After months of the tedium, irritations, and uncertainties of the COVID-19 pandemic, the media and healthcare organizations are talking more about the pandemic’s mental health toll on healthcare workers.

Burnout

In addition to various stressor-related injuries, such as symptoms of acute stress, “burnout” is one of the most common complaints of healthcare workers. Freudenberger (1974) was among the first to scientifically explore the problem. Borrowing the term “burnout” from those with severe addictions to drugs, he described the negative effects on staff members from working at a New York City free clinic. Within two decades, thanks to Freudenberger’s popularization of the term and the influential work of Christina Maslach (1976), who had come across the term from healthcare and social workers, the condition was applied to teachers, lawyers, and others who complained of stress, fatigue, and exhaustion related directly to their work.

Today, “burnout” is one of the most talked about problems for frontline workers in COVID-19 media articles, healthcare publications, and in workplace conversations. In healthcare settings, research indicates that burnout appears to be associated with working long hours at a job where empathy is required. Rebecca Clay (2020, June 11) likened it to compassion fatigue, a term coined by traumatologist Charles Figley. She quotes Figley: “It was an occupational hazard of ‘any professionals who use their emotions, their heart’ … and represents the psychological cost of healing others. ‘It’s like a dark cloud that hangs over your head, goes wherever you go and invades your thoughts’.” And it is unlikely that we’ll stop talking about it anytime soon; like COVID-19, “Burnout can be contagious” (Maslach & Leiter, 2016).

Healthcare workers tend to discuss burnout as if it were a definitive thing, well-defined and agreed upon by the experts. The reality, however, is that most countries do not admit it as a mental disorder. And those who do are not in agreement on what it is (Heinemann & Heinemann, 2017, January-March). Freudenberger (1974) reported physical symptoms of burnout as exhaustion, fatigue, frequent headaches, frequent gastrointestinal disorders, sleeplessness, shortness of breath. Affective symptoms included frustration, anger, suspicion, omnipotence or overconfidence, drug use, cynicism, and depression.

Some researchers interpret burnout as a one-dimensional construct equivalent to exhaustion, but others see this as too simplistic. Maslach and colleagues developed the Maslach Burnout Inventory, now used in 93 percent of burnout studies, which is based on three factors: emotional exhaustion, negative perceptions and feelings about patients/clients, and crises in professional competence because of emotional turmoil.

In 2018 the World Health Organization (WHO) accepted burnout as a real phenomenon and not just another name for depression or anxiety. But it did not propose burnout as a medical condition. WHO’s 11^th revision of its International Classification of Diseases lists “burn-out” under “Factors influencing health status or contact with health services.” It defines burnout in line with Maslach and colleagues as: (1) feelings of energy depletion or exhaustion; (2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and (3) reduced professional efficacy.

Thus, burnout is not, in itself, a mental health disorder. However, it makes a person vulnerable to depression, anxiety, trauma, and other mental health complications.

Stressors Attached to Burnout

Studies of COVID-19 have described a small catalogue of stressors can that burn out healthcare workers. These stressors include worries about bringing the virus home to their family, worries about daycare for their kids, feelings of isolation when their families distance themselves out of fear of infection, lack of sufficient personal protective equipment, lack of ventilators and testing equipment, lack of policy direction in life and death decisions (eg, who gets one of the limited number of ventilators), worries about working with colleagues who are making mistakes because of burnout, poorer job performance, disinterest in patients/clients, and exhaustion.

Mainstream Efforts to Reduce Burnout

So what can we do for healthcare workers who are complaining of burnout? The World Health Organization (2019, May 28), for example, focuses on burnout prevention measures such as ensuring sufficient personal protective equipment for workers, offering direction to staff in making difficult decisions, rest, diet, exercise, and social support from colleagues and managers. These are no doubt useful practices, but studies of burnout suggest they are likely insufficient.

The research on mental health for frontline workers during the COVID-19 pandemic is, obviously, preliminary. Still, it offers some interesting conclusions. Medical staff at one Chinese hospital said they would not participate in any psychological interventions for themselves. “Individual nurses showed excitability, irritability, unwillingness to rest, and signs of psychological distress, but refused any psychological help and stated that they did not have any problems” (Chen, et al., 2020, February 18). The hospital workers said they didn’t fear infection once they were working, and they worried more about their families. Their biggest reported struggle was dealing with patients who were unwilling to follow the rules on isolating.

In a meta-analysis of 19 controlled studies exploring interventions to prevent physician burnout (Panagioti, Panagopoulou, Bower, et al., 2017), there was little evidence that any of them worked. Solutions have largely targeted the physician, proposing exercise classes and relaxation techniques, snacks and social hours for decompressing, greater access to childcare, hobbies to enrich free time, and ways to increase efficiency and maximize productivity. The study data, however, suggest that these solutions do not address burnout. The actual problem, according to the authors, is that the reconfigured institutional system did not align with the personal values of the healthcare workers.

This conclusion reflects more recent pandemic studies that the best protective factor against burnout is to ensure workplace practices mirror employees’ personal values. Greenberg, Docherty, Gnanapragasam, and Wessely (2020) highlight “moral injury” as the biggest mental health issue for healthcare workers in the pandemic. “Moral injury, a term that originated in the military, can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.” Moral injury is not itself a medical condition; however, its presence is a vulnerability to negative thoughts about self or others, “as well as intense feelings of shame, guilt, and disgust.”

Burnout & Meaning

The idea that burnout is the consequence of a workplace that does not reflect employees’ personal values means that burnout is far more complicated that merely working a lot of hours under difficult conditions.

Burnout may be the consequence of a loss of meaning. For example, burnout profoundly affects identity (Schaufeli, Leiter, Maslach, 2009). Studies had shown that those who were affected by burnout typically began as idealists in their profession, with certain goals to achieve. Only after repeatedly being frustrated in achieving their goals did they become disillusioned, wondering why they signed up for the career. Thus, burnout was, in large part, an identity crisis.

If burnout affects identity, it also appears to affect the purpose of working in the healthcare field. It’s instructive to realize that some workers do not experience burnout. Early research had shown no complaints of burnout in monasteries, Montessori schools, or religious care centers—professions in which staff members felt a calling. Burnout appeared to be attached to professionalized and bureaucratic organizations, with their focus on rules, unions, and red tape.

In their article on responses to the pandemic by medical students, Gallagher and Schleyer (2020, June 18) reported that some students felt a moral injury because they could not provide care at the level they were trained for because of lack of personal protective equipment or ventilators. But many students who seemed to view medicine as a calling had a more positive perspective: “I feel lucky to be working during this time.” “I feel underutilized.… It’s so hard to be a student and not help when you feel morally and ethically inclined to do so.” “I’m excited to be able to make a difference, but I’m just as scared as everyone else.” This sort of purposeful endeavour—keeping an eye on the big picture—appeared to help students remain optimistic and engaged in their careers.

Hartzband & Groopman (2020) looked to Self-Determination Theory (SDT; Gagne & Deci, 2005) to help frontline physicians during the pandemic. They argued that increasing an individual physician’s intrinsic motivation in the workplace would be a protective factor against burnout. SDT proposes that the key to intrinsic motivation is autonomy, competence, and relatedness—the consequence of which is a more meaningful work-life.

What these examples show is that those who do not succumb to burnout appear to enthusiastically commit to the purpose of their work. This greater perspective likely allows them to avoid being bogged down in the mundane tasks and long hours of routine, and overcome moral struggles such as a lack of PPE. As Langle (2012) suggested, “A wider perspective can help imbue suffering with meaning” (p. 234).

References

Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L …Zhang, Z (2020, February 18). Mental health for medical staff in China during the COVID-10 outbreak. The Lancet [online], 7, e15. Doi: 10.1016/S2215-0366(20)30078-X

Clay, R. A. (2020, June 11). Are you experiencing compassion fatigue? As psychologists continue to help those suffering from the impact of COVID-19, they should watch for signs of their own distress or burnout. American Psychological Association [online].

Figley, C. R., & Figley, K. R. (2017). Compassion fatigue resilience. In E. M. Seppala, E. Simon-Thomas, S. L. Brown, M. C. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford Handbook of Compassion Science. New York: Oxford. Doi: 10.1093/oxfordhb/9780190464684.013.28

Freudenberger, H. J. (1974). Staff burn-out. Journal of Social Issues, 30(1), 159–165. Doi: 10.1111/j.1540.1974.tb00706.x

Gagne, M., & Deci, E. L. (2005). Self-determination theory and work motivation. Journal of Organizational Behavior, 26, 331–362. Doi: 10.1002/job.322

Gallagher, T. H., & Schleyer, A. M. (2020, June 18). “We signed up for this!”—Student and trainee responses to the Covid-19 pandemic. New England Journal of Medicine, 382, e96. Doi: 10.1056/NEJMp2005234

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges facing healthcare workers during covid-19 pandemic. British Medical Journal [online], 368. Doi: 10.1136/bmj.m1211

Hartzband, P., & Groopman, J. (2020). Physician burnout, interrupted. New England Journal of Medicine [online]. Doi: 10.1056/NEJMP2003149

Heinemann, L. V., & Heinemann, T. (2017, January-March). Burnout research: Emergence and scientific investigation of a contested diagnosis. Sage Open, 1–12. Doi: 10.1177/2158244017697154

Langle, A. (2012). Suffering—an existential challenge: Understanding, dealing, and coping with suffering from an existential-analytic perspective. In P. T. P. Wong, L. C. J. Wong, M. J. McDonald, & D. W. Klaassen (Eds.), The positive psychology of meaning and spirituality: Selected papers from meaning conferences (pp. 223–236). Birmingham, AL: INPM, PurposeResearch.

Maslach, C. (1976). Burned-out. Human Behavior, 5(9), 16–22.

Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103–111. Doi: 10.1002/wps.20311

Panagioti M, Panagopoulou E, Bower P, et al. (2017). Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Internal Medicine, 177(2),195–205.

Schaufeli, W. B., Leiter, M. P., Maslach, C. (2009). Burnout: 35 years of research and practice. Career Development International, 14(3), 204–220. Doi: 10.1108/13620430910966406

World Health Organization (2019, May 28). Burn-out an “occupational phenomenon”: International Classification of Diseases.