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Burnout
Exhaustion of physical or emotional strength or motivation, usually
as a result of prolonged stress or frustration.
—Merriam-Webster Online Dictionary, 2006
"Surprise, surprise, we have a full house!" exclaimed Mary
Anne Brown, a registered nurse and co-presenter at the workshop "Lest
Your Flame Burn Too Brightly: An Everyday Remedy for Preventing Professional
Burnout." The workshop1 was part of
the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Training
and Technical Assistance Grantee Meeting in August 2006. The crowded room
quickly came alive as laughter and knowing looks were exchanged among those
in attendance, conveying a sense of relief that an issue on so many people's
minds was being put squarely on the table.
DID YOU KNOW? |
- Burnout is more prevalent among service professionals—including
health practitioners and caregivers—than among other professionals.2
- Studies also show that burnout is more common among those who care
most about their jobs.3
- Physicians, particularly female physicians, have higher suicide
rates than the general population.4
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The large turnout at the session underscored concerns about burnout among
HIV/AIDS professionals and the hunger for a solution. Burnout is not a trivial
issue, and its influence is not limited to professionals. Ultimately, it
affects patients and the quality of services they receive.
While burnout
may be particularly severe among those who provide HIV/AIDS services, it
is not unique to this kind of work. People in many high-demand, fast-paced
work environments must constantly remain "on fire" to
meet rising expectations, even as they inadvertently heighten the risk of
physical and emotional exhaustion. Millions of people feel overworked and
overstressed, and studies indicate that the number of people in the United
States who work more than 50 hours per week is on the rise.5,6,7
This
phenomenon is partly the result of an exaggerated—even celebrated—association
between stress and success in our society, as evidenced by films and television
shows in which the most "successful" people are those who are
portrayed as leading the most frenetic lives.
Burnout also is related to
the amount of time not actually working while at work. "Every week I spend
time in meetings talking about what I'm going to do, while what I need to
do is sitting on my desk," laments
a New York State government worker. Her problem is not unique.
In 2005, the
Microsoft Corporation conducted an online survey on productivity to which
more than 38,000 people from 200 countries responded.
- U.S.-based respondents spent an average of 16 unproductive hours per
45-hour work week;
- U.S. respondents also spent 5.5 hours per week in largely
unproductive meetings;
- In addition, they indicated that they managed an
average of 56
e-mails per day.8
In 2003, an independent research firm conducted a nationwide survey of 613
men and women to determine the biggest time-wasters for individuals at work.
- More than a quarter of those surveyed indicated that meetings that last
too long wasted the most time for them at work.
- More than a quarter of respondents
identified unnecessary interruptions at work as a primary time-waster.9
Whatever the factors, this demanding, yet unproductive and draining, mode
of working comes with this reality for most of us: It simply is not sustainable.
People working in caregiving professions are more susceptible to burnout
than those in other fields because of the emotionally draining nature of
their work.10 People providing HIV/AIDS services are particularly at risk
because of the daily cocktail of stressors that accompany the fight against
this disease.11
Those stressors include the challenges of supporting clients
who often are grappling with a multitude of chronically unmet needs. They
also include administrative burdens that distract providers from their client
services mission and the frustrations that can accompany rising costs and
reduced resources. Other stressors include a sense of lack of control over
one's
job, ambiguity related to one's role, increases in work hours or workload,
and vague or unfitting office policies.12,13
Molly Cooke is founding co-director
of the AIDS Task Force of the Society for General Internal Medicine and a
professor of medicine at the University of California, San Francisco. Fifteen
years ago, she identified several specific issues that challenge HIV/AIDS
care professionals either directly or indirectly, through patients:
- Occupational risk
- Fear for patients' and their own well-being
- Anger toward obstacles to
care
- Conflict among providers
- Concerns about professional competence and ability
- Discomfort with issues
of sexuality
- Stigma
- Reproductive rights
- Illegal drug use
- Grief.14
Fifteen years of progress have not eliminated those stressors.
Consider stigma: "Sometimes people ask what you do [for a living], and once
you say, "HIV," the conversation is over. They say, "Oh," and
then they're speechless," explains Cheryl Boxx, a registered
nurse with the Specialty Care Clinic in Athens, Georgia.
New challenges exist
as well, like "AIDS fatigue," whereby some
people have become desensitized to the problem.15 This can reduce the level
of support that service providers receive from their organizations and communities
while increasing the level of support and encouragement HIV-positive patients
need.
Finally, consider people's relationships with their coworkers. Colleagues,
supervisors, and administrators all play important roles in a caregiver's
professional experience. Sometimes managing those relationships can be more
stressful than managing one's workload. Although research suggests
that reaching out to coworkers can be helpful in times of stress, difficulty
interacting with coworkers sometimes increases job-related stress levels
and prevents people from seeking out coworkers as a resource.16
Burnout: Do You Have It?
The term "burnout" was coined by psychoanalyst Herbert Freudenberger
to put a name to the set of feelings experienced by professionals who find
themselves emotionally depleted.17 Burnout syndrome is the reaction of the
body and mind to persistent stress.18,19 The symptoms are similar to those
of stress, but burnout syndrome also involves a depletion of emotional energy.
It can lead to aversion toward activities and people that are part of life
in and out of work.20
Christina Maslach has spent her professional career
at Stanford University and is an expert on burnout. She developed the Maslach
Burnout Inventory (MBI) tool for measuring the levels of the three primary
components of burnout syndrome, summarized below.21
Exhaustion is the first
component: feeling overextended and drained, both emotionally and physically;
experiencing a lack of energy or desire to face the next project, patient,
or person. Rest comes intermittently, and efforts to "unwind" are unsuccessful.
Maslach identifies exhaustion as the first reaction to the stress of job
demands or major change.22
Cynicism is the second burnout component—taking
a cold, distant approach to work and the people at work; having an indifferent
attitude, especially when the future is uncertain. According to Maslach,
people may feel that it is safer to be indifferent than to risk emotional
damage.23
Ineffectiveness is a growing sense of inadequacy, in which every
case or project appears overwhelming. Maslach believes that when people feel
ineffective, they lose confidence in their ability to make a difference.
They also lose confidence in themselves—and others lose confidence
in them.24
Symptom Type |
Manifestations |
Physical |
Difficulty sleeping
Fatigue and exhaustion
Gastrointestinal problems
Headaches
Increased vulnerability to illnesses, such as colds and flu |
Emotional |
Anxiety
Depression
Guilt
Irritability
Sense of helplessness |
Behavioral |
Aggression
Callousness
Cynicism
Defensiveness
Pessimism
Substance abuse |
Work-related |
Decreased or poor work performance
Absenteeism
Attrition
Misuse of work breaks
Tardiness
Thefts |
Interpersonal |
Dehumanization of patients
Reduced
communication with colleagues or patients
Withdrawal from colleagues
or patients |
In some
cases, burnout in providers can be related to the caregiver-patient relationship.25 The
emotional strain of continual stressful interactions can gradually eat away
at caregivers' tolerance, leaving them susceptible
to burnout.26 One nurse described the
emotional overload in the following way: "I'm like a wire that has too much
electricity flowing through it—I've burned out and emotionally disconnected
from others."27 It is no wonder
that the symptoms of burnout have been defined as "compassion
fatigue."28
As debilitating as they
are, the effects of burnout are not limited to the person experiencing it.
The loss of enthusiasm and purpose, physical and emotional exhaustion, and
negative attitude toward work that accompany burnout can lead to a loss of
empathy for patients. Caregivers who experience the changes that typically
accompany burnout generally have a difficult time relating to patients, colleagues,
and loved ones in a caring way.29 In
addition to patients, the effects of burnout ripple throughout the organization,
causing low morale and depletion of organizational know-how and capacity.
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Burnout: Who Is Most at Risk?
Burnout occurs most frequently among people in care professions, and the
most dedicated and idealistic among these professionals tend to suffer from
burnout the most.30 While burnout is certainly not just a mental health issue,
people who suffer from depression or anxiety are more likely than others
to feel the effects of burnout, as are those who believe that events are
due to fate, luck, or chance rather than themselves.31 Other predictors of
risks for burnout include coping styles and even gender. The bottom line
is: no one is immune.
People generally cope with stress in one of two ways:
through internal coping strategies (e.g., expression of feelings, patience,
and optimism) or through external coping strategies (e.g., outright denial,
avoidance, or passive acceptance of stressful situations).32
People who practice
internal coping strategies usually have lower risk of burnout. "Sometimes
I come home and I have a good cry," says
Yvonne Kingon, pediatric nurse practitioner with The Family Program, the
Program for AIDS Treatment and Health (PATH) in Brooklyn, New York. Her expression
of emotion is an example of an internal coping strategy. "You have
to get it out and start over, and you know that that's normal. It's
a sign of your humanity."
Research shows that among nurses, older workers
are more likely to use internal coping strategies to control their workplace
stress than are those who are younger or less experienced.33
Health care
workers who use external coping strategies typically do not believe that
they have control over work-related stressors.34 They demonstrate negative
expectations and a passive or fatalistic attitude that contributes to a feeling
of helplessness. People who use such strategies tend to have a higher rate
of burnout.
Compared with their female counterparts, male caregivers have
a more pronounced risk of burning out. Research by Larry and Kelly Hubbell
of the University of Wyoming shows that male caregivers are more likely to
experience the typical symptoms of burnout but are less likely to seek out
support and community services to help alleviate the symptoms.35 This pattern
may be because male caregivers tend to view their role from an instrumental
or intellectual level, thereby distancing themselves from the emotional aspects
of their role.36
In addition, people of both genders are more likely to find
fault with their line of work when they view their jobs as conflicting with
a prescribed gender role. Because some men view caregiving as a role that
conflicts with societal expectations for their gender, they are at higher
risk for burnout.37
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Prevention and Treatment
You won't always be thanked by a patient who you feel should
thank you and they don't. They don't realize the strings you're
pulling, and you have to be okay with that.
—Yvonne Kingon, Pediatric Nurse Practitioner
For HIV/AIDS services
providers, a first step in managing burnout is recognizing and accepting
the stressful nature of HIV/AIDS work as a necessary evil in the fight against
this disease and in the care of those who are affected by it. Part of acceptance
also includes accepting one's own humanity—which
comes with limitations. Those limitations vary from person to person and
from situation to situation.
D
Equally important for
preventing and treating burnout is addressing its signs and symptoms. Some
providers have been trained to control burnout by identifying the factors
that lead to it or even by avoiding their specific weaknesses in treating
patients. Others find themselves at significant risk for becoming overwhelmed.
Types of Coping |
Internal |
External |
Characteristics |
Expression of feelings
Patience
Optimism |
Denial or avoidance of feelings
Passive
acceptance
Passive fatalistic attitude
Feeling of helplessness
Pessimism
|
Burnout Risk |
Low |
High |
According to the CARE Act Conference
workshop, a person's awareness
of how he or she reacts to certain stressors, and knowing what steps can
be taken to ease stress, are invaluable in fending off burnout.38 Knowledge
is not enough, however. Action is required.
1. Take Time Out
Experts indicate that an important strategy for preventing the wear and tear
of HIV/AIDS care is to step away from it.39 This approach can include taking
advantage of scheduling options, such as rotations away from HIV/AIDS care,
or perhaps alternating between HIV/AIDS care and non-HIV/AIDS care on a
regular basis. It most certainly includes taking time off.40
2. Connect
Positive social interaction can also serve as a coping mechanism. Socializing
with friends outside of work or engaging in discussions with trusted colleagues
or loved ones can offer catharsis and support.41
3. Exercise
Not all exhaustion is bad. In fact, physical exhaustion from exercise offers
a world of benefits, particularly for stress relief. Cardiovascular exercise
is a powerful way of relieving tension and frustration, and the release
of endorphins that it generates has been proven to help relieve the symptoms
of depression as well.42,43,44
4. Vent
Physical release of stress can occur in other ways as well. At the CARE Act
Conference workshop, Brown's co-presenter and coworker at the Hudson
Headwaters Health Network in Glens Falls, New York, Dr. Joseph McKay, shared
an anecdote from his workplace.
One day, he found one of his nurses sitting
at her desk with her head in her hands. The look on her face told him that
she was drowning in her stress and needed a release. So he told her to
go to her office and close the door behind her. And scream. When the nurse
left the office, she told Dr. McKay that she felt much better. Her body
needed a way to vent externally what she was feeling internally. Allowing
oneself to cry, scream, or otherwise express feelings can help one cope
with them.
5. Sleep
The 2005 Sleep in America poll found that American adults sleep an average
of only 6.8 hours per night on weekdays.45 That is not enough. The average
adult needs 8 to 8.5 hours of sleep, and some people may require even more.45 The
long-term effects of insufficient sleep have been linked to a number of
harmful health consequences. People with chronic sleep deficits are more
accident prone, have lower levels of productivity, and have greater health
care needs.
To improve sleep habits, a variety of tactics have proven
useful. One is to establish a routine to help relieve stress before bedtime.
It can include bringing closure to the day by making a list of concerns
and a plan to deal with them, or reading, meditating, or taking a warm
bath or shower. Ensuring a relaxing sleep environment, including eliminating
all unnecessary noise and light, also will promote a restful night's sleep.46,47,48,49,50
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How Organizations Can Help
Organizations not only contribute to employee burnout but also suffer
its consequences. Burnout may manifest itself in employees' physical and
emotional ailments, reduced job performance, and attrition. All those results
can cost organizations money and—more importantly—experienced
and dedicated employees.51 The effects
of burnout most frequently lead to attrition at about the 2-year mark, at
which point some caregivers may choose to switch organizations. Others may
leave the profession entirely, giving up the highly draining work that attracted
them in the first place.52
Management
must learn to identify the signs of burnout in employees and offer assistance
and solutions before burnout takes a damaging toll. Research has found that
when stress-reduction services are made available at AIDS care organizations,
they are utilized by workers and perceived as helpful in reducing job-related
stress.53 The same study indicated that among employees who did not currently
have access to such services, the interest in onsite services was high.
No matter what [the patients] are going through, you can’t let it
encompass you to the point where you feel paralyzed. You can only do and
give as much as you have, and sometimes that isn’t enough.
An
increase in responsibility may actually lead to a decreased risk of employee
burnout. It may seem counterintuitive, but allowing workers to have more
accountability over their day's work allows them to retain a sense
of purpose and control over their careers. This change in outlook, in turn,
may help ameliorate the effects of workplace stressors. Providing improved
opportunities for professional growth also may help caregivers put their
work in a healthy perspective.
Other ways in which organizations can reduce
the risk of employee burnout include supportive services, such as workshops,
support groups, and retreats.54 Offering such services to employees is not
enough to fight burnout, however. Naturally, employees have to take advantage
of the services to make them effective. Directing employees to online support
groups, such as caregiver-dedicated chatrooms, can provide an alternative
to onsite support services when funds are lacking or when greater privacy
is desired.
Burnout Burns All
No matter what [the patients] are going through, you can't let
it encompass you to the point where you feel paralyzed. You can only do
and give as much as you have, and sometimes that isn't enough. It isn't
personal.
—Advice given to HIV nurse Jennifer Okonskyby a friend
and fellow nurse
The answer to burnout can lie in the realization that although caregivers
cannot control the circumstances and stressors they encounter in their work
day, they can control the way that they respond to those stressors. The best
weapon against burnout is self-awareness, but successful management of stress
that leads to burnout also involves the development of productive coping
strategies.
Productive coping strategies do not happen without resources,
however. Organizations have a big role to play in providing supportive resources,
encouraging coping strategies, and reducing stressors in the workplace. The
combination of self-care and organizational support can help improve employee
morale and quality of care and, ultimately, patient satisfaction.55
We live
in a culture that often does not reward making personal health a priority.
Particularly in the health care profession, where the focus is more commonly
on sacrifice for the patient, there may be insufficient attention to personal
care. As a result, health care providers may feel guilt or embarrassment
at experiencing burnout when they see their patients suffering. They may
think that their feelings of stress are not legitimate or that they are a
sign of weakness.
Burnout is the elephant in the room for the HIV/AIDS care
profession. It is a silent problem that desperately needs a voice. Maybe
that is why the workshop at the conference was so packed and there was so
much laughter in the room—because people finally felt that they could
acknowledge the problem.
Burnout is not just an issue for the people in that
room. It affects organizations. It affects patients. And it affects the people
caring for these patients. With so much at stake, it is time to look the
elephant in the eye.
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- Background material on this and other sessions at
the 2006 conference are available at www.rwca2006.com.
- Hutman S, Jaffe
J, Segal R, et al. Burnout: signs, symptoms, and prevention. Available
at: http//www.helpguide.org/mental/burnout_signs_symptoms.htm. Accessed
September 22, 2006.
- Vikesland G.
Employee burnout. Available at:
http://www.employer-employee.com/Burnout.html. Accessed September 25, 2006.
- Batchelor, S. Female Physicians face higher suicide
risk. Sacramento Observer. February 16, 2005. Available at: http://www.sacobserver.com/health/021605/female_physician_suicides.shtml.
Accessed September 25, 2006.
- Vendantam
S. In today’s rat race, the most overworked win. The
Washington Post. September 4, 2006. Available at:
www.washingtonpost.com/wpdyn/content/article/2006/09/03/AR2006090300773_pf.html.
Accessed September 4, 2006.
- Harvard School of
Public Health. The Project for Global Working Families:
adequate family availability on a routine basis. Available at: www.hsph.harvard.edu/globalworkingfamilies/FamAvailUS.htm.
Accessed September 22, 2006.
- Messenger J. Working time and
worker’s
preferences in industrialized countries: finding the balance. New York:
Routledge; 2004.
- Microsoft. Survey finds workers average only three
productive days per week. Available at: www.microsoft.com/presspass/press/2005/mar05/03-15threeproductivedayspr.mspx.
Accessed December 8, 2006.
- PR Newswire. Runaway meetings: survey shows meetings,
interruptions top time-wasters at work. Available at: https://goliath.ecnext.com/free-scripts/document_view_v3.pl?item_id=0199-22654167&format_id=XML.
Accessed September 27, 2006.
- Macks JA, Adams DI. Burnout among HIV/AIDS health
care providers: helping the people on the frontlines. AIDS
Clin Rev. New
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- Oktay J. Burnout in hospital social
workers who work with AIDS patients. Social Work. 1992;37(5):432-8.
- McKay
J, Brown MA. Lest your flame burn too brightly: an everyday remedy for
preventing professional burnout. Conference presentation. RWCA Training
and Technical Assistance Grantee Meeting; Washington, DC, August 30, 2006.
- Brown LK, Schultz JR, Forsberg AD, et al. Predictors
of retention among HIV/hemophilia health care professionals. Gen
Hosp Psychiatry.
2002;24:48-54.
- Cooke M. Supporting health care workers in the
treatment of HIV-infected patients. Primary Care. 1992;19(1):245-56.
- Marie Stopes International. Program of action. Conference
presentation at the Transatlantic dialogue US-EU Knowledge is Power Youth
Advocacy Conference; Brussels, February 15-16, 2006.
- Maslach C, Leiter MP. The truth
about burnout: how organizations cause personal stress and what to do
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San Francisco: Jossey-Bass; 2003.
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- Demmer C. Burnout: the healthcare
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- Hubbel L, Hubbel K. The burnout
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Welcome to the new HRSA CAREAction. We hope that
the redesign of this newsletter reflects our commitment to support
HIV/AIDS service providers. And by “providers” I mean the
tough people doing the tough work of designing, managing, and providing
HIV/AIDS services.
In today’s world of increasing HIV/AIDS prevalence
and growing need for services, there is a lot of work to do. Consequently,
in our over-extended, too-busy worlds, we sometimes leave support for
people addressing HIV/AIDS on the backburner. We do so at our peril.
There
are many side effects of working too much with too little relief. One
of them is burnout. This issue is not new to anyone reading this newsletter,
perhaps because it has affected a friend or a colleague—or
you.
Looking at the world from a glass-half-full perspective, we might
say that there are some good things about burnout. First, we know what
causes it, and we know how we can protect ourselves from it. Second,
burnout is a reminder of something that binds us together with the
people we serve: the need to take an organized and methodical approach
to taking care of ourselves.
We hope that you will find this issue
of our publication helpful in your quest for balance and a pace and
approach that can be sustained overtime. Because, in our field, sustaining
oneself over time is what it’s
all about—whether you are a bureau director, a direct service
provider, or a person living with HIV/AIDS.
Deborah Parham Hopson
HRSA Associate Administrator for HIV/AIDS
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