Burnout Syndrome

Introduction

Occupational disorder

The International Statistical Classification of Diseases and Related Health Problems (ICD), the ICD-10 edition (current 1994-2021) has classified “burn-out” as a type of non-medical life-management difficulty, and considered it as one of the ‘factors influencing health status’ of the individuals.1 The new version of ICD, ICD-11 has made the entry under “OD85 Burnout.”

On June 2018, a new version of the ICD, ICD-11, was released and was first used in January 2022. It has an entry coded and titled as “QD85 Burnout” with features of exhaustion, distancing from one’s job and decreased professional efficiency. Burnout has been referred as an ‘occupational disorder.’ Thus, the condition is specifically related to workplace.¹

Professional life

Each passing year, an increasing number of physicians and persons from other professions are dissatisfied in their professional life. They often speak on workload, monetary benefits, and quality of patient care. The monetary benefits are not commensurate with the high-quality care expected and /or provided to the patients by them. The workload is often too heavy and work is tiresome. It keeps them away from family and personal life. They lack job satisfaction. The growing discontentment and job stress lead to unhappiness and poor quality of services. This vicious cycle affects the physician, family and patients.

Herbert Freudenberger while studying drug addicts in 1974, used the term ‘burnout’ and described it as a condition characterised by exhaustion resulting from excessive demands from the work, with features such as headache and sleeplessness. He stated that the burntout person ‘looks acts and seems depressed.’2 It may be recalled that the phrase ‘burnt out’ had been used by Graham Greene as the title for his novel ‘A Burnt-Out Case’ in 1961.

Definition

WHO defined burnout as “a syndrome resulting from chronic workplace stress that has not been successfully managed.”1 This work-related condition is noted in individuals without any previous history of psycho logical or psychiatric ailments. There is a discrepancy between the expectations and ideals of the employee and the actual requirements of their position.³ The individuals feel emotional stress and increasing disillusionment about their job. They find it difficult to adapt to the work environment and exhibit negative attitudes towards their job, their colleagues and the patients under their care.³ The individual exhibits exhaustion and finds difficulty in working effectively.

Maslach and Leiter have referred the condition as a psychological syndrome developing as a prolonged response to chronic interpersonal stressors encountered at work. The response presents in a three-dimensional model as follows:⁴

• An overwhelming exhaustion resulting in energy depletion, debilitation, and fatigue 
• An inappropriate attitudes towards clients, irritability, loss of idealism, and withdrawal
• Reduced productivity or capability, low morale, and an inability to cope.

Stress of work

Burnout has been recognized as an occupational hazard for different people-oriented professions. Burnout has deleterious effects on the individual. The person gets exhausted and does not find any joy in the work. An increased stress in burnout person brings about marked exhaustion, feeling of cynicism and detachment from the job, a sense of ineffectiveness and lack of accomplishment. There is loss of motivation and energy.⁵

In her paper, ‘The Future of Burnout”, Maslach categorizes three types of burnout such as - individual burnout, interpersonal burnout and organizational burnout. Individual burnout is encountered when one places extremely high standards on self. Interpersonal burnout is caused by difficult relationship with others (boss or coworkers) at work or at home. Poor organization, extreme demands and unrealistic deadline lead to an organizational burnout.⁵

Burnout is encountered in physicians working under constant pressure.⁶ Burnout is not simply a synonym for stress. The condition is the result of continued stress that has not been dealt with either by the sufferer or their employer. The stress of work is further aggravated in physicians who work in institutions with marked constraints in resources and high expectations by the organization. The personality, the family setup and responsibility, family support, happiness and difficulties will influence the development of Burnout syndrome among physicians.

Healthcare professionals who were on the frontline fighting COVID-19 for over eight months experienced fatigue and burnout. They were tired of handling COVID-19 cases. They had to spend considerable time wearing personal protection equipment and stay away from near and dear. They needed recuperation break during those stressful situations. Before going for the destress break, they had to undergo COVID-19 test.

During the pandemic, they had to work continuously for extended hours which requires a sound state of mind. An individual may not suffer from all three serious consequences, namely exhaustion, cynicism and inefficiency at one time.

Risk factors

The American Thoracic Society has considered the risk factors leading to burnout under the headings, individual or institutional.³ They are outlined as follows:

Individual risk factors

Poor self-esteem

Maladaptive coping mechanism

Younger adults with an idealistic worldview

Unrealistically high expectations

Financial issues

Institutional risk factors

Heavy workload

Conflicts with coworkers

Diminished resources

Lack of control or input

Effort-reward imbalance

Understaffing

Rapid institutional changes

Causes

Work overload brings about depletion in the capacity of people to meet the demands of the job. When this persists for a long time, the individual fails to restore the balance as there is little opportunity to rest and recuperate. It is only when a person has a manageable workload, the individual can improve his skills and can make positive contributions.

These individuals will be able to experience job engagement if there is professional autonomy and access to the resources. Recognition of their work and appropriate rewards will improve their engagement. Not feeling valued at work makes them susceptible to burnout.

There should be support and trust to experience job engagement. Lack of this leads to burnout. Individuals expect to be treated with respect in their job. It should be fair. An ill-treatment leads to cynicism and anger. Values are the ideals and motivations attract people to their job. When this motivational force is lacking at work, it leads to burnout. Decreased job satisfaction leads to marked impairment in the quality of work.

Individuals having burnout make a negative impact on their colleagues and cause disruption of the work. Thus, burnout can be contagious and perpetuant.⁷

Health plays a pivotal role in the development of burnout. According to Ahola and Hakanen, poor health contributes to burnout and burnout contributes to poor health. Exhaustion, the principle feature of burnout develops from stress.⁸

Clinical manifestations

Burnout syndrome (BOS) presents in persons without any prior history of psychological or psychiatric diseases.³ A discrepancy between the expectation and the ideals of the employee and the actual requirements of the position may trigger the condition. Initially there is emotional stress and increased job-related disillusionment. It is followed by loss of ability to adapt to the work environment. They begin to show negative attitudes towards their job, their co-workers and their patients.³ The clinical manifestations of Burnout syndrome are emotional exhaustion, cynicism, perceived clinical ineffectiveness, a sense of depersonalization in relationship with colleagues, patients or both and a decreased sense of personal accomplishment.⁵

1. Exhaustion: They exhibit generalized fatigue as substantial amount of time and effort is spent on a job or project that is perceived not beneficial. They feel exhausted. Often it is emotional exhaustion. It is usually encountered when they are taking care of a patient with poor prognosis and little chance for recovery.
2. Depersonalization: The individuals do not take interest in the job and develop a feeling of negativism. They develop an indifferent attitude towards work. They begin to exhibit a callous attitude and cynical behavior. They behave impersonally while interacting with colleagues or patients. They begin to make unprofessional comments on coworkers, blame patients and fail to show grief on death of a patient under their care. 
3. Reduced personal accomplishment: They begin to undertake a negative evaluation of the work performed by them. They feel insufficient about their capacity to undertake the job, and exhibit a poor professional self-esteem.³

They show exhaustion as the symptom of burnout and the other two features suggest that burned-out employees simply cannot work effectively. Burnout refers specifically in the occupational context.

Performance at work and health are affected. They complain of headache, disturbed sleep, irritability, frustration, fatigue, hypertension, gastrointestinal upset, anxiety, depression, inability to feel happy, discontentment, marital difficulties and even myocardial infarction.³ It can lead to alcoholism and drug addiction Burnout leads to decreased productivity and makes one feel helpless, hopeless and cynical. Its negative effects affect different facets of life including home, hospital, office, and society. The bodily changes affect the health over a period.

Burnout is a gradual process and the manifestations are explained under physical, emotional and behavioral categories by Smith and coworkers.⁹ Burnout is a sense of empty feeling, mental exhaustion, and lack of motivation.⁹

Subtypes

Barry Farber has proposed three types of burnout such as wear-out and brown-out, classic/frenetic burnout, and under challenged burnout.¹⁰

Stages of burnout

Hans Selye, pioneer of stress research has identified three stages in the development of burnout.

Stage 1: Alarm stage - Presents as a difficult situation involving a ‘fight or flight’ response.

Stage 2: Resistance stage - A lengthy stage involving issues on a psychological basis.

Stage 3: Exhaustion stage - Final stage with reappearance of alarm stage exhibiting extreme fatigue, disease, disability and even death.

Assessment

According to Maslach and Leither, Burnout is ‘an erosion of the soul’ representing deterioration of values, dignity, spirit and will.⁴ The condition deteriorates gradually over years. These physicians/professionals find their work unsatisfactory, tedious and unrewarding, and are disturbed. They feel they unappreciated. This affects their work, patient care, may result in errors in diagnosis and management.

BOS is measured by Maslach Burnout inventory (MBI). MBI has been designed to assess the three dimensions of burnout experience and consists of a 22-item self-report questionnaire.¹¹ The points are divided in the following manner: Nine points on emotional exhaustion or feeling of being overworked; five points on depersonalization where they exhibit an impersonal response to patients under their care; and eight points to assess a lack of personal accomplishment and success related to work. The Spanish Burnout Inventory evaluates four dimensions, such as enthusiasm towards job, psychological exhaustion, indolence and guilt.¹²

The dissatisfaction of the physician affects patients, family, and him/herself. A stable childhood, caring family, stable marriage and supportive spouse provides encouragement in their work. A conducive work environment, friendly colleagues, adequate resources, good organizational setup, and adaptive behavior will help in restoration of happiness.

Engagement

There is a positive side of burnout and it is engagement. Engagement with work is a productive and fulfilling state.¹³ The positive side of the engagement consists of a state of high energy, strong involvement and a sense of efficacy. They should enthusiastically work with enthusiasm and dedication.

It was earlier believed the three dimensions of burnout developed sequentially. To begin with, there is exhaustion in response to an increased demand and overload of work. It will lead to detachment and negative reactions to people and the job. If the condition persists, it will lead to a feeling of inadequacy and inefficacy in the profession.

The stress in the profession leads to strain. There is an imbalance between work demands and individual resources. The resulting strain appears as an emotional response of exhaustion. This brings about a change in attitudes and behaviour making them more cynical.⁴

The Job Demands-Resource (JD-R) model has been formulated on the notion that burnout develops when the job demands are greater than the available resources.¹⁴ The conservation of resources (COR) model assumes that burnout arises from persistent threats to the existing resources. Both the JD‐R and COR model have significant influence on the development of burnout.⁴

The Areas of Work life (AW) model enumerated six key areas such as, workload, control, reward, community, fairness and values. Any mismatch in these areas will lead to burnout affecting their job performance, social behaviour and personal wellbeing. An increased mismatch leads to burnout and greater match brings about engagement.¹⁵

Consequences

Burnout syndrome has many adverse consequences. It can lead to alcohol abuse and even suicidal tendencies in those working in critical care health setup. There is decreased clinical effectiveness and poor work performance impairing the patient care. Many-a-times the person quits the job.³

Management and prevention

Management requires an understanding of the factors that are contributing to the development of burnout.⁴ Intervention strategies are necessary to treat and prevent occurrence of burnout. They can be tried after development of burnout or focus on how to prevent burnout by promoting engagement.

Maslach and Goldberg have recommended the following interventions such as, changing work patterns, developing coping skills, obtaining support, promoting sound health and developing better self-understanding at individual level.¹⁶

Burnout can be successfully prevented by undertaking treatment of co-existent medical conditions, stress management, time management, depression treatment, psychotherapies, ergonomic improvement, other physiological and occupational therapies, physical exercise and relaxation.¹⁷ There should be regular group discussions on work-related issues. Physician’s burnout must be prevented with personal and professional wellbeing, encompassing physical, psychological, social, intellectual, and spiritual components. This must be integrated in their lifestyle from their student days. Physician satisfaction influences the patient’s wellbeing and prevents his/her burnout. The physician should balance his personal and professional lives. Profession should not become whole life for the physician. He should give time to family, take vacation, and participate in continuing medical education programs. He should develop hobbies and personal interests. There should be a flexible schedule at work so as to allow time to attend family events such as birth, marriage, death, care of aging parents, children’s education, travel and religious festivals. The physician must be healthy by following proper lifestyle, healthy nutrition and exercise.

It is advised the persons with BOS should adapt resilience that enables them to adjust in a healthy way. Resilience technique includes optimism, development of cognitive flexibility, establishment and maintenance of a supportive social network, mindfulness-based stress reduction training and exercising.¹⁸ The organization should sustain a healthy work environment.

A happy physician will find new meaning in his life and work. The job becomes less stressful, enjoyable, and satisfactory. The organization in which they work plays a crucial role in promoting their wellbeing.

The American Thoracic Society outlined tips to prevent the occurrence of burnout.³ These include -

• Understanding the ways to manage work-related stressors that act as risk factors
• Obtain the support of management, colleagues and friends to cope with stress at work and burnout syndrome
• Take breaks from work; go for a walk, get fresh air, undertake exercise to enhance the physical state and mood
• Make the work enjoyable, and concentrate on your interests and passions
• Be optimistic while dealing with stressful work

Justice Oliver Wendell Holmes had said, “Too many people die with their music still in them.” To this a question was asked, “What if the problem is that people are still alive but their music has died?” Davis-Lacks aptly replied ‘burnout feels like – being alive but feeling like your music has died.’¹⁹ She created the following action plan to help in slowing or preventing the process of burnout.

• Increase your self-efficacy

• Identify what you need from your work •

Have creative outlets

• Take care of yourself

• Get support where you can find it

• Get real and go there

• Increase your diet of positive emotions

Relentless work can push an individual to a debilitating state referred to as burnout, that affects one’s performance and well-being including his/her team and organization. Valcour suggested certain strategies to overcome this.²⁰

1. Prioritize self-care: It is necessary to replenish one’s physical and emotional energies along with the capacity to focus, by prioritizing good sleep habits, nutrition, exercise, and social connections.
2. Shift your perspectives: Rest, relaxation and replenishment relieve exhaustion, curb cynicism and enhance efficacy.
3. Reduce exposure to job stressors: Reset the expectations of persons around you and work with them.
4. Seek out connections: Seek rich interpersonal interactions and continued personal and professional development.

By implementation of these four strategies, one can build a road map to prevent burnout.

The prescription given by Dalai Lama for Burnout is as follows: “In dealing with those who are undergoing great suffering, if you feel “burnout” setting in, if you feel demoralized and exhausted, it is best, for the sake of everyone, to withdraw and restore yourself. The point is to have a long-term perspective.”

Smith and co-workers suggested that dealing with burnout requires the “Three R” approach that includes recognition of warning signs, reversing the damage and building resilience:²¹

When an individual is working for long, hard hours without taking time to recharge, he/she will inevitably stop being effective at work, which makes the individual feeling tired and resentful. Since it is important to recognise the signs early and manage them, Forbes Coaches Council asked its members for best advice on avoiding burnout at work. They had given the following tips:²²

• Watch for warning signs

• Prioritize your time

• Use your vacation

• Work in alignment with your values

• Make great self care a consistent priority

• Seek joy

• Avoid overachievement

• Draw strong boundaries

• Take a hard look in the mirror

• Be your most important client

• Remove the badge of honor

• Be grateful

• Take five minutes

Conclusion

Burnout syndrome is not a situation that cannot be overcome. It exhausts the soul of an individual. One must be aware of this condition, its causes, and manifestations. One should develop capability to prevent its occurrence and if comes, know the methods to recover from it. It is possible for one to enjoy the work and derive inspiration for a happy and healthy life.

Conflict of Interest

None