Burnout: What Every Regulator Should Know

Clinician burnout has negative effects on patient safety. This article is based on a presentation by Nikki Sleddens and Betsy Becker at the 2019 FSBPT Annual Meeting.

Burnout is defined as “a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity.”ⁱ

There are three dimensions under the umbrella of burnout:

• Emotional Exhaustion (EE): tiredness, lack of vigor or drive, higher irritability, psychosomatic symptoms, overextended, fatigued due to work^ii,iii,iv
• Depersonalization (DP): distancing oneself during interpersonal contact, negative, cynical attitudes and feelings about one’s clients^ii,iii
• Low Feelings of Personal Accomplishment (PA): feeling of decreased competence and decreased efficiency, difficult to gain a sense of accomplishment, low effectiveness^ii,iii

In 2007, the Institute for Healthcare Improvement proposed three initiatives that health care should strive to meet. This included improving population health, improving the patient experience, and reducing cost. These initiatives were referred to as the Triple Aim. It has been suggested that in order to accomplish the goals of the Triple Aim, a fourth aim, improving the clinician experience, must be included. This four dimensional approach to improving health care is referred to as the Quadruple Aim.^v

Burnout has a significant impact on the clinician experience and will need to be addressed to meet the goals set forth by the Quadruple Aim. In order to move forward, delivery models should be revaluated and science leveraged to develop evidence-based solutions.

State of the Science

Nikki Sleddens conducted an integrative review of the available literature regarding burnout of physical therapists in the United States. Seven studies were identified that addressed this issue. Of those seven, five provided data regarding the prevalence of burnout using a valid and reliable instrument. The dates of these studies ranged from 1993 to 2015. Four of these were published prior to 2003.  All five studies that measured burnout used the Maslach Burnout Inventory. The figure below represents the ranges of scores found in the studies for each of the burnout dimensions.^{iv, vi, vii, viii, ix} 

The ranges of burnout reported in the studies using the Maslach Burnout Inventory for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA)^{iv, vi, vii, viii, ix}

While studies of academic faculty were not included in this particular integrative review, two studies were identified that examined burnout in physical therapy academic faculty. In general, faculty experience high levels of personal accomplishment, moderate levels of emotional exhaustion, and low levels of depersonalization. This is relevant as it has been suggested in the literature that faculty wellness could impact student wellness.^x

The literature identified in the integrative review pinpointed four factors associated with burnout:

• Support from Supervisors and Coworkers^{vi, vii, viii, xi, xii}
  • Communication and connectedness
  
  
• Time and Resources^{vi, xi, xii}
  • Clinicians felt they did not have enough time and they had inadequate resources.
  
  
• Professional Development^vii,vii,xii
  • Meaning in work
  • Professional development activities
  
  
• Work Environment^ix,xii
  • Settings that have higher rates of burnout included rehabilitation and acute care settings.

Watch a short video that summarizes the factors associated with burnout

Based on this review, there appears to be significant gaps in the current literature regarding burnout amongst physical therapists in the United States. While the studies cited did note some level of burnout and outlined factors associated with burnout, the majority of the literature is outdated. Further research is recommended to better understand burnout in this population.

Given the lack of current research in physical therapist burnout, we can look to other medical professions to help us better understand what impact burnout has on clinicians. Research in other health care providers has shown that burnout affects both well-being and safe and competent practice.

• Well-being^{xiii, xiv, xv, xvi, xvii}
  1. Decrease in cognitive, psychological, and physical function
  2. Psychosomatic complaints
  3. Somatic and physiological arousal
  4. Compromised immunity
  5. Alcohol and drug use
  6. Negative self-concept
  
  
• Safe and Competent Practice^{xiii, xv, xvi, xvii, xviii, xix, xx, xxi, xxii, xxiii}
  1. Loss of concern for patients
  2. Decreased quality of care provided
  3. Increased risk for error
  4. Absenteeism
  5. Increased job turnover
  6. Decreased morale and negative attitudes toward job

Additionally, in 2016, Salyers and colleagues, conducted a meta-analysis where they specifically studied the relationship between burnout and the quality of care provided and burnout and safety. They found a negative relationship between burnout and quality of care provided and burnout and safety. The relationship between burnout and quality was stronger for emotional exhaustion than any other dimension. According to the authors, these findings suggest 1)emotional exhaustion may be one of the most important elements to address and 2) burnout may interfere with optimal patient care.^xxiv

Solutions to Promote Healthy Practice

FSBPT’s Guidelines for Continuing Professional Development define healthy practice as “conditions under which safe, effective, and ethical practice is most likely to thrive.” While individual self-care strategies such as yoga may be beneficial, we can’t yoga our way out of burnout. If the environment is contributing to burnout, even the best self-care can’t singularly address that. Therefore, promoting healthy practice requires us to take a systems approach.

A systems approach includes professional organizations, third-party payers, government organizations, electronic health record vendors, professional schools, organizations where health care providers are employed, accrediting bodies, the individuals, and, of course, regulators. If all of those systems come together, changes can be made in the way clinician burnout is tackled.

Frameworks

There are two frameworks that may help guide these solutions, the Health Professional Wellness Hierarchy^xxv and Job-Person Fit.^xxvi

Health Professional Wellness Hierarchy

The Health Professional Wellness Hierarchy is adapted from Maslow’s Hierarchy of Needs. It’s based on the same premise that basic needs must be met first before other needs in the hierarchy can be met. They proposed that interventions should be directed from the bottom up. Physical and mental needs such as being given a lunch break, getting enough sleep, and using the restroom must be addressed first. Once these basic needs are met, interventions can be directed at the higher levels of safety, respect, appreciation, and eventually healing patients and contributing.^xxv

Job-Person Fit

Another helpful model is the job-person fit, which was proposed by Maslach and Leiter in 2017. They suggested that both the individual and the organization have a role in preventing and alleviating burnout, and the job-person fit is a way to incorporate both of these entities.

The model identifies six areas of potential frustration that can lead to burnout:

• Workload
• Control
• Reward
• Community
• Fairness
• Values

Because these are areas of potential frustration, they are also areas where strategies could be targeted. The authors emphasized the importance of looking at each of these areas from the individual and organizational level and directing interventions appropriately depending on whether it is an individual issue or an organizational issue.^xxvi 

Organizational Initiatives

With these frameworks in mind, what can the various organizational stakeholders do?

Professional Organizations and Societies

Professional organizations should encourage providers to seek both preventative and curative treatment. Self-care should be promoted to reduce the stigma associated with seeking treatment for mental health issues. Clinicians tend to be hard-working and caring. It can be difficult for caregivers to admit that they are in need of help. The availability and accessibility of confidential counseling should be expanded, and providers should be educated about the resources that are available. There are many resources out there, but if someone is already overwhelmed and burned out, it is unlikely they have time to seek these out. Communications to the public around the issue of provider wellness also might be helpful.^xxvii

Third Parties

Medicare, Medicaid, and other third-party payers should closely evaluate any new requirements that they're placing on providers to determine the impact that each has on provider wellness. New requirements should be evidence-based and have a strong rationale to improve patient care and protect patients' safety in order to be implemented. When evaluating the quality of care provided, payers need to look beyond cost savings and also consider physician health and practice patterns that promote wellness.^xxvii 

Government Agencies

State governments, health departments, and legislatures should weigh the potential value of new regulations against the potential risk to clinicians.^xxvii

Electronic Health Record (EHR) Vendors

Ideally, electronic health records should help clinicians improve patient safety and care. This requires vendors to make an effort to design systems that avoid redundancy that can increase workload and frustration.  They should also seek input from clinicians to improve the user experience.^xxvii

Professional Schools

Professional schools should have conversations with students about wellness and how this could impact patient care. They also need to be open with students about the challenges they may encounter as new professionals. Additionally, schools should make sure students’ voices are heard within their own programs as it relates to wellness.^xxvii

Health Care Facilities

Shanafelt and Noseworthy (2017) proposed nine strategies to promote engagement at health care facilities, which they say is the antithesis of burnout.^xxix

• Acknowledge and address the problem.
• Harness the power of leadership.
• Develop and implement targeted interventions.
• Cultivate a community of work.
• Foster wise use of rewards and incentives.
• Align values and strengthen culture.
• Promote flexibility and work-life integration.
• Provide resources to promote resilience and self-care.
• Facilitate and fund organizational science.

Providers

While self-care alone isn’t going to solve the problem, individual providers should work to build their own resilience and manage stress.

There are several self-care strategies that should be considered:^{xxviii, xxx, xxxi,} 

• Network connections
• Self-awareness
• Change conversation
• Exercise
• Sleep
• Reflective writing
• Breathe
• Mindfulness
• Meditation

Regulators

Regulatory boards have the duty to protect the public. The Federation of State Medical Boards has specific recommendations grounded in patient safety and specific to state medical boards with a focus on the licensing process.^xxvii 

They recommend that regulators should do the following things:^xxvii

1. Consider the necessity of probing questions on applications.
2. Re-work questions that address mental health so they are posed in the same manner as questions that address physical health.
3. Offer the option of “safe haven non-reporting.”
4. Ensure privacy of licensee-reported personal health information.
5. Emphasize the importance of provider health.
6. Clarify that investigation is not the same as disciplinary action.
7. Support the use of data for decision making.
8. Examine policies and procedures about providing safe care to patients.
9. Be aware of potential regulatory burdens on licensees.

Conclusion

Burnout is a complex issue and it will take commitment at all levels to address. Ultimately, it is about the quality of the care we provide and ensuring the safety of the patients we serve. If all stakeholders are involved in the conversation, we can make a difference.