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.

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

Source: Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. In: Stamm, BH (ed). Secondary traumatic stress (2d ed.). Baltimore, MD: Sidrian Press; 1999: 16.

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.

Source: Demmer C. Burnout: the healthcare worker as survivor. AIDS Read 2004;14(10):522-37.

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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