Burnout, defined as a syndrome of depersonalization (detached to the point of viewing people as objects), emotional exhaustion, and low personal accomplishment that leads to decreased effectiveness at work,(1) is highly prevalent in physicians. In a 2021 study, high emotional exhaustion, depersonalization, and one symptom of burnout were seen in 38.8%, 27.4%, and 44.0% of participants, respectively.(2)
Burnout in physicians differs based on race and gender. For example, physicians in minority racial/ethnic groups report less burnout compared with non-Hispanic White physicians.(3) Another study, of internists and internal medicine trainees, indicated odds of burnout among women was 56% higher than among men.(4)
An important risk factor for physician burnout is chronic insufficient sleep (e.g., due to extended work hours, circadian misalignment, or unrecognized sleep disorders). Interventions to promote healthy sleep may reduce physician burnout susceptibility.(5)
An extensive study of physicians reported sleep-related impairment in 40% of attending physicians and 51% of house staff physicians.(6) There was large correlation between sleep-related impairment and interpersonal disengagement, work exhaustion, and overall burnout.(6) After adjustment for other variables, high sleep impairment levels increased the odds of self-reporting a clinically significant medical error by 96%.(6)
Besides medical errors, sleep-related impairment and occupational distress have also been associated with unsolicited patient complaints. Professional fulfillment seems protective against such complaints, suggesting that strategies to promote professional fulfillment may improve patient care.(7) Yet administrative tasks are often seen as unfulfilling. In a national cross-sectional survey of physicians, 32% reported engaging in unprofessional behaviors related to administrative aspects of patient care in the past year (e.g., documenting something they did not do to close an encounter in the medical record), and burnout was found to be associated with these behaviors.(8)
Unprofessional behavior, reduced motivation, and suboptimal communication with patients in physicians with burnout often reflect the physicians’ sense of no control over environment and are accompanied by reduced self-regulation mediated by the prefrontal cortex.
Restoring the physician’s sense of control over working conditions could contribute to wellness.(9) Giving physicians the opportunity to shape their clinical and vacation schedules is one way in which to restore a sense of control. Activities that enhance social supports (e.g., peer support programs and Balint groups) and add meaning to work (e.g., professional development time, mentorship, time to develop connections with patients, etc.) are likely to provide some benefit, as they support physicians' capacity to maintain perspective, sense of purpose, and enhance sense of control over their situation.(9,10)
One study showed such a group normalized struggles, reduced isolation, and provided new strategies for navigating challenging interactions.(11) In another study, self-facilitated physician small-group meetings improved burnout, symptoms of depression, and job satisfaction.(12)
Although rates of burnout among physicians have grown, physicians are resilient when compared to other occupational groups. A survey found that mean resilience scores were higher among U.S. physicians than the general employed population. Nevertheless, 29% of physicians with the highest resilience scores still had burnout.(13) This suggests that burnout is a serious issue even for the most resilient.
Burnout in Nurses: Findings, Impact Of Covid, and Career Implications
Just as with physicians, there are recent notable findings regarding burnout in nurses (Table 1). A recent review found the rate of burnout among nurses working in hospitals ranged widely from 5% to 50%, based on specialty differences and geographical regions.(14) More specifically, the review indicated the overall prevalence of emotional exhaustion was 34.1%, of depersonalization 12.6%, and of lack of personal accomplishment 15.2%.(15)
This same review took COVID-19 into account and noted nurse burnout risk factors as younger age, decreased social support, low family and colleague readiness to cope with COVID-19 outbreak, increased perceived threat of COVID-19, longer working time in quarantine areas, working in a high-risk environment, working in hospitals with inadequate and insufficient material and human resources, increased workload, and lower level of specialized training regarding COVID-19.(15)
Burnout has many consequences in nurses. Emotional exhaustion is negatively associated with the quality and safety of care, patient satisfaction, nurses’ organizational commitment, and productivity.(14) Nurse burnout has been a significant factor in predicting medication-associated errors.(16)
Protective factors in nurses include belief in readiness to cope with COVID-19 outbreaks, willingness to participate in frontline work, prior training and experience in COVID-19 patients’ management, safe practices, and increased social support.(15) Empathy and nursing organizational climate have been found to be protective against burnout, suggesting this could be targeted in managerial interventions.(17)
Nursing surveys of three types of work engagement (i.e., vigor, dedication, and absorption) and resiliency suggested some protection from burnout.(18) Mindfulness-based interventions could potentially have a protective effect for burnout in nurses.(19) (See Table 2 for an overview of how burnout impacts feelings about careers in nurses and physicians.)
COVID-19 Pandemic as Accelerant to The Burn
Healthcare workers were already hurting before 2020 and the start of the COVID-19 pandemic. The pandemic accelerated high-effort/low-reward conditions for many. Representative 2021 social media posts by healthcare workers describe a pandemic that is fatiguing and disorienting: It “keeps getting more & more emotionally and physically exhausting” … “everything we knew & did has been turned upside down” … “I’m just tired, and the threat of another surge has me looking back on things through a darker lens.”
The prevailing mood among many includes a sense of helplessness, futility, and lack of meaning. Physicians at various stages of education and careers left the profession — often quite publicly.
The attitude and response of the public at large can also undermine the physician’s capacity to derive meaning. In his description of bitterness that arose in concentration camp survivors after their release, psychiatrist Viktor Frankl described a “superficiality and lack of feeling” among the public that was as significant to the mental health of some survivors as the concentration camp itself. Survivors felt so disgusted by the public’s response “that one finally felt like creeping into a hole and neither hearing nor seeing human beings anymore.”(23)
Polarizing attitudes and ideological blindness add to the sense of fruitlessness in our shared work. Frontline care providers have faced public threats and even violence. Meanwhile, accurate or not, reports of employer indifference to the plight of healthcare workers are legion. Leaders and organizations have their work cut out for them to engage their employees and positively influence their mental health.
Sustainability — A Path To Humanity Over Profits
As physicians, nurses, and other healthcare workers are burning out, there is a massive accounting trend impacting corporate reports: “sustainability.” These novel sustainability changes are driven by rethinking “shareholder value” and looking at the impact of the organization on people and the planet.
Potentially eclipsing the impact of the Sarbanes-Oxley Act, the governance and financial accounting world is in a period of massive change.(24) Targeting new aspects of the work of an organization, sustainability focuses on documenting “ESG” criteria: environment, social, and governance.
ESG includes many broad goals such as emissions reduction, energy efficiency, recycling, clean water, healthy living, support for people, etc. The Governance & Accountability Institute notes 86% of the S&P 500 have published sustainability reports.(25) Furthermore, between 2016 and 2019, organizations have doubled (from 29% to 49%) in their intent to voluntarily report on ESG for their shareholders.(26) Examples of the financial magnitude of ESG’s impact are highlighted in Table 3.
How does this relate to burnout? Most importantly, this new accounting expectation provides a path of alignment between burned out physicians (and other healthcare providers) and the “bottom line” focus of the C-suite of healthcare organizations and hospitals.
The prior singular focus on profit and shareholder value has shifted as companies are being asked for formal statements documenting aspects of ESG and being urged to have in place a chief sustainability officer (CSO) who reports to the CEO and is a member of the senior executive team. Reporting on ESG for formal public statements will be complex, challenging to document, and require immediate planning by leadership.
This new method of corporate governance requires new measures rather than simply counting profits, and burnout ought to be one of these measures. How might burnout be logically inserted into the sustainability reports? Physician leaders must be prepared to do so; the following concept will help.
Psychological Materiality: A New Way Of Accounting?
In traditional accounting of corporate bottom lines, monetary figures are included in the calculation of the balance sheet when they are “material,” or more formally, “financially” material (see Table 4 for a definition). The specific standards vary per organization and overall performance; however, there are governing principles for what is material.
Financial materiality focuses financial professionals and directs the governance of accounting systems to measure performance. Ultimately, if the numbers are aligned with strategy and the expected organizational performance, or “good,” this instills confidence that the business is doing well.
But how does financial materiality fit with the current and significant momentum behind “sustainability” and ESG? We believe there is a similar concept within the context of organizational values that gets at the triple bottom line. As psychiatrists, we know that what happens in the mind will influence behavior, and the environment plays a role. The mind of each individual physician leader and the environment for all healthcare providers will impact “psychological materiality” (see Table 4 for a definition).
In the end, it is people’s action that will determine the triple bottom lines. And, in every case, when human beings act in the world, their actions are determined by what they see is worth their effort. This has been shown throughout the literature in the effort-reward-imbalance model of burnout, which suggests that high-effort/low-reward occupational conditions are particularly stressful. Conversely, when efforts are aligned with rewards, there is engagement, and burnout is less likely.(37) Leaders should be aware that rewards must be psychologically as well as financially material.
Efforts are psychologically material when people feel like what they do matters, when they feel that by working, they are making a difference. For example, higher levels of mattering have been associated with lower burnout and higher engagement in nurses and nurse practitioners. Mattering was thought to increase with experiences at work such as demonstrating professional competence, positive interactions with patients and inter-professional peers, and receiving recognition from one’s organization.(38)
Work must address concerns relevant to the healthcare workers and what they value for their work to matter. It matters psychologically, and so, it is psychologically material.
Avoiding Bankruptcy: Moving Toward The Psychologically Material
One can frame the problem of burnout as a form of “bankruptcy” in our capacity to derive meaning from our work. The problem of meaning is implicit in the definition of burnout. A sense of “increased mental distance” from one’s job to the point of “not caring” constitutes a defining aspect. In burnout, as in other clinical syndromes, the import of meaning is most easily recognized when it is absent.
Healthcare workers may not ordinarily attend to issues related to meaning and mattering. They simply show up and do their jobs in “flow” with things that matter without conscious appreciable effort.(39) When feelings of emotional depletion seen in burnout interrupt “flow,” healthcare workers may begin to question what matters.
Burnout can progress to a sense of futility and reduced self-efficacy that ultimately diminishes capacity to derive meaning. The healthcare worker with burnout implicitly asks: “Why mobilize and sustain my skills and capacities when the outcomes will be negative regardless of my efforts?”
Workers who find intrinsic meaning in the job itself (beyond merely getting paid) may be at lower risk for burnout.(40) Healthcare workers, like workers in general, need to see some purpose in what they are doing beyond simply surviving. Work must make some sort of difference for us to experience it as meaningful.
Although “we are often taught to think of ourselves as inherently selfish, the longing to act meaningfully in our work seems as stubborn a part of our make up as our appetite for status and money.”(41) When we consider psychological materiality, pursuing meaningful work moves us toward a truly “full bank.”
Organizational Response Starts With Leadership
The literature is clear that organizational responses to burnout should ensure that leadership is present at the level of the work unit. In one study, physicians’ ratings of their immediate supervisors’ leadership qualities were associated with their subsequent levels and changes in burnout and satisfaction with their organization two years later.(43) In another survey completed by physicians and physician leaders, increase in leadership score of immediate supervisors was associated with increase in personal-organizational values alignment score.(44) A similar study in non-physician healthcare employees showed that better leadership scores of immediate supervisors correlated to decrease in odds of burnout and increase in odds of satisfaction.(45)
These studies highlight that healthcare workers’ experience with their organization is highly dependent upon the leadership skills and engagement of their direct-report leaders.
Healthcare workers may emulate specific behaviors of their leaders. One study found leaders’ sleep-related impairment was associated with sleep-related impairment among those they supervised. Authors of that study suggested that training, skill building, and support to improve leader well-being should be considered a dimension of leadership development rather than simply a dimension of self-care.(46) Such evidence supporting development of leader well-being underscores the trend toward organizational recognition of what is psychologically material.
Principles To Guide Healthcare Leaders Responding To Burnout
Even though strong leadership is crucial, there is no specific “checklist” or “recipe” to which healthcare leaders can turn to protect employees from burnout. Evidence in the literature points toward a new integrative model of wellness-centered leadership (WCL) with three elements: care about people always, cultivate individual and team relationships, and inspire change.
Organizations that implement WCL primarily rely on intrinsic motivators to drive results rather than focusing on aligning incentives using a carrot-and-stick model (e.g., rewarding clinicians for relative value unit generation and high patient throughput). Intrinsic motivators include meaning, purpose, values, voice, input, control, and professional development.(47)
Along the lines of WCL, we suggest principles that leaders can use to help preserve a sense that what we do matters. Healthcare executives should recognize:
The need to derive meaning from one’s work is at the core of human psychology. A failure of management and healthcare executives to recognize this key fact about human psychology probably increases the risk that employees will be adversely impacted by the enormous challenges that the pandemic has introduced.
The need to feel that one’s work is meaningful is often stronger than the desire for pleasure or the need to avoid pain. A major lesson to be drawn from human history is that we can endure even extreme suffering if we feel that such suffering is meaningful.
While no one chose the situation the pandemic created, we have the freedom to choose our response to the situation. When we cannot change what is happening to us, “we are challenged to change ourselves.”(42) Recognizing this sense of responsibility is the beginning of responding to the burnout crisis.
We must find as much meaning as possible in specific situations. There is no overarching “meaning” that applies to every situation or every individual. Each situation is different, and each situation has its own meaning. “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”(23) This is also true for leaders. Not all healthcare providers can find meaning on their own. We must work on finding the meaning in this moment, this space, together.
Deriving meaning from work entails three aspects. The first is purely subjective and is captured in the “commonsense” notion that intrinsic aspects of one’s work can be fulfilling.(40)
The joy of patient care and the sense of gratification derived from one’s capacity to alleviate suffering typically motivate healthcare workers. This joy is often extinguished in burnout. The job of the healthcare executive entails locating and addressing systemic sources of this problem. Leaders can help by acknowledging the reality and recognizing some of the frustrations in the work of the pandemic: lack of full public support, polarized attitudes, the patients who die despite our best efforts, and of course, the capacity of the virus to mutate.
The second aspect of meaningful work relates to the objective value of the work activity.(40) A sense of personal fulfillment in one’s work will not suffice if there is no value to one’s efforts (i.e., if nothing ever comes of them). The pointlessness of an activity may not change even if one enjoys the activity; one needs to see one’s work as valuable in a way that can be recognized and understood from a point of view other than one’s own.
Working toward value that has a source outside oneself is psychologically material and alleviates the individual’s sense of insignificance. It is important that our interest in pursuing meaningful work is not understood exclusively as an interest in feeling a certain way about one’s work. We have an interest that our work be a certain way, that our work makes a difference in reality.
It is impossible to overestimate the importance of having an authority figure express genuine appreciation, admiration, and recognition for an employee’s real contribution. Here, again, the physician leader must be self-aware enough to distinguish between sending pizzas to the ICU, for example, or showing up and being there as part of the team at the hospital.
A study that used staff engagement interventions (e.g., structured huddles and recognition events) among nurses, physician assistants, and medical assistants decreased rates of burnout from 42.3% to 25%. Job-related stress also dropped from 41.2% to 34.5%, whereas job satisfaction increased from 70.6% to 82.8% from pre-intervention to post-intervention.(48)
The third aspect of meaningful work relates to our capacity to vitally engage with work activity.(40) One may recognize that one’s work is important but still feel that one’s efforts might be better used elsewhere (i.e., poor use of one’s own set of talents or skills). This third aspect of meaning entails an ability to deeply engage with and do something about the problem upon which one focuses. The worker must be able to fully attend to her work, she must enter a state of “flow” (i.e., intensive and engaged immersion) with the work activity.(39)
Bottom Line For Leaders Responding To Burnout
Leaders must make a human connection. Healthcare workers are drawn to the field to make a difference, and they need leaders to connect with them and help them see they are making a difference. Leaders can support mental health by acknowledging the reality that confronts workers while fully connecting with initiatives that engender connection and meaning.
These are unprecedented times in healthcare, and the daily challenges are daunting. But leaders who occupy the “trenches” with workers, appreciate and understand them, and help them experience their work as meaningful are much more likely to meet those challenges.
Burnout is an adaptive problem and thus never completely solved. It needs to be steadily monitored and managed. With this in mind, we strongly recommend that the leaders of healthcare systems and physician leaders:
Report burnout metrics if they keep them.
Address the concerns within the metrics (or reported metrics) that could lead to demoralization and make matters worse.
Strengthen ties between workers and the meaning of the work they perform.
Leverage the current momentum of ESG to solicit metrics and processes to identify and follow the role of meaning and work.
Follow up and follow through. It is not enough to say, “I fixed it,” as this is not a one-time fix.
Use the process to have current (transitory) and long-term dialogues about the meaning of the work within and throughout all departments of the organization.
The challenge of healthcare worker burnout underscores what we have long known regarding leadership: The best leaders are in tune with the people they lead and inherently know how to motivate them. Organizations with visionary leaders who fully understand this will put themselves in position to succeed in people and profits.
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