Clinician burnout has negative effects on patient safety. This article is based on a presentation by Nikki Sleddens and Betsy Becker at the 2019 FSBPT Annual Meeting.
Burnout is defined as “a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity.”i
There are three dimensions under the umbrella of burnout:
In 2007, the Institute for Healthcare Improvement proposed three initiatives that health care should strive to meet. This included improving population health, improving the patient experience, and reducing cost. These initiatives were referred to as the Triple Aim. It has been suggested that in order to accomplish the goals of the Triple Aim, a fourth aim, improving the clinician experience, must be included. This four dimensional approach to improving health care is referred to as the Quadruple Aim.v
Burnout has a significant impact on the clinician experience and will need to be addressed to meet the goals set forth by the Quadruple Aim. In order to move forward, delivery models should be revaluated and science leveraged to develop evidence-based solutions.
Nikki Sleddens conducted an integrative review of the available literature regarding burnout of physical therapists in the United States. Seven studies were identified that addressed this issue. Of those seven, five provided data regarding the prevalence of burnout using a valid and reliable instrument. The dates of these studies ranged from 1993 to 2015. Four of these were published prior to 2003. All five studies that measured burnout used the Maslach Burnout Inventory. The figure below represents the ranges of scores found in the studies for each of the burnout dimensions.iv, vi, vii, viii, ix
The ranges of burnout reported in the studies using the Maslach Burnout Inventory for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA)iv, vi, vii, viii, ix
While studies of academic faculty were not included in this particular integrative review, two studies were identified that examined burnout in physical therapy academic faculty. In general, faculty experience high levels of personal accomplishment, moderate levels of emotional exhaustion, and low levels of depersonalization. This is relevant as it has been suggested in the literature that faculty wellness could impact student wellness.x
The literature identified in the integrative review pinpointed four factors associated with burnout:
Watch a short video that summarizes the factors associated with burnout
Based on this review, there appears to be significant gaps in the current literature regarding burnout amongst physical therapists in the United States. While the studies cited did note some level of burnout and outlined factors associated with burnout, the majority of the literature is outdated. Further research is recommended to better understand burnout in this population.
Given the lack of current research in physical therapist burnout, we can look to other medical professions to help us better understand what impact burnout has on clinicians. Research in other health care providers has shown that burnout affects both well-being and safe and competent practice.
Additionally, in 2016, Salyers and colleagues, conducted a meta-analysis where they specifically studied the relationship between burnout and the quality of care provided and burnout and safety. They found a negative relationship between burnout and quality of care provided and burnout and safety. The relationship between burnout and quality was stronger for emotional exhaustion than any other dimension. According to the authors, these findings suggest 1)emotional exhaustion may be one of the most important elements to address and 2) burnout may interfere with optimal patient care.xxiv
FSBPT’s Guidelines for Continuing Professional Development define healthy practice as “conditions under which safe, effective, and ethical practice is most likely to thrive.” While individual self-care strategies such as yoga may be beneficial, we can’t yoga our way out of burnout. If the environment is contributing to burnout, even the best self-care can’t singularly address that. Therefore, promoting healthy practice requires us to take a systems approach.
A systems approach includes professional organizations, third-party payers, government organizations, electronic health record vendors, professional schools, organizations where health care providers are employed, accrediting bodies, the individuals, and, of course, regulators. If all of those systems come together, changes can be made in the way clinician burnout is tackled.
There are two frameworks that may help guide these solutions, the Health Professional Wellness Hierarchyxxv and Job-Person Fit.xxvi
The Health Professional Wellness Hierarchy is adapted from Maslow’s Hierarchy of Needs. It’s based on the same premise that basic needs must be met first before other needs in the hierarchy can be met. They proposed that interventions should be directed from the bottom up. Physical and mental needs such as being given a lunch break, getting enough sleep, and using the restroom must be addressed first. Once these basic needs are met, interventions can be directed at the higher levels of safety, respect, appreciation, and eventually healing patients and contributing.xxv
Another helpful model is the job-person fit, which was proposed by Maslach and Leiter in 2017. They suggested that both the individual and the organization have a role in preventing and alleviating burnout, and the job-person fit is a way to incorporate both of these entities.
The model identifies six areas of potential frustration that can lead to burnout:
Because these are areas of potential frustration, they are also areas where strategies could be targeted. The authors emphasized the importance of looking at each of these areas from the individual and organizational level and directing interventions appropriately depending on whether it is an individual issue or an organizational issue.xxvi
With these frameworks in mind, what can the various organizational stakeholders do?
Professional organizations should encourage providers to seek both preventative and curative treatment. Self-care should be promoted to reduce the stigma associated with seeking treatment for mental health issues. Clinicians tend to be hard-working and caring. It can be difficult for caregivers to admit that they are in need of help. The availability and accessibility of confidential counseling should be expanded, and providers should be educated about the resources that are available. There are many resources out there, but if someone is already overwhelmed and burned out, it is unlikely they have time to seek these out. Communications to the public around the issue of provider wellness also might be helpful.xxvii
Medicare, Medicaid, and other third-party payers should closely evaluate any new requirements that they're placing on providers to determine the impact that each has on provider wellness. New requirements should be evidence-based and have a strong rationale to improve patient care and protect patients' safety in order to be implemented. When evaluating the quality of care provided, payers need to look beyond cost savings and also consider physician health and practice patterns that promote wellness.xxvii
State governments, health departments, and legislatures should weigh the potential value of new regulations against the potential risk to clinicians.xxvii
Ideally, electronic health records should help clinicians improve patient safety and care. This requires vendors to make an effort to design systems that avoid redundancy that can increase workload and frustration. They should also seek input from clinicians to improve the user experience.xxvii
Professional schools should have conversations with students about wellness and how this could impact patient care. They also need to be open with students about the challenges they may encounter as new professionals. Additionally, schools should make sure students’ voices are heard within their own programs as it relates to wellness.xxvii
Shanafelt and Noseworthy (2017) proposed nine strategies to promote engagement at health care facilities, which they say is the antithesis of burnout.xxix
While self-care alone isn’t going to solve the problem, individual providers should work to build their own resilience and manage stress.
There are several self-care strategies that should be considered:xxviii, xxx, xxxi,
Regulatory boards have the duty to protect the public. The Federation of State Medical Boards has specific recommendations grounded in patient safety and specific to state medical boards with a focus on the licensing process.xxvii
They recommend that regulators should do the following things:xxvii
Burnout is a complex issue and it will take commitment at all levels to address. Ultimately, it is about the quality of the care we provide and ensuring the safety of the patients we serve. If all stakeholders are involved in the conversation, we can make a difference.
Assistant Professor, Division of Physical Therapy Education, University of Nebraska Medical Center
Nikki Sleddens, PT, MPT, is an Assistant Professor and Director of Clinical Education for the PT Program at the University of Nebraska Medical Center (UNMC). Nikki received a Masters in physical therapy from UNMC in 1995. She is currently a PhD student in the Department of Psychiatry in the College of Medicine – Medical Science Interdepartmental Area at UNMC. She completed the requirements for a Medical Education Research Certificate from the American Academy of Medical Colleges. Her scholary interest is focused on studying burnout amongst physical therapist. She is an APTA Credentialed Clincial Instructor Program Trainer and TeamSTEPPS Master Trainer. She serves as chair of the UNMC College of Allied Health Clinical Affairs committee. She is an active member of the APTA, currently serving as Vice President of the Nebraska Physical Therapy Association. She has been an invited speaker at the regional, national, and international level on topics related to clinical education, interactive learning, and TeamSTEPPS.
Betsy J. Becker, PT, DPT, PhD
Program Director, Division of Physical Therapy Education, University of Nebraska Medical Center
Betsy Becker, PhD, DPT, is the Director of Physical Therapy Education in the College of Allied Health Professions at the University of Nebraska Medical Center (UNMC). Dr. Becker holds Master’s and PhD degrees from UNMC. She has her clinical doctorate in physical therapy from the University of South Dakota. She was an inaugural inductee in the UNMC Interprofessional Academy of Educators, and she currently serves as co-chair of the UNMC E-Learning Steering Committee.
Dr. Becker’s scholarly agenda focuses on education, chronic disease management, and the role of professional networking in faculty development and career advancement. She is nationally recognized for her work related to the development and implementation of innovative educational technologies, and she recently completed the requirements for a Medical Education Research Certificate from the American Academy of Medical Colleges. She was founding director of the Southeast Community College physical therapist assistant program. She is currently vice chair of the Nebraska State Board of Physical Therapy, and she serves as a director on the board for the Foreign Credentialing Commission of Physical Therapists.
iMaslach, C., Jackson, S. E., Leiter, M. P. (1996). Maslach burnout inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.
iiC. Maslach, W. B. Schaufeli, and M. P. Leiter, “Job burnout,” Annual Review of Psychology 52 (2001): 397-422, doi:10.1146/annurev.psych.52.1.397 [doi]
iiiU. ustulka-Piwnik, Z. J. Ryn, L. Krzywoszanski, and J. Stozek, “Burnout syndrome in physical therapists - demographic and organizational factors,” Medycyna Pracy 65(4) (2014): 453-462.
ivJ.W. Berry and C.C. Hosford“A regional survey and analysis of burnout among physical therapists in frontier counties,” HPA Resource, 15(3) (2015), J1-J11.
vL. Sobal and S. Jaskie (2016), What’s missing from the triple aim of healthcare. Cardiac Interventions Today, 10(2), 20-27.
viJ.A. Balogun, V. Titiloye, A. Balogun, A. Oyeyemi, and J. Katz, “Prevalence and determinants of burnout among physical and occupational therapists,” Journal of Allied Health, 31(3) (2002): 131-139.
viiE. Donohoe, A. Nawawi, L. Wilker, T. Schindler, and D. U. Jette, “Factors associated with burnout of physical therapists in massachusetts rehabilitation hospitals,” Physical Therapy, 73(11) (1993):, 750-6; discussion 756-61.
viiiK. C. Schlenz, M. R. Guthrie, and B. Dudgeon, “Burnout in occupational therapists and physical therapists working in head injury rehabilitation,” The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 49(10) (1995): 986-993.
ixB. J. andling, and B.S. Smith, “Burnout in orthopaedic physical therapists,” The Journal of Orthopaedic and Sports Physical Therapy, 26(3) (1997):, 124-130. doi:10.2519/jospt.19126.96.36.199 [doi]
x N. A. Gillespie, M. Walsh, A. H. Winefield, J. Dua, and C. Stough, “Occupational stress in universities: Staff perceptions of the causes, consequences and moderators of stress,” Work & Stress, 15(1), (2001):53–72. https://doi.org/10.1080/02678370110062449
xiG. J. Deckard, and R. M. Present “Impact of role stress on physical therapists' emotional and physical well-being,” Physical Therapy, 69(9) (1989): 713-718.
xiiN. D. Schuster, D. L. Nelson, and C. Quisling, “Burnout among physical therapists,” Physical Therapy, 64(3), (1984): 299-303.
xiiiW. B. Schaufeli, A., Bakker, C. Schaap, A. Kladler, and C. A. L. Hoogduin, On the clinical validity of the Maslach Burnout Inventory and the Burnout Measure. Psychology & Health, 16, (2001): 565-82.
xivP. K. S. Patrick, “Professional roles at risk for burnout,” Family Community Health, 6, (1984): 25-31.
xvC. Maslach, The Cost of Caring (New York, NY: Prentice Hall Press, 1982).
xviH. J. Freudenberger, “The staff burn-out syndrome in alternative institutions,” Psychotherapy Theory Research Practice, 12, (1975): 73-82.
xviiG. A. Wolfe, “Burnout of therapists: Inevitable or preventable,” Physical Therapy, 61, (1981): 1046-1050.
xviiiS. Bahrer-Kohler Burnout for experts: Prevention in the Context of Living and Working. (New York, NY: Springer, 2013).
xixC. Cherniss, Staff Burnout: Job Stress in Human Services. (Beverly Hills, CA: Sage Publications, Inc1980).
xxC. Maslach, “Burned-out,” Human Behavior, 5, (1976): 16-22.
xxiA. Pines. C. Maslach, “Characteristics of staff burnout in mental health settings,”Hospital Community Psychiatry, 29, (1978): 233-237.
xxiiY. Zhang, X. Feng, “The relationship between job satisfaction, burnout, and turnover intention among physicians from urban state-owned medical institutions in Hubei, China: A cross-sectional study,” BMC Health Services Research, 11, (2011): 235.
xxiiiJ. N. Scanlan, M.Still, “Job satisfaction and burnout and turnover intention in occupational therapists working in mental health,” Australian Occupational Therapy Journal, 60(5), (2013): 310-318.
xxivM. P. Salyers, K. A. Bonfils, L. Luther, R. L. Firmin, D.A. White, E. L. Adams, A.L. Rollins, “The relationship between professional burnout and quality and safety in healthcare: A meta-analysis,” Journal of General Internal Medicine, 32(4), (2016): 475–482.
xxvD. E. Shapiro, C. Duquette, L.M. Abbot, T.Babineau, A. Pearl, P. Haidet, “Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level,” The American Journal of Medicine, 32 (5), (2019): 556-563.
xxviC. Maslach, M.P. Leiter, (2017), “New insights into burnout and health care: Strategies for improving civility and alleviating burnout,” Medical Teacher, 39 (2), 160-163, DOI: 10.1080/0142159X.2016.1248918.
xxvii Physician Wellness and Burnout (Washington, DC: Federation of State Medical Boards, 2018), http://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf.
xxviiiR. L. Piedmont, “A longitudinal analysis of burnout in the health care setting: The role of personal dispositions,” Journal of Personality Assessment, 61(3), (1993): 457-473.
xxixT. D. Shanafelt, J. H. Noseworthy, “Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout,” Mayo Clinic Proceedings, 92(1), (2017): 129-146.
xxxR. Sapolsky, Why zebras don’t get ulcers: A guide to stress, stress related diseases, and coping, (New York, NY: W.H. Freeman, 1994).
xxxiS. Wadill-Goad, Nurse burnout: Combating stress in nursing (Indiana, IN: Sigma Theta Tau International, 2016),. C. Finkelstein, Improving physician resiliency (Chicago, IL: American Medical Association, 2017).
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