Excerpt
Contents
1 Introduction
2 Research question
3 Concepts
3.1 Recovery
3.1.1 Conservation of Resources
3.1.2 Effort-Recovery Model
3.2 Burnout
3.3 Resilience
4 Ways to reduce or prevent burnout
4.1 Stress Management and Resilience Training
4.2 Psychosocial skills training
4.3 Mindfulness based Resilience training
4.4 Counselling
4.5 Recovery Experiences
4.5.1 Detachment
4.5.2 Mastery experiences
4.5.3 Recovery Training Program
4.5.4 Relaxation
5 Discussion, Conclusion and Suggestions
5.1 Summary of strategies
5.2 Conclusion and Advise to Organizations
5.3 Suggestions for further research
1 Introduction
The well-being of employees is not only important to the employees themselves, but also to the organization at which they are employed. Research has shown that concern for the employees welfare by the company is significantly correlated with productivity (Patterson et al., 2004, p. 206). Higher levels of well-being result in less burnout (Milfont et al., 2007, p. 173) and therefore in higher performance (Chen & Kao, 2012, p. 62). People working in healthcare have a higher risk of burnout (Tang et al., 2020, p. 72). In a recent study among german general practioners Werdecker and Esch (2021, p. 8) found that 26.5% of GPs reported a high prevalence of work-related burnout. T.. Shanafelt et al. (2017, p. 1827) found in their review paper that ’’Multiple large, national studies... indicated that burnout is one of the largest factors determining whether or not physicians intend to leave their current position over the next 24 months”. Dam et al. (2018, p. 16) found that nearly 75% of the residents who responded to their survey experienced burnout and nearly half of them had low well-being. This is also confirmed by Leung et al. (2021, p. 59), who found in their study that burnout was prevalent in 42% of the physicians who saw the patients interviewed. T. D. Shanafelt et al. (2002, p. 361) reported 76% of the residents that returned their survey reported symptoms of burnout. About 50% of the french physicians have recently been found to report burnout (Kansoun et al., 2019, p. 141). Generally are jobs that are mentally highly demanding experiencing much higher levels of need for recovery than less mentally challenging jobs, however, all surveyed employees showed at least some need for recovery (Jansen et al., 2002, p. 329).
Organizations are experiencing adverse effects such as receiving less work effort by their physicians who experience higher burnout as confirmed by T. D. Shanafelt et al. (2016, p. 430) who reported that ’’Among the physicians in a large health care organization, measures of burnout and satisfaction were strongly associated with subsequent reductions in work effort as measured by independent employment records over the following 24 months.”. Schaufeli (1998, p. 135) also stated that burnout causes lower productivity in employees. Physicians suffering from a high degree of depersonalization have been shown to be much more likely to consume too much alcohol (Pedersen et al., 2016, p. 123). Burnout even worsens patient outcomes (Halbesleben and Rathert (2008, p. 36); see also Klein et al. (2010, p. 529); T. D. Shanafelt et al. (2002, p. 362); Patel et al. (2018, p. 5)). Figure 1 provides an illustration of the effects of burnout in physicians.
Therefore burnout and its prevention is a key concern for researchers as well as organizations.
2 Research question
Researchers have theorized many ways of dealing with burnout. This starts at providing, or even requiring, breaks during working hours, long weekends or vacation and goes on with the idea of increasing resilience or the ability to have and benefit from recovery experiences. This article firstly describes the concepts of recovery, burnout and resilience and does thereafter provide an overview of recent research into strategies and/or trainings that may be used by organizations to prevent or reduce burnout, specifically in physicians. Thus the question to be researched is:
How to reduce burnout in physicians?
3 Concepts
3.1 Recovery
3.1.1 Conservation of Resources
Hobfoll (1989) proposed a new stress model in 1989 that he named ’’The model of conservation of resources”. The basic premise of this model is that humans endeavour to obtain resources and try to defend them from whatever is threatening them (Hobfoll, 1989, p. 516). He further explains this by stating that within this model it predicts that individuals will, when stress is applied to them, try to ’’minimize net loss of resources” (Hobfoll, 1989, p. 517). And that individuals will try to hoard resources in anticipation of possible future losses. These resources can be all kinds of different things or concepts. Hobfoll (1989) names several of them: ’’Object resources” are defined as resources that are valued because their actual physical value or because of their rarity. Some ’’Object resources” are valued for both reasons, according to Hobfoll, because they provide shelter and because they may be a particularly impressive house that also shows status. ’’Conditions” are all kinda of desirable states an individual may be in, like marriage, cohabitation, employment or other similar conditions. However, Hobfoll also lists ’’Energies” as a resource, into which he included ’’such resources as time, money and knowledge.” and argues that these are not valued for their own value, but for how they may help acquiring other resources. Within this model, which does not define recovery itself, recovery is best defined as the process of the individual reacquiring lost resources after being exposed to stress.
3.1.2 Effort-Recovery Model
The classical ’’load-capacity” model to study workload was derived from exercise physiology (Meijman & Mulder, 1998, p. 5). This model, as described by Meijman and Mulder (1998, p. 5) says that (work)load causes a disruption in the balance of an employee bodily systems. If too much load is endured for too long ”a situation of overload will arise with the risk of negative effects” (Meijman & Mulder, 1998, p. 6). However, this model was criticized from several perspectives (Meijman & Mulder, 1998, p. 7). For once Meijman and Mulder (1998) argued that the load-capacity model requires a defined maximum capacity of the individual, which hasn’t been possible to calculate consistently (Meijman & Mulder, 1998, p. 7). However, Meijman suggests that the ’’willingness to spend capacity” be used instead, which can be measured.
For these and other reasons Meijman and Mulder (1998) published their Effort-Recovery model, which is described using three distinct areas. Firstly, the work demand, consisting of work assignments and environmental factors. Secondly, the work potential of the individual, which encompasses all skills and effort the employee is able to provide, and lastly their decision latitude (Meijman & Mulder, 1998, p. 8). Within this model recovery is defined as the process that stabilized the biological levels back to baseline after the work potential exceeding workload stops (Meijman & Mulder, 1998, p. 9). This model says that negative effects from too much workload are generally reversible, if persons are allowed to recover. However, if recovery is not happening the effects may be non-reversible (Haun, 2017).
Zijlstra et al. (2014, p. 250) later proposed to think of recovery as the process that is returning the current state to the original, because the model of conservation of resources did not define recovery at all according to Zijlstra. And the Effort-Recovery model, according to Zijlstra et al. (2014, p. 245), is too simplistic in that it describes recovery as the process by which fatigue is removed from the individual after they have been exposed to too much workload.
3.2 Burnout
The most used definition of the term burnout remains the Maslach burnout inventory, albeit it is not unanimously agreed upon (Guseva Canu et al., 2020, p. 99). The Maslach burnout inventory or MBI was intended to provide a definition of three main components of burnout, ’’emotional exhaustion, depersonalization and reduced personal accomplishment” (Maslach et al., 1996, p. 193). The inventory consists of 22 questions in three categories which are rated by the test-taker on a scale ofO to 6 (Maslach et al., 1996,p. 193). Within the category of emotional exhaustion it assesses whether the person examined suffers from emotional overextension and/or feels exhausted from work. If the examinee suffers from impersonality or is unfeeling towards their clients is measured within the depersonalization scale. Higher scores within either of these scales were found to correlate with burnout (Maslach et al., 1996, p. 194). The scale of personal accomplishment is used to measure whether the person feels competent and/or successful in their work, for this scale it was found that lower scores correlate to higher burnout experiences (Maslach et al., 1996, p. 194). To summarize, according to Maslach et. al. a person suffers from burnout if they experience either emotional exhaustion or overextension, impersonality or does not feel competent or succesful at what they do. Of the three categories emotional exhaustion is the one most strongly correlating with burnout (Schaufeli, 1998, p. 98).
The secondly most used definition of burnout according to Guseva Canu et al. (2020, p. 99) is that of Schaufeli (1998). Schaufeli (1998, pp. 21-24) starts their definition by listing 132 common burnout symptoms, which they categorized into five categories. Firstly the ’’Affective symptoms” like being sad, depressed or wary of the future. Schaufeli (1998, p. 25) believe this is caused by the person having spent too much energy and simply being exhausted. This can cause irritability and emotional detachment and following from that the person does not feel well at work and is not satisfied with their job. In the second category are the ’’Cognitive symptoms” (Schaufeli, 1998, p. 25) of which the most important is a feeling of help- or powerlessness. This may lead to the individual feeling trapped and unable to perform their work, which in turn causes them to feel guilty because they believe they’re not doing their job right, even if they are, this may cause actual low job performance where the individuals become forgetful, are making careless mistakes and/or are no longer able to concentrate (Schaufeli, 1998, p. 25). Thirdly they defined a third category of symptoms, which they named ’’Physical symptoms”. Within this category can be found all symptoms of a physical kind such as ’’headaches, nausea, dizziness, restlessness, nervous tics, and muscle pains” (Schaufeli, 1998, p. 26). However, the most common physical sign of burnout is chronic fatigue (Schaufeli, 1998, p. 26). Behavioural symptoms include hyperactivity, not being able to concentrate, impulsiveness, procrastination or indecisiveness (Schaufeli, 1998, p. 27). Lastly, there are also motivational symptoms according to Schaufeli (1998, p. 29). These include a loss of motivation or interest in people, a ’’strong resistance to go to work” and a loss of initiative at work. Schaufeli (1998, pp. 33,186) conclude by stating three elements that they believe to be the most important. Firstly, symptoms of ’’emotional or mental exhaustion” going in tandem with negative attitudes, decreased effectiveness, motivation and performance. Secondly, that it is caused by ’’inappropriate expectations and emotional demands”. Thirdly, that the condition has to work-related for it to be referred to as burnout.
However, the term is still not adequately defined within a medical context(Guseva Canu et al., 2020, p. 97) and therefore Guseva Canu et al. (2020) conducted a systematic review and produced, with the help of the Delphi technique, a definition: ”In a worker, occupational burnout or occupational physical AND emotional exhaustion state is an exhaustion due to prolonged exposure to work-related problems” (Guseva Canu et al., 2020, p. 104).
As can be seen, the definition of the concept of burnout is still far from complete and being unanimously agreed upon, however, most of the used definitions stem from mostly the same symptoms. Still it is prudent to carefully examine the used definition in every study read.
3.3 Resilience
Such as with burnout there has not yet been found a definition of resilience that is agreed upon by the majority, in the past 30 years alone more than one dozen theories were published (Fletcher & Sarkar, 2013, p. 17). They go on to say that even though ’’different theories have emerged, it is possible to identify a number of common features across the approaches taken.”. Most of these theories incorporate the idea that ’’resilience is a dynamic process that changes over time” (Fletcher & Sarkar, 2013, p. 17).
Dunn et al. (2008, p. 45) proposed a so called ’’coping reserve” which varies from one individual to another, i.e. that one person suffer more from smaller negative inputs than another. These negative inputs defined by Dunn et al. (2008, p. 45) ’’include stress, internal conflict, and time and energy demands”, which were already found above to be contributors to burnout. Dunn also theorized that exceptional work demand and not getting enough sleep may deplete their ’’coping reserve”, they also defined a number of factors they thought to refill the coping reservoir, such as support from friends and family or social activities (Dunn et al., 2008, p. 47). Overall, this model appears to be very similar to the load-capacity model as described by Meijman and Mulder (1998, p. 5) in that both conclude that burnout-symptoms start to appear once the load-capacity has been exceeded or the coping-reservoir has been depleted.
Richardson (2002) published a metatheory of resilience, which may be used generally. Within this theory Richardson (2002, p. 314) posits that persons who are affected by physical ailments may recover from them by being exposed to positive inputs. However, also that resilience to adverse inputs may be improved by experiencing and coping with disruptions of their normal life (Richardson, 2002, p. 311).
Gillespie et al. (2007, p. 427) performed a cross-sectional survey in which 1,430 australian nurses participated in 2006. They used the Connor-Davidson Resilience scale (CD-RISC) to measure resilience (Gillespie et al., 2007, p. 430).
The factors found to beneficial to resilience were hope, defined as ’’the belief that goals can be attained” (Gillespie et al., 2007, p. 429), self-efficacy and control (Gillespie et al., 2007, p. 433).
Connor and Davidson (2003) developed the Connor-Davidson Resilience Scale, which uses 25 items scored on a range of one to five, where higher scores mean the subject possesses a higher resilience (Connor & Davidson, 2003, p. 78). These 25 items include the ability to cope with changes, the belief that one can grow more able to cope with stress by being exposed to stress and others that are similar to those that were found to be beneficial to resilience by Gillespie et al. (2007). Please refer to figure 2 for a complete list. The CD-RISC has been shown to provide consistent results and retestability (Connor & Davidson, 2003, p. 81).
Nurses that score high on the CD-RISC are significantly less likely to suffer from burnout and more likely to be satisfied with their lives (Mealer et al., 2012, p. 295). Nurses who score high for resilience on the CD-RISC are less likely to suffer from burnout (Rushton et al., 2015, p. 417). Arrogante and Aparicio-Zaldivar (2017, p. 114) were able to show in their study of critical-care workers that resilience is very important to enable nurses to be resistant against stress and that it does reduce the effects of burnout.
4 Ways to reduce or prevent burnout
4.1 Stress Management and Resilience Training
Sood et al. (2012, p. 859) adapted Attention and Interpretation therapy to be used within their study among physicians and called it Stress Management and Resilience Training (SMART). It consists of a single 90 minutes training that helps the employees to be more flexible as well as teaching them skills that are useful in being more resilient. They are also taught how to not judge as quickly and to be more curious about the world (Sood et al., 2012, p. 859). They were also trained in ’’paced breathing meditation”. A rather large effect of improvement on several factors that cause burnout was found after eight weeks even after just one training session (Sood et al., 2012, p. 860). Sharma et al. (2014, p. 249) were able to show that simply handing their study participants a 443-page book was able to significantly increase resilience (Sharma et al., 2014, p. 250). In a later Study Sood et al. (2014) were again able to show that the SMART was able to decrease stress and anxiety among their participants (Sood et al., 2014, p. 360).
4.2 Psychosocial skills training
Psychosocial skills training has been shown to significantly decrease stress and emotional exhaustion (Mache, Baresi, et al., 2016, p. 157), which are key contributors to burnout. The training that was tested within this study consisted of several topics like coping strategies, conflict management, communication training and others. It required 1.5 hours per week over three months (Mache, Baresi, et al., 2016, pp. 155, 156). They also confirmed these results later in Mache, Bemburg, et al. (2016, p. 241). A similar method, however administered in one five hour and another two hour session, confirmed that psychosocial skills training can be used to significantly decrease stress, fatigue, depression and other burnout-contributing factors in physicians (Pipe et al., 2011, p. 16).
4.3 Mindfulness based Resilience training
Mindfulness based Resilience training, i.e. an ”eight-week group-based program designed”, consisting of 2.5 hours per week, to improve self-care skills and well-being can be used to decrease depression and stress in clinically depressed healthcare professionals (Johnson et al., 2015, pp. 437, 438). Johnson et al. (2015) used meditation to increase mindfulness while also providing physical exercise guidance and lessons about nutrition. Kinser et al. (2016, p. 23) was able to confirm statistically significant positive effects on stress and burnout.
4.4 Counselling
Ro et al. (2008) conducted a study among Norwegian doctors wherein they offered two different intervention opportunities. One of them consisted of a one day individual counselling session where the physician would by counsellor would help the physician identify the individual needs of improvement and provide advise (Ro et al., 2008, p. 2). The other type was a group course over a whole week where the doctors would attend a daily 90 minute lecture where they were taught about taking charge of their own life, how to identify their potentials and communication, followed by a group session of the same length. They would also be able to engage in physical exercise during this week (Ro et al., 2008, p. 2). Burnout did decrease significantly and that was even still the case one-year after the intervention (Ro et al., 2008, p. 5).
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