Professional burnout among doctors and nurses as a result of

Professional burnout among doctors and nurses as a result of

Galęba
Probl
Hig
A, Epidemiol
et al. Professional
2015, 96(3):
burnout
547-551
among doctors and nurses as a result of exposure to considerable stress at work
547
Professional burnout among doctors and nurses as a result
of exposure to considerable stress at work
Zespół wypalenia zawodowego wśród lekarzy i pielęgniarek jako rezultat narażenia
na znaczny stres w pracy
Anna Galęba 1,2/, Beata Bajurna 1/, Jerzy T. Marcinkowski 1/, Mariola Gałązka 3/
Chair of Social Medicine, Poznan University of Medical Sciences, Poland
Private Practice of Aesthetic Medicine and Anti-Aging in Warsaw and Poznan, Poland
3/
Public Central Teaching Hospital in Warsaw, Poland
1/
2/
Zjawisko wypalenia zawodowego było znane i opisywane już pod koniec lat
60. XX wieku, jako tzw. reakcja wyczerpania. Termin „wypalenie zawodowe”
wprowadził po raz pierwszy w 1974 r. H. J. Freudenberger. Szczególnie
narażone są osoby wykonujące zawody związane bliskim kontaktem
z innymi ludźmi, pomocą innym. Wypalenie zawodowe nie omija również
pielęgniarek jak i lekarzy i to różnej specjalności. Przyczyny wypalenia
zawodowego lokalizowane są w trzech płaszczyznach: indywidualnej,
interpersonalnej i organizacyjnej. Dzielimy je na dwie grupy: 1. przyczyny
tkwiące w strukturze zawodu oraz 2. w cechach osobowości pracownika
i jego stosunku do wykonywanej pracy. Jedną z najważniejszych ról
w zapobieganiu wystąpienia syndromu wypalenia zawodowego odgrywa
poradnictwo zawodowe. Ważna jest współpraca z psychologiem, bieżące
rozwiązywanie problemów i zapobieganie ich narastaniu. W przypadkach
znacznie zaawansowanych konieczna jest długotrwała współpraca
z psychoterapeutą.
A burnout syndrome phenomenon was known and described at the end of
the 1960s as the so-called response to exhaustion. The term “burnout” was
introduced for the first time in 1974 by H. J. Freudenberger. Professionals
involved in helping others at their work are particularly subjected to this
phenomenon. The burnout syndrome bypasses neither nurses nor doctors
of any specialization. The causes of burnout can be found on three levels:
individual, interpersonal and organizational. We divide them into two
groups: 1. causes inherent to the structure of the profession, and 2. the
employee’s personality traits and their attitude to work. A career counselling
plays one of the most important roles in the prevention of burnout
syndrome. It is important to work with a psychologist, systematically solve
problems and prevent their formation. In more complicated cases a longterm psychotherapy is needed.
Key words: burnout syndrome, stress at work, doctors, nurses
Słowa kluczowe: zespół wypalenia zawodowego, stres w pracy, lekarze,
pielęgniarki
© Probl Hig Epidemiol 2015, 96(3): 547-551
www.phie.pl
Nadesłano: 01.08.2015
Zakwalifikowano do druku: 15.08.2015
Introduction
The phenomenon of a burnout syndrome was
known and described in German psychiatry textbooks
at the end of the 1960s as the so-called response to
exhaustion. The term “burnout” was introduced for
the first time in 1974 in H. J. Freudenberger’s pioneer
article. According to the literature there is no total
conformity on the definition of the mechanisms and
causes of this phenomenon. It is also difficult to specify
the boundaries between burnout and alienation,
stress, exhaustion, bitterness, or even depression
[1]. Burnout appears among members of various
professions, especially among those assisting others,
in particular the sick, weak, or children.
Adres do korespondencji / Address for correspondence
Anna Galęba PhD, MD
5C Rokietnicka Str., 60-806 Poznan, Poland
e-mail: [email protected]
Chronic stress and its consequence, in form of the
burnout syndrome, bypasses neither nurses nor
doctors of any medical specialty. The highest level
of stress and accompanying it symptoms are found
among general medicine doctors and psychiatrists, the
lowest among surgeons. It is associated with the way
of work. General medicine doctors and psychiatrists
are often emotionally associated with their patients
by getting to know their families and their personal
and professional problems. The surgeons are visited by
patients with a specific disease in order to surgically
cure it, after that the role of the surgeon typically
ends. The first crisis often appears between the 3rd
and the 7th year of work, the second between the 40th
and 50th year of life when most people assess their
548
life achievements [1]. The stress among nurses also
depends on their workplace. The surgical ward nurses
are the most and the pediatric ward nurses are the least
prone to stress. The most severe burnout is experienced
by nurses working at the internal medicine unit and
the least severe by the ones working at the pediatric
ward [2].
In the medical profession, on the one hand we deal
with a very high responsibility and social pressure, and
on the other – with the realistic healthcare difficulties,
poor work organization and incommensurable low
wages. Long-lasting close contact with a patient, the
lack of autonomy in the operation or insufficient
support are stressors that together with organizational
burdensomeness can additionally lead to chronic
tension, symptoms of depression, substance abuse,
iatrogenic errors, lack of job satisfaction, absence and
in the end a desire to quit the profession [1, 3].
The imbalance between the expectations from
nurses and doctors and their potential leads to the
burnout syndrome. Typical attitudes for people at
risk of suffering from burnout are: wholehearted
engagement in one’s work, voluntarily and willingly
taking on new tasks and responsibilities, high
expectations towards themselves, denying their own
limits and disregarding personal needs and interests
[1, 3]. On the one hand, work provides the right social
and economic status, allows to learn new skills and
expand knowledge, guarantees satisfaction and sense
of identity, develops personality, makes it possible to
acquire new contacts and friendships. On the other
hand, it is one of the biggest stressors and sources of
problems in human life [4, 5]. Work satisfaction is an
important aspect of human life, lack of which leads
to frustration that influences a burnout [6]. Doctors
and nurses spend more than 40 hours a week at work,
which exceeds the average working time of an ordinary
citizen.
The purpose of this paper is the exploration of
the burnout syndrome problem among medical staff,
mainly doctors and nurses, an overview of its causes,
characterization of symptoms and, above all, the
indication of the ways to prevent and fight burnouts.
Characteristics of burnout syndrome
The characteristics of the burnout syndrome
proposed by Aronson can be divided into three
categories [1]. The first of these regards physical
exhaustion, chronic fatigue, lack of energy, weakness,
sleep disturbances, increased susceptibility to
infections, accidents, tension and neck and shoulders,
muscle cramps, backache, changes in dietary habits
and body weight, and an increased use of drugs and
alcohol in order to eliminate the physical exhaustion.
The second category covers emotional exhaustion.
Probl Hig Epidemiol 2015, 96(3): 547-551
It includes the following symptoms: hopelessness
and a lack of prospects, helplessness, depression,
disappointment, loneliness and discouragement,
excitability, dysfunctions of emotional control
mechanisms, a sense of emotional emptiness and
uncontrolled crying. The last category considers
mental exhaustion – negative attitude towards life,
towards oneself and work, disconnection with patients
and colleagues, a sense of incompetence and low selfesteem and cynical, irreverent or aggressive attitude
towards others. The concentration and intensity of
specific characteristics may differ and depend on
individual and situational factors.
A similar breakdown of the burnout characteristics
is proposed by Maslach [7]. In the first phase there
is an excessive and long-term work overload, which
is not overcome by common activity. The results are
irritation, fatigue, and emotional exhaustion. In the
second phase there appear negative dehumanized
forms of behavior towards co-workers; apathy,
cynicism and stiffness, which is a negative defense
against stress, appearing in the form of emotional
distancing to professional problems. In the third
phase, called “a terminal burnout”, there appear
permanent changes in attitudes and motivation.
A team of scientists believes that the burnout
syndrome is expressed by clear dissatisfaction with
work, a growing number of sicknesses, the search for
other careers, as well as alcohol and drug abuse [8]. In
the study involving students of the Medical University
in Poznan it has been shown that in this group there
is a high risk of addiction to drugs, psychotropic
drugs and alcohol, consumption of which continues
to increase [9]. Therefore, the burnout problem may
have already started in college.
Causes of burnout syndrome among doctors
and nurses
The causes of the burnout syndrome are usually
found on three levels: individual, interpersonal and
organizational. A professional burnout is favored by
the following individual features: insecurity, low selfesteem, lack of resourcefulness, defensive behaviors,
dependence, inaction, irrational beliefs about the
professional role, high reactivity, avoiding difficult
situations, the sense of control from the outside and
strong motivation at work. On the interpersonal level,
the main source of burnout are relationships between
the doctor and patients, and stressful situations
coming from contacts with supervisors and coworkers.
On the organizational level, the most common source
of burnout (stress) are sets of employer’s or patients’
or others’ expectations of the employee, which cannot
be implemented within the expected worktime or with
the help of essential resources [1, 10].
Galęba A, et al. Professional burnout among doctors and nurses as a result of exposure to considerable stress at work
Among the reasons inherent in the personalities of
doctors and nurses, it is important to mention three
types of personalities conducive to the burnout
syndrome. The first are traits of immature and
psychasthenic personalities, which foster low
efficiency and effectiveness as well as superficial and
partial relationships with other people. It is worth
noting here: low self-esteem, passivity, uncertainty in
public relations and dependency on others. Hysterical
personality traits such as lack of self-esteem and
the ability to control strong emotions in difficult
situations, strong negative response contributing to
the deterioration of work efficiency and reduction in
contacts with colleagues, and traits of psychopathic
personality such as: aggressiveness, manipulation
of the surroundings, suspicion, inability to control
emotions and ignoring others also foster professional
burnout [1, 10].
It has been shown that men who occupy
managerial positions are more likely to succumb to
the phenomenon of burnout and depersonalization
in relation to men who occupy lower job positions
[11]. However, it has not been noted that there is
a differences in the incidence of burnout between
women and men [8]. Among the non-modifiable
factors it is important to point at the female gender.
It has been proven that women are more vulnerable
to this phenomenon [12]. It has also been shown that
women receive support faster, which probably is tied to
a greater desire of women to talk about their mistakes
and shortcomings at the time of being influenced by
the syndrome. The relation to work is also important.
Any extremes, such as lack of commitment and interest
in work, as well as excessive involvement in work, cause
the risk of developing burnout, including doctors and
nurses. Burnout increases with the number of tasks per
doctor and decreased possibilities of ability to control
some situations, which especially influences emotional
exhaustion and depersonalization [13].
Żbikowska [14] in her research regarding stress
and burnout, carried out among physicians of various
specialties has stated that doctors evaluate higher when
it comes to some risk of burnout and, to a lesser extent,
they apply it directly to themselves; together with the
awareness of the risk of the burnout syndrome, there
increases the ability of doctors to cope with it; doctors
use outside-work hobbies in order to refresh their
biopsychic balance and neutralize the work-related
tensions; are more likely to seek and receive support
at the time of the first burnout signs, they also find
more ways to cope with stress and burnout than, for
example, nurses.
C. Maslach [5, 7] underlines that the burnout
process is an inevitable consequence of the prolonged
or repetitive destruction, that happens in psyche of
549
persons who excessively exploit their strength for
others. Burnout is also a result of a disagreement at
work, mainly arising from excessive work overload,
lack of possibilities for control and for decisionmaking. It has also been noticed, based on studies
among nurses working in England, that there exists
a correlation between requirements at work, an
effort and incidents of fear and depression [15]. The
research conducted in Poland also shows that nurses
who are more addicted to work suffer from a more
severe burnout syndrome [16].
Causes of stress at work among doctors and
nurses
Doctors, nurses and other medical personnel are
exposed at work to two types of stressors; traumatic
situations and chronic stressors [17]. Traumatic
situations involve a continuous contact with harmed
and suffering individuals. Doctors are frequent
witnesses to life-threatening situations or receive
information about such threats. Chronic stressors are
weaker when it comes to potency; however, they are
continuous in duration. They are often unnoticed by
the medical staff but lead to depletion of resistance
resources as a result of their continuous operation. We
include here the poor organization at the workplace,
bureaucratic overload and working shifts, night work
in particular.
The main stressors for health professionals are:
low wages, inadequate to the responsibility for the
life of patients, staff shortages and continuous time
constraints. In addition to the stressors associated
with the professional role there are also stressors
associated with the operation simultaneously at the
clinic/hospital and outside it: the inability to connect
professional duties with obligations to family, friends
or the development of own non-professional interests;
stressors related to the professional development
– dissatisfaction with the career, lack of career
opportunities for further development; stressors
related to the functioning of the employee as a member
of the health facility for example; responsibility for
things and people, the lack of participation in decisionmaking, the inability to speak one opinion in matters
significant to the particular health facility; stressors
related to the way of working for example; rush,
monotony, night work, the physical environment,
for example noise, congestion or inadequate way of
managing. In the Western countries medical staff
point at contact with patients, health endangerment
(injuries), conflicts of roles and dependencies from
medical staff [17, 18].
The factors such as prolonged close contact with
the patient, lack of autonomy in the operation or
insufficient support, along with the organizational
550
nuisances can additionally lead to a chronic state of
tension, symptoms of depression, substance abuse,
iatrogenic errors, lack of job satisfaction, absenteeism
and in the end a desire to move away from the
profession [17].
Prevention and treatment
The burnout syndrome is one of the main reasons
for the low quality of medical services provided by
medical personnel, including doctors and nurses.
It is important to be aware that this problem can
affect anyone, regardless age, time of overwork or
specialization, which forms the basis of prevention
[1]. Currently the curricula in medical schools
and medical specialty programs are very poor.
Missing is the training of occupational medicine and
ergonomics of the profession, which would increase
the awareness of medical staff of the risks in future
professional life, and the recognition of the problem
among patients would be more effective and correct
[19]. It would be necessary to introduce training
in interpersonal communication, assertiveness and
relaxation techniques [9].
Career counseling plays one of the most important
roles in the burnout syndrome prevention. It is
important to choose the future career carefully, get
involved with its difficulties and realistically assess
one own abilities to perform it. It would be worth
introducing mandatory psychological tests before
beginning medical studies, which is currently rare.
It is also important to raise awareness of the workers
regarding the importance of resting and separation of
the private life from the professional one. Education
should also be provided to the supervisors, so that they
could induce creativity and counteract the destruction
in their employees [5, 14].
Many medical professionals claim that it is possible
to avoid the burnout syndrome if one likes their job,
which agrees with one’s own beliefs, when the career
path is planned, when one develops and gets promoted.
New challenges are significant, as is the diversification
of tasks and proper relaxation. It has been proven that
a hobby reduces the burnout risk [12]. Job satisfaction
is important, not only in the medical profession.
A study carried out in the population of nurses [20]
showed that only 16% of those polled were fulfilled
and satisfied with their profession, which positively
translated into their mental health. Most of them
cannot adopt the attitude of a distance and have
a sense of resignation in difficult situations. It is also
associated with lower social support of this occupation
and the lack of their faith in the possibilities of
Probl Hig Epidemiol 2015, 96(3): 547-551
a professional success. Other authors have noticed
that the burnout syndrome can negatively influence
nurses’ psychosomatic health which in consequence
has a negative influence on their work at medical units.
The research conducted in Japan among psychiatric
wards nurses shows significant correlations between
variables such as: demographic factors, multitasking,
work related stress and week mental strength [21].
In the early stages of medical staff burnout, some
rest and a temporary isolation from work are beneficial.
Psychological consultation should eliminate guilt,
allow to get rid of negative emotions, clear the doubts
[12]. A doctor or a nurse should realize the core of
the problem and the way to deal with it. In much
complex cases, a long-term cooperation with the
psychotherapist is crucial. In extreme situations, it is
recommended that one changes the work environment
and sometimes even profession. However, in case of
doctors and nurses, such decision is extremely difficult,
often means giving up the dream. It is important to
keep the balance and distance and to separate the
private life from the professional one [1, 5, 14].
Conclusions
There is no doubt that people employed in
healthcare pay a high price for the opportunity
to exercise their profession. The price is also paid
by patients, waiting longer for their appointments
and receiving less interest and understanding.
Bad emotions often lead to families’ conflicts. The
burnout syndrome is one of many possible body
reactions to chronic work-related stress in professions
with constant contact with people and emotional
involvement in their problems. Doctors and nurses
often present an attitude known as “distant care” to
defend them against burnout, however, this process,
instead of distancing, converts into depersonalization
of the patients. Burnout affects first and foremost
workaholics, who are not able to find ways for
abreaction, resting and separation of the personal
from the professional life. The concept of burnout has
played a big role in the social psychology.
The psychologist Freudenberg said that burnout
robs our society of what it cannot afford to lose,
that is of the people accomplishing their highest
achievements. Similarly, Maslach [22] says that
burnout “causes a huge waste of talent and education
in workers, has harmful psychological consequences,
both for employees and for their patients.” Prevention
is therefore by far easier and less expensive than the
loss of a specialized doctor or a nurse.
Galęba A, et al. Professional burnout among doctors and nurses as a result of exposure to considerable stress at work
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