare providers mental health and wellbeing, reducing stress, and in preventing a decrease in quality of care delivered .
Cocchiara et al.  asserted that it is possible to benefit from improved physical, emotional and mental health related to yoga activity. It was further noted that yoga appears to be effective in the management of stress in healthcare workers. Varney and Buckle  studied a small sample of healthcare workers, in order to determine the effectiveness of a mixture of essential oils (peppermint, basil, and helichrysum) on mental exhaustion and moderate burnout. Their results indicated that aroma therapy was helpful in lowering stress and burnout. A study which explored how a spa therapy retreat may affect burnout, was carried out by Blasche et al.  where a group of 65 actively working healthcare individuals were undergoing spa therapy primarily for musculoskeletal pain and changes in fatigue, distress, reduced motivation, and quality of sleep were monitored. Results pointed out the significant improvement for those individuals, compared to their pre-treatment level. This improvement was sustained up to 3 months post-treatment for both burnout groups.
Nutrition, hydration, and exercise. It is now well known that exercise is central in improving mood and building mental stamina . Ergonomic components to the office can aid in achieving that goal . Eating and drinking as per recommended amounts and doing so with healthy, balanced foods are a must  in order to provide nutritious fuel to our body and mind. Additionally, walking, playing tennis, or bicycling are highly recommended . High levels of engagement in physical activity demonstrates a moderately strong relationship with reduced levels of burnout symptoms even with high levels of perceived job stress [72,73]. Therefore, a healthy and active lifestyle must be at the forefront for healthcare professionals to promote not only improved long-term physical health benefits, but also enhanced mental wellbeing.
Receiving support from our social support network. We all need social support, which may be offered by friends or from supervisors who would be encouraged by the institutions in which they are employed to empower, assist, and encourage employees [55,74,75]. Personal therapy, just as it helps the population at large, could help healthcare workers to sort through issues, receive support, and enhance personal growth. Personal therapy may be done in the institution, in a group format for example, or in privacy by the healthcare .
3.1 Developing Resilience
3.1.1 Moral Resilience
Building moral resilience, or “the ability to preserve or restore integrity in response to moral adversity” ( p. 126) is seen as a promising approach to reduce the negative impact of moral distress and burnout and enhance clinicians’ ethical competence, and to foster mindfulness and integrity. Moral resilience involves a focused attention and clarity about what values one adopts and the actions which are congruent with one’s value .
Moral resilience specifically includes individual factors that can aid healthcare workers practice in a manner that takes into account and is influenced by their intentions, character, and integrity, in general, and particularly when they confront an ethically difficult situation . Moral resilience is premised on the belief that under certain circumstances (such as during the COVID-19 period) there may be some unavoidable situations that the clinician must face and attend to. Mindfulness, moral efficacy, and self-stewardship can assist in restoring stability so that healthcare workers who will then experience less distress, so that they can fully utilize their resources in addressing stressful situations, and consequently they may reduce the possibility of developing burnout, depression, and secondary post-traumatic stress disorder (PTSD) [43,44,79]. Spilg et al.  asserted that higher moral resilience is often accompanied with support and backing from employers or co-workers. For that to happen, it is necessary to bolster relational integrity, respecting others’ values but not forgetting our own, and embracing interconnection. All that may amplify individual moral resilience within the context of the clinical team. Additionally, suggested Spilg , strengthening institutional structures so that ethical concerns are addressed and resolved, allowing dialogue and discussion will all contribute to strengthen moral resilience.
Spirituality has been a fascinating theme for humans. In recent years, there has been increased interest in workplace spirituality. Research highlights spirituality in the workplace as a crucial component in improving employees’ conditions and increasing theirs and the organizational performance . According to Kinjerski and Skrypnek  workplace spirituality is a positive state which encompasses physical, affective, cognitive and interpersonal dimensions, which result in a state of high energy which results in a feeling of wellbeing, knowing that one is authentic and engaged in an occupation which is meaningful to that person, being connected to others, and a mystical dimension which could be described as transcendence. The positive effects of workplace spirituality stretch from enhancing a sense of a community, to foster feelings of involvement and engagement in work, and it enhances integrity, responsibility, and personal growth which, in turn, directly affect work structures, technological innovations, and job satisfaction [82,83,84]. As far as personal factors are concerned, positive energy and conscientiousness were seen as central to that process. Interestingly, individual differences, such as age or gender, do not appear to significantly influence the experience of spirit at work . Based on their own research and related literature, Dal Corso et al.  recommended that interventional programs, and especially those geared towards improving supervisor behavioral competencies, need to be developed, since the role of supervisors in shaping the work environment is crucial. They asserted that involving spirituality at work is now recognized in healthcare, and needs to be further enhanced, since workplace spirituality enhances wellbeing, social responsibility, and prevent or limits workplace stress.
As the healthcare industry continues to expand, it is important to understand how healthcare workers are at an increased risk of being susceptible to burnout leading to physical and mental health consequences. In summary, this article provided insight on the peril of working in the healthcare profession, the detrimental consequences associated with burnout, and the impact it has on the quality of patient-centered care provided. We reviewed the physical and psychological manifestations associated with signs of burnout, external environmental factors impacting the clinician’s rapport and attention when working with clients, the unavoidable secondary trauma associated with reliving the traumatic experiences of the clients they work with, navigating dilemmas conflicting against one’s own morals and values, and the influence of significant changes within the healthcare professional’s own personal life. As healthcare professionals, we have been engrained to provide our services with a patient-centered focus, and this may often lead to us neglecting our own wellbeing. As Eleanor Brownn  wisely observed “When you take time to replenish your spirit, it allows you to serve others from the overflow. You cannot serve from an empty vessel” (n.d.). Healthcare professionals work closely with their clients to ensure they can live a well-balanced and healthy lifestyle. In this brief review, we feature the importance of practicing self-care as healthcare providers and reflect on using self-care as part of our own therapeutic toolkit. Self-care activities, which are uniquely tailored to the individual, can be expressed through various strategies. This includes internal and external strategies and lifestyle modifications, as well as reaching out for support from one’s social network, and developing one’s own sense of resilience and spirituality, which can be a protective barrier from workplace stress and burnout. Above all, as healthcare professionals, practicing consistent self-care will lead to not only better health outcomes but importantly, in the exponential personal and professional growth of the self. We wish to mention that self-care by itself is good, but it will not resolve burnout. Burnout is a widespread issue, which needs to be addressed by governments and institutions, and employees need to be told that it is a legitimate expectation that burnout may occur, and consequently, prevention is better than treatment.
A. Rokach initiated this project, and A. Rokach & K. Patel were both equally responsible for writing this manuscript.
The authors have declared that no competing interests exist.
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