Analysis – Burnout in healthcare: the case for organisational change (Published 30 July 2019) BMJ 2019;366:l4774 by A Montgomery, professor in work and organizational psychology et al.
Burnout has become a big concern within healthcare. It is a response to prolonged exposure to occupational stressors, and it has serious consequences for healthcare professionals and the organisations in which they work.1 Burnout is associated with sleep deprivation,2 medical errors,345 poor quality of care,67 and low ratings of patient satisfaction.8 Yet often initiatives to tackle burnout are focused on individuals rather than taking a systems approach to the problem.
Evidence on the association of burnout with objective indicators of performance (as opposed to self report) is scarce in all occupations, including healthcare.9 But the few examples of studies using objective indicators of patient safety at a system level confirm the association between burnout and suboptimal care. For example, in a recent study, intensive care units in which staff had high emotional exhaustion had higher patient standardised mortality ratios, even after objective unit characteristics such as workload had been controlled for.10
The link between burnout and performance in healthcare is probably underestimated: job performance can still be maintained even when burnt out staff lack mental or physical energy11 as they adopt “performance protection” strategies to maintain high priority clinical tasks and neglect low priority secondary tasks (such as reassuring patients).12 Thus, evidence that the system is broken is masked until critical points are reached. Measuring and assessing burnout within a system could act as a signal to stimulate intervention before it erodes quality of care and results in harm to patients.
Burnout does not just affect patient safety. Failing to deal with burnout results in higher staff turnover, lost revenue associated with decreased productivity, financial risk, and threats to the organisation’s long term viability because of the effects of burnout on quality of care, patient satisfaction, and safety.13 Given that roughly 10% of the active EU workforce is engaged in the health sector in its widest sense, the direct and indirect costs of burnout could be substantial.14
We need effective strategies for preventing and ameliorating burnout within healthcare settings. The most common responses have put the responsibility on healthcare professionals to take better care of themselves, become more resilient, and cope with stressors on their own. But such an individualistic approach can ignore the sources of chronic stressors in the workplace such as incivility, staff shortages, and austerity measures, which are often beyond an individual’s control. The exhaustion, cynicism, and consequent feelings of inefficacy experienced by people with burnout are often a shared experience in response to shared job stressors, and we should frame it as a systems problem, and not simply as an individual one.1
Individually focused solutions are important to support overburdened staff but are less likely to have longevity and sustainability than solutions that are organisationally embedded.15 They may even compound problems in the long run by reinforcing a dysfunctional coping approach that interprets failure as wholly personal. Locating solutions for organisational problems within individuals is common in healthcare, particularly with the physician culture that valorises inappropriate self care16 and the avoidance of emotionally challenging events.171819
The current focus on narrow definitions of burnout as a medical diagnosis and inadequate measurement approaches have hampered progress. Viewing burnout as a disease has hindered efforts to focus on the work place values that are driving burnout. In addition, a focus on the exhaustion component of burnout has overestimated some relationships and underestimated others, meaning that interventions are less evidence based. We discuss four practical steps to move us towards understanding burnout at a systems level and therefore implementing a systems approach to the problem: using burnout as an indicator of healthcare quality, assessing it at the departmental and the individual level, explicitly developing healthy workplaces, and including practitioners and patients in the process of articulating research questions.
Including burnout in assessments of healthcare quality
We need a different approach to integrate wellbeing as a quality marker within the healthcare system (such as the JAMA charter on physician wellbeing).20 We can think of hospitals measuring safety in four categories: structure (eg, facilities, organisational culture), process (eg, consistency of care), outcome (eg, survival rates), and patient experience (eg, satisfaction).21 In the UK, research among NHS staff indicates an almost universal desire to provide the best quality of care but also shows that organisations can find it difficult to obtain valid insights into the quality of the care they provide.22 However, better quality, safer care for patients has been linked to higher rates of staff engagement.2324 In addition, staff satisfaction is weakly correlated with hospital standardised mortality ratios.25 Medical departments reporting high levels of burnout could therefore be a signal of erosion of hospital safety. If burnout can be considered an indicator of organisational malfunctioning, it should be included in the assessment of healthcare quality. The World Health Organization’s recent recognition of burnout as an occupational phenomenon (and not a medical disease) opens the way for policy makers to fund organisational strategies aimed at research and amelioration.26
Measuring staff experience of work may help to understand organisational drivers of poor quality care. Leiter and Maslach describe five profiles of work experience, each suggesting a different approach to tackling the drivers of burnout and thus a different intervention and solution.27 There is a continuum from burnout (high on all three dimensions of dysfunction) to engagement (low on all three). The three intermediate profiles are disengaged (characterised by high cynicism only), overextended (high exhaustion only), and ineffective (high inefficacy only) (fig 1). Each profile reflects a different worklife crisis that would require a unique intervention strategy. The ineffective profile has been largely ignored, with most researchers focusing on exhaustion and cynicism. But feeling negatively about how well you are doing your job needs more than just a lighter workload and lunch with colleagues.
We need to widen our approach to tackling burnout. The challenge for health systems in an increasingly complex health environment, with the twin pressures of limited resources and increasing levels of burnout, is to develop interventions to counter the factors that are leading to burnout. The problem is not the workforce but the way that the environment is becoming toxic. Measurement of burnout can provide an early signal of a problem. Prevention, which is more desirable than treatment, will be enabled by a healthy workplace approach that includes both continuous evidence based assessment of burnout and action on the structural drivers of burnout tailored to staff experience and co-designed with input from the users of the health service.
Burnout is an occupational problem not a medical diagnosis
Healthcare organisations should assess burnout at departmental level and use it as a metric of safety of care
More focus is needed on developing healthy workplaces
Staff and patients must be included in developing actions to reduce and prevent burnout