Workplace stress and career burnout among clinicians

 

Depersonalization consists of negative or cynical attitudes and feelings about patients and a dehumanized perception of others. Examples of depersonalization include viewing patients as impersonal objects, acting more callus toward others, and not caring what happens to patients.

A reduced sense of personal accomplishment may include the feeling of ineffectively dealing with the problems of patients, the inability to positively influence the lives of others, and the lack of feeling exhilarated after working closely with patients. Burnout is associated with higher ratings of emotional exhaustion and depersonalization and lower ratings of personal accomplishment. 


Clinician burnout that is ignored and goes unaddressed will ultimately have negative effects on every aspect of one’s family and social life and can lead to such conditions as depression, anxiety, and substance abuse. The initial signs and symptoms of burnout may be difficult to recognize because the process typically occurs over a lenghty period of time. I

t is important to be aware of the presence of the signs and symptoms of burnout as soon as possible, because early recognition and intervention can restore balance and prevent the development of other psychiatric conditions. Early recognition can also help avoid the professional consequences of burnout, including potential patient harm. 


Managing stress


Stress management is the key to maintaining a healthy balance in life and preventing career burnout. Clinicians who fail to find effective and healthy ways to manage personal and professional stress are more likely to develop unhealthy habits. Although unhealthy ways of coping with stress may seem effective temporarily, such behavior can eventually lead to more damage.

Health-care providers must acknowledge the presence of stress in their lives, reflect on the ways that stress is currently being managed, and develop healthy coping strategies to successfully manage stressors. 


Unhealthy habits. It is important to be aware of unhealthy habits that may slowly develop over time, such as overeating; under-eating; binge drinking; using drugs to relax; smoking; sleeping too much; withdrawing from friends, family, or participation in activities that were enjoyable in the past; checking out mentally; and lashing out at others in an abusive fashion.

Such unhealthy habits will ultimately have a negative effect on family, friends, coworkers, and patients and will only compound the person’s current level of stress. If current habits are not improving the individual’s overall emotional or physical health, it is time to consider developing more healthy habits. 


Healthy habits. The most effective way to manage stress and prevent the occurrence of detrimental coping mechanisms and, ultimately, professional burnout is to develop healthy habits. Healthy activities allow the body and mind to decompress, relax, and recharge. Such beneficial activities may include getting regular exercise, eating nutritious food, getting sufficient sleep, listening to music, spending time outside in nature, interacting with a pet, watching a funny movie, or soaking in a hot bath.

Such social interaction as calling or visiting with a close friend or family member is also a healthy, stress-relieving activity. Some individuals find relaxation by writing in a journal, working in a garden, or reading a book. 


Avoidable vs. unavoidable stressors


Learning to better manage stress requires the person to change either the current situation or the way he or she reacts to the situation. Avoiding stressful events or individuals is one way to keep stress levels in check. The person should also learn how to say no to additional requests, stay away from individuals who create a stressful environment, or simply be more assertive. Giving priority to activities a person deems most important can be a very effective way to manage stress levels.


However, not all stress is unavoidable, and change lies at the heart of effective management of unavoidable stress. Devising healthy ways to manage unavoidable stress is one of the keys to preventing burnout. 


Strategies on coping with unavoidable stress may include changing the way one communicates, changing how one chooses to react to a situation, and changing one’s expectations and attitude. The person should consider expressing feelings instead of keeping them inside, being open to compromise, being more assertive, and improving time management. He or she should have realistic expectations, admit that perfection does not exist, and focus on the positive aspects of a situation.

Realizing that the behavior of others cannot be controlled enables one to focus on factors that can be controlled. Talking with a trusted friend or therapist and learning to forgive others are additional ways of managing unavoidable stressors. 


Preventing and treating burnout


The ability to prevent burnout ultimately depends on the effective management of stress, which requires rigorously setting and keeping boundaries at the workplace. A strategy to prevent burnout should include avoiding unhealthy habits, developing healthy habits, and maintaining professional boundaries (Table 2).

Table 2. Strategies to prevent burnout

Avoid such unhealthy habits as:

Overeating/undereating Binge drinking Drug use Smoking Sleeping too much Withdrawing from friends, family, or activities that were once enjoyable Checking out mentally Taking your stress out on others in an abusive fashion

Develop such healthy habits as:

Regular exercise Healthy nutrition Interacting with a pet Watching a funny movie Long, warm baths Reading Writing in a journal Gardening

Maintain professional boundaries

Ensures adequate self-care of the health-care provider Serves as a healthy barrier for the health-care provider Decreases disruptive or intimidating behavior by the health-care provider Ensures that patient harm does not occur

Differentiating between avoidable and unavoidable stressors is another important aspect of burnout prevention. Attention to underlying illness is imperative, and prompt treatment of such health problems or psychiatric conditions as substance-use disorders or major depressive disorder is a primary component of an effective burnout-prevention strategy. 


As noted previously, implementing these strategies will require changes to be made in one’s daily lifestyle and behaviors as well as rigorous maintenance of personal and professional boundaries.


Maintaining professional boundaries


The topic of personal and professional boundaries is extremely important and deserving of much thought and attention. Although a detailed discussion of the subject is beyond the scope of this article, several aspects of maintenance of professional boundaries may have significant impact on prevention and treatment of burnout among health-care providers. 


From the provider’s standpoint, maintenance of professional boundaries primarily prevents burnout through the mandate for self-care. Health-care providers are expected to commit to ongoing professional development and excellence in patient care. However, the expectation of providing care for others is difficult or impossible to achieve when it is separated from the imperative to care for oneself. Maintaining personal boundaries to ensure adequate self-care is a fiduciary duty owed to the patient, because the presence of burnout does not excuse any patient harm that may result.


Self-care demands incorporation of healthy behaviors, including adequate exercise and healthy eating, as well as avoidance of unhealthy behaviors and excessive use of addictive substances. Increased stress is associated with increased substance use as providers search for relief. Substance abuse can lead to addiction, which exponentially increases stress and the potential for career burnout.


Strict adherence to professional boundaries minimizes stress associated with difficult patient interactions. These boundaries ensure that patient harm does not occur by preventing psychological, financial, and sexual exploitation of the patient. However, maintenance of professional boundaries also serves as a protective barrier for the provider by establishing ground rules for the professional services that promote self-care. For example, not allowing after-hours refills of controlled substances could minimize unnecessary stress by eliminating a potential negative patient interaction before it happens.


Finally, maintaining professional boundaries reduces disruptive or intimidating behaviors on the part health-care providers. Disruptive behavior in a health-care setting is associated with increased medical errors, poor patient satisfaction, staff turnover, and burnout.

On January 1, 2009, The Joint Commission (www.jointcommission.org) enacted new standards for accredited hospitals and programs centering on a code of conduct that defines acceptable, disruptive, and inappropriate behaviors exhibited by health-care workers, as well as a process for managing disruptive and inappropriate behaviors.¹⁷

In short, The Joint Commission mandated enforcement of professional boundaries to strengthen the protective barrier against disruptive behavior by employees. The anticipated result is a less stressful environment that ultimately reduces burnout and the potential for patient harm. 


Conclusion


Stress and burnout are on the rise among health-care providers. Research has shown a correlation between burnout among providers, negative patient outcomes, and increased health costs. With the current shortage of practitioners and increasing pressure to do more work with less help, clinician burnout could be a major national problem for the foreseeable future. 


Health-care providers must be aware of effective ways to manage stress, recognize the signs of potential burnout, and adopt effective prevention strategies. Professionalism demands adequate self-care, and clinicians owe it to themselves as well as to their loved ones, colleagues, and patients to fulfill this duty.  


Mary Smith, DNP, FNP-BC, is Assistant Professor of Nursing, Mississippi University for Women, Columbus, Miss.; and Adjunct Faculty, Capstone College of Nursing, University of Alabama, Tuscaloosa, Ala. 


Scott Hambleton, MD, is Medical Director, Mississippi Professionals Health Program, Ridgeland, Miss.