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Burnout

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Peter Yellowlees, MBBS, MD and Margaret Rea, PhD | September 27, 2022

Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regularly reviewed and updated to ensure that they reflect current research and practice in the patient safety field.

Background

Burnout is described by the World Health Organization as an occupational phenomenon and is not classified as a medical condition.1 The most accepted definition from the 11th Revision of the International Classification of Diseases2 describes burnout as a syndrome that is characterized by three dimensions:

  • feelings of energy depletion or exhaustion;
  • increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
  • reduced professional efficacy.

Using this definition of burnout, which refers specifically to phenomena and stressors in the occupational context, it is not surprising that the syndrome is widely prevalent in health care professionals, despite their well-documented high levels of personal resiliency.3 While it is difficult to determine specific causal relationships, burnout has been associated with increased patient safety incidents, including medical errors, reduced patient satisfaction, and poorer safety and quality ratings.

The reported prevalence of burnout among health care professionals varies widely and is somewhat controversial due to the difficulty of accurately measuring burnout in the workplace. Many measures exist, but none are yet accepted as being truly adequate, and this leads to the differing prevalence rates among studies. A recent systematic review found prevalence estimates for overall physician burnout from 0%–80.5%, with an average of 19%–24% across studies.4 A national study from 2021 showed average physician-reported rates of burnout of 42%, with women (51%) having higher rates than men (36%).5 The gender difference may be related to the fact that female physicians suffer from more workplace discrimination and mistreatment than male physicians.6,7   Multiple studies have also reported high prevalence of burnout among nurses, nursing home workers, and mental health providers.

Further complicating this measurement issue is the relationship between burnout and depression, which are both common and which also appear to be bidirectionally causally related.5 In other words, the symptoms of both disorders are very different, but burnout can be a vulnerability factor that leads to depression, and depression can make an individual more likely to suffer from burnout.5 Concerns have been raised about distinguishing between depression and burnout due to fear that physicians with depression may not receive needed treatment if they are misdiagnosed as having burnout.8,9 Further, the stigma that continues around physicians seeking care for mental health concerns can lead to continued denial of depression and subsequent undertreatment.10

Clinicians report that drivers of burnout are primarily organizational and systems-related, including excessive and difficult documentation and regulatory requirements, cumbersome electronic health records, increased expectations of availability from patients, poor organizational and team leadership, long work hours, lack of or erosion of autonomy, relentless pressure to increase quality while decreasing cost, insufficient appreciation for clinicians' individual contributions, and lack of respect for personal life.

Data increasingly support taking a systems perspective; for example, a recent meta-analysis concluded that packages of interventions at the system-level are likely to be more effective than individual-level interventions. An expert guide from SAMHSA has described organizational-level interventions to prevent and reduce burnout among behavioral health workers by modifying six drivers of burnout: workload, control, reward, community, fairness, and values. The National Academies of Medicine Action Collaborative on Clinician Well-Being and Resilience has developed a conceptual model that includes seven domains affecting burnout and lack of well-being. The Collaborative strongly recommends focusing on the five domains of external factors (organizational factors, rules and regulations, society and culture, learning/practice environment, and health care responsibilities) using systems approaches and design thinking. Others have focused on the importance of changing the health care culture with respect to well-being,11 and of improving efficiency and teamwork.

Application to Patient Safety

Clinicians who have been involved in errors or serious safety events may be at increased risk for burnout. At the same time, burnt out clinicians are more at risk of making errors or of practicing unsafely. Large systematic reviews have supported the association of high levels of burnout and medical error. The studies have highlighted the important role of systems issues as impacting the development of burnout and subsequent self-reported medical errors. Excessive workload and lack of organizational support are factors that have been identified as contributing to the relationship between burnout and adverse outcomes. The emotional exhaustion and depersonalization that are the key elements of burnout can trigger health professional feelings of exhaustion and cynicism and they can become distant and cold when facing the patients’ needs, all of which compromises the quality of care. Indeed, high levels of burnout have been associated with the deterioration of teamwork, safety, and job satisfaction as well as greater patient and family complaints and patient dissatisfaction. Studies have identified that burnout and measures of well-being (such as depression, stress, and anxiety) have independent associations on patient errors, separate from their relationship with other variables. In a cross-sectional study of 11,395 physicians, sleep-related impairment and burnout showed to be independent risk factors for clinically significant error rather than attributed to the relationship between sleep and burnout.

There appears to be a need for prospective studies to better understand the directionality of the relationship between burnout and errors. For example, a large study of US physicians reported an association between physician burnout and adverse quality of care, including self-reported errors. However, if you are experiencing significant burnout, you might be overly critical of your abilities as a provider and thus over report your errors. Self-reported errors might differ from events identified through retrospective reviews, a factor to be considered in ongoing research to best identify areas for interventions at the personal and system level with the goal of impacting patient safety.

Efforts to Prevent and Reduce Burnout

Many groups and organizations have taken up the call to address burnout among health care professionals. In 2018, the National Patient Safety Foundation/Institute for Healthcare Improvement launched a National Steering Committee for Patient Safety co-led with the Agency for Healthcare Research and Quality (AHRQ), which produced the National Action Plan to Advance Patient Safety. One of the four foundational areas of the National Action Plan is workforce safety, which includes issues related to provider burnout. A group at Penn State College of Medicine advocates organizing intervention targets according to Maslow's Hierarchy of Needs, addressing basics such as ensuring adequate hydration, healthy food, and freedom from violence at work before moving on to respect, appreciation, and meaningful contributions to work.

The Mayo Clinic produced a detailed guide for implementing organizational strategies to prevent and reduce burnout by addressing individual, work unit, organizational, and national factors across seven domains (See Table).

Table. Domains for implementing strategies to reduce burnout

  1. Workload and job demands
  2. Efficiency and resources
  3. Meaning in work
  4. Culture and values
  5. Control and flexibility
  6. Social support and community at work
  7. Work–life integration

The National Academies Collaborative on Clinician Well-Being has published a comprehensive report detailing multiple organizational and design related solutions, while the American Medical Association12 has been very active in educating its physician membership and in supporting culture change. Others have called for enhancing user experience with electronic health records, improving team-based care, and engaging multisector stakeholders in resolving broader systems factors that contribute to an overburdened health care workforce. The common thread across these efforts is the focus on system-level change.

Current Context

The Agency for Healthcare Research and Quality has been funding research on physician burnout for several years. Recently, there has been a national explosion of interest in burnout among clinicians, particularly as a consequence of the COVID-19 pandemic. Over $103 million has been invested by the Health Resources and Services Administration (HRSA) to further research and education related to clinician wellbeing.13 In early work on burnout, the focus was on the individual clinician but this has changed as burnout and clinician well-being have been understood to be system-level concerns that can have significant safety, quality, economic and organizational performance implications. The National Academies of Medicine have convened working groups to assess the science and report on best organizational practices. In the meantime several groups (e.g., AHRQ, American Medical Association, Mayo Clinic,) have offered roadmaps for organization leaders for prompt local action to improve the work environment for all health care professionals.

COVID-19’s Impact on Burnout

Addressing the hierarchy of needs of health care workers has become even more salient during the COVID-19 pandemic. In one seminal paper, the authors suggested supporting health care workers using the paradigm of, “hear me, protect me, prepare me, support me and care for me.”14 In the context of a global pandemic, systems factors such as the availability of personal protective equipment (PPE) and inadequate testing protocols provided a stark reminder of how system failures can contribute to burnout. The increased focus on addressing burnout and emotional distress in health care workers during the pandemic has resulted in opportunities to intervene.15-18 For example, there has been increased interest in implementing peer support programs for health care workers during the pandemic which can lead to significant culture change which can in turn impact burnout.16,19,20

Peter Yellowlees, MBBS, MD
Chief Wellness Officer  
Allan Stoudemire Distinguished Endowed Professor of Psychiatry
pmyellowlees@ucdavis.edu

Margaret Rea, PhD
Director Student and Resident Wellness
UC Davis Health
mrea@ucdavis.edu

References

  1. World Health Organization. Burn-out an "occupational phenomenon": International Classification of Diseases. Accessed May 10, 2022. [Available at]
  2. World Health Organization. ICD-11: International Classification of Diseases 11th Revision. Accessed May 10, 2022. [Available at
  3. Brazeau CM, Shanafelt T, Durning SJ, et al. Distress among matriculating medical students relative to the general population. Acad Med. 2014;89(11):1520-1525. [Free full text]
  4. De Hert S. Burnout in healthcare workers: prevalence, impact and preventative strategies. Local Reg Anesth. 2020;13:171-183. [Free full text]
  5. Kane L. Death by 1000 Cuts: Medscape National Physician Burnout & Suicide Report 2021. Medscape. January 22, 2021. Accessed May 10, 2022. [Available at]
  6. Yaghmour A, Alesa A, Anbarserry E, et al. Challenges and obstacles faced by trainee female physicians: an integrative research on gender discrimination, stress, depression and harassment. Healthcare (Basel). 2021;9(2):160. [Free full text]
  7. Templeton K, Bernstein, CA, Sukhera, L et al. Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives. Discussion Paper, Washington, DC: National Academy of Medicine; 2019. [Available at]
  8. Oquendo MA, Bernstein CA, Mayer LES. A key differential diagnosis for physicians- major depression or burnout? JAMA Psychiatry. 2019;76(11):1111-1112. [Available at]
  9. Moran M. Distinguishing burnout from MDD: It’s not trivial. PsychNews. September 1, 2019. Accessed May 10, 2022. [Available at]
  10. Brower KJ. Professional stigma of mental health issues: physicians are both the cause and solution. Acad Med. 2021;96(5):635-640. [Free full text]
  11. Shanafelt TD. Physician Well-being 2.0: Where are we and where are we going?. Mayo Clin Proc. 2021;96(10):2682-2693. [Free full text]
  12. American Medical Association (AMA) Ed Hub. Peer support programs for physicians: mitigate the effects of emotional stressors through peer support. Accessed May 10, 2022. [Available at]
  13. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133–2134. [Free full text]
  14. US Department of Health and Human Services (HHS). HHS announces $103 million from American Rescue Plan to strengthen resiliency and address burnout in health workforce. July 16, 2021. Accessed May 10, 2022. [Available at]
  15. Brower KJ, Brazeau CMLR, Kiely SC, et al. The evolving role of the chief wellness officer in the management of crisis by health care systems: lessons from the Covid-19 pandemic. NEJM Catal Innov Care Deliv. 2021;2(5). [Free full text]
  16. American Medical Association (AMA) Ed Hub. Caring for the health care workers during crisis: creating a resilient organization. Accessed May 10, 2022. [Available at]
  17. Berg S. Amid COVID-19 strain on physicians, 5 steps to build peer support. AMA Physician Health. Accessed May 10, 2022. [Available at]
  18. Feist JB, Feist JC, Cipriano P. Stigma Compounds the Consequences of Clinician Burnout During COVID-19: a Call to Action to Break the Culture of Silence. NAM Perspectives. Washington DC: National Academy of Medicine; 2022. [Free full text]
  19. Sharifi M, Asadi-Pooya AA, Mousavi-Roknabadi RS. Burnout among healthcare providers of COVID-19: a systematic review of epidemiology and recommendations. Arch Acad Emerg Med. 2020;9(1):e7. [Free full text]
  20. Morgantini LA, Naha U, Wang H, et al. Factors contributing to healthcare professional burnout during the COVID-19 pandemic: a rapid turnaround global survey. PLoS One. 2020;15(9):e0238217. [Free full text]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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