Medical Teacher

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New insights into burnout and health care:

Strategies for improving civility and alleviating
burnout

Christina Maslach & Michael P. Leiter

To cite this article: Christina Maslach & Michael 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

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Published online: 13 Nov 2016.

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MEDICAL TEACHER, 2017
VOL. 39, NO. 2, 160–163
http://dx.doi.org/10.1080/0142159X.2016.1248918

New insights into burnout and health care: Strategies for improving civility
and alleviating burnout
Christina Maslacha and Michael P. Leiterb
a
Psychology Department, University of California, Berkeley, Berkeley, CA, USA; bSchool of Psychology, Deakin University, Geelong,
Burwood, Victoria, Australia

ABSTRACT
What do we know about burnout, and what can we do about it? This article will provide an overview of what has been
learned from current research on burnout, and what are the implications of the key themes that have emerged. One theme
involves the critical significance of the social environment in health care settings. A second theme is the challenge of how
to take what we know, and apply it to what we can do about burnout. What we need are new ideas about potential inter-
ventions, and clear evidence of their effectiveness. One example of this perspective addresses burnout by improving the bal-
ance of civil, respectful social encounters occurring during a workday. Research has demonstrated that not only can civility
be increased at work but that doing so leads to an enduring reduction in burnout among health care providers. Lessons
learned from this extensive research form the basis of recommendations for medical education. Specifically, the effectiveness
of both the academic content and supervised practice would be enhanced by giving a greater emphasis to the social
dynamics of healthcare teams. This perspective can help new physicians in avoiding potential pitfalls and recovering from
unavoidable strains.

Introduction
Burnout is a hot topic in today's workplace, given its high Practice points
costs for both employees and organizations. What causes  Know the Problem: Get educated about what
burnout is, and what to do about it.
this problem, and what can be done about it?
 Enhancing Team Perspective: Developing skills to
Conventional wisdom says that burnout is primarily a prob-
work well with others.
lem of individuals, but research argues otherwise. Burnout
 Build a Culture of Appreciation: Giving and receiv-
is not a problem of people but of the social environment
ing recognition.
in which they work. The structure and functioning of the
 Realistic Recovery: Strategies and support for
workplace shape how people interact with one another restoring energy.
and how they carry out their jobs. When that workplace
does not recognize the human side of work, and there are
major mismatches between the nature of the job and the
nature of people, then there will be a greater risk of callous, or excessively detached response to various aspects
burnout. of the job. It usually develops in response to the overload
of exhaustion, and is self-protective at first – an emotional
buffer of “detached concern.” If people are working too
Understanding burnout
hard and doing too much, they will begin to back off, to
Job burnout is a psychological syndrome that involves a cut down, to reduce what they are doing. But the risk is
prolonged response to chronic interpersonal stressors on that the detachment can result in the loss of idealism and
the job. The three key dimensions of this response are the dehumanization of others. Over time workers are not
overwhelming exhaustion, feelings of cynicism and detach- simply creating a buffer and cutting back on the quantity
ment from the job, and a sense of ineffectiveness and lack of work but are also developing a negative reaction to peo-
of accomplishment. ple and to the job. As cynicism develops, people shift from
The exhaustion dimension is the physical and emotional trying to do their very best to doing the bare minimum.
response of stress, and it is often the first sign that people The inefficacy dimension represents the self-evaluation
are having a problem with their job. People feel overex- component of burnout. It refers to feelings of incompe-
tended by work demands and depleted of emotional and tence and a lack of achievement and productivity in work.
physical resources. They feel drained and used up, without This lowered sense of self-efficacy is exacerbated by a lack
any source of replenishment and recovery. They lack of job resources, as well as by a lack of social support and
enough energy to face another day or another problem. of opportunities to develop professionally. This sense of
The cynicism dimension represents the interpersonal inefficacy may make burned-out workers feel that they
context component of burnout. It refers to a negative, have made a mistake in choosing their career path and

CONTACT Michael P. Leiter [email protected] School of Psychology, Deakin University, Geelong, 221 Burwood Highway, Burwood, Victoria
3125, Australia
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
 MEDICAL TEACHER 161

often makes them dislike the kind of person they think many job demands, and too few resources to address those
they have become. Thus, they come to have a negative demands (Bakker & Demerouti 2007). Such a poor align-
regard for themselves, as well as for others. When the third ment of organizational structures and processes with
dimension of inefficacy, and a diminished sense of accom- employees’ skills and aspirations can create tensions that
plishment, begins to occur, that can lead to a loss of confi- deplete energy, reduce involvement, and discourage
dence, and even depression. employees’ sense of efficacy.
Thus, the experience and etiology of burnout builds on Our own work has identified six areas of worklife (AW)
a foundation of exhaustion, which starts a landslide result- in which the degree of mismatch between the person and
ing in a personal career crisis. Cynicism takes the experi- the job is predictive of burnout, while better fit in these
ence of exhaustion to another level, and is compounded by areas is predictive of work engagement (Maslach & Leiter
inefficacy. Instead of healthcare work bringing the greatest 1997). Not only does this AW model point to the key sour-
satisfaction, fulfillment, and confirmation of one’s identity, ces of burnout or engagement, it can be translated into
work becomes a joyless burden to be minimized, avoided, strategies for improving matches between people and their
and escaped. work in these six areas.

 Workload. Contending with more demands than one

The costs of burnout can manage aggravates burnout, especially the exhaus-
Not surprisingly, the experience of burnout has been linked tion dimension of the syndrome. People with a deep
to a long list of negative outcomes – personal, social, and dedication to their work experience considerable frustra-
organizational. Within health care, these outcomes include tion when failing to complete tasks that they consider
such things as poor quality of patient care and more med- important. The propensity of work to spill over into their
ical errors. For example, when hospital staff are experienc- personal lives creates a distinct burden, partly because
that situation interrupts opportunities for recovering
ing higher levels of burnout, their patients are less satisfied
depleted energy.
with the care they are receiving, and are at a greater risk
 Control. The second area of worklife relates to participat-
for patient mortality. Burnout is also linked to dysfunctional
ing in decisions that affect one’s work. People vary in
relationships with colleagues, and with a stronger intention
the extent to which they aspire to exercising choice and
to leave the medical profession altogether. And like all
control at work. Some find comfort in others looking
experiences of stress, burnout can lead to poor physical
after the details, while some feel compelled to partici-
health, family problems, greater substance abuse, and a
pate actively in workplace decisions. Control allows peo-
higher risk of depression and suicidal ideation (Shanafelt
ple to exercise initiative in their work, giving them a
et al. 2012).
sense of agency and volition.
The urgency for addressing burnout arises not simply
 Reward. Recognition for one’s contributions at work
from the discomfort inherent in the syndrome, but from
defines the third area of worklife. Again, people vary,
all these other serious consequences in the workplace. It
with some content with the intrinsic rewards of their
is not simply that workers are having a “bad day” (and
work activities, and others especially concerned with
therefore it is their own personal problem). The prepon-
receiving confirmation from colleagues and leaders. The
derance of the research evidence indicates that burnout
extent to which the workplace aligns with the extent
does not arise as a personal failing. Rather, burnout devel-
and the type of recognition one seeks influences one’s
ops in response to problematic relationships between
vulnerability to burnout.
employees and their workplaces, and is therefore a social
 Community. The quality of relationships with others at
and organizational issue. “The fact that almost one in two work plays a central role. People vary in the extent to
US physicians has symptoms of burnout implies that the which they value close friendships or limited profes-
origins of this problem are rooted in the environment and sional associations at work. However, people do always
care delivery system, rather than in the personal charac- want positive social exchanges within whichever mode
teristics of a few susceptible individuals.” (Shanafelt et al. they prefer to encounter one another. It is often said
2012, p. 1381) that people do not quit a job, but they quit a boss.
Unfortunately, there is a general tendency to blame the They may also quit a team when relationships are
person, rather than the job, for burnout – and also to strained among colleagues.
assume that the person is the only one who can take care  Fairness. A sense of justice engages people with their
of it. This kind of “either-or” perspective prevents a more workplace while the experience of injustice exhausts
realistic “both-and” approach, which recognizes that both and discourages them, prompting them to distance
the person and the organization have a role to play themselves emotionally and physically from the work-
in improving the workplace and people’s performance place. In a way, unjust treatment excludes people from
within it. being considered full members of the workplace com-
munity. Physicians often feel alienated from workplaces
The job–person fit that they perceive as treating patients unjustly.
 Values. The alignment of personal and organizational
The most useful framework for this “both-and” approach is values characterizes the sixth area of worklife. The
one that identifies the key ways in which the person expe- nature of healthcare as value-driven work makes this
riences either a good or poor “fit” or “match” or “balance” area especially pertinent to all health care staff. Working
with the job conditions within which he or she works. For with a team with whom one shares core values ener-
example, a person may experience mismatches with too gizes people, while doing work that seems useless or
162 C. MASLACH AND M. P. LEITER

even damaging to patients generates both exhaustion interface, thus recognizing how both the person and the job
and cynicism. can contribute together to better strategies for preventing or
alleviating burnout. Second, it points to six different areas in
The AW model points toward management areas where which these new proposals can occur, thus widening the
professionals encounter frustrations contributing to burn- range of innovative approaches to the burnout problem.
out; it also thereby points toward ideas for intervention. We have explored the potential of the community area
Processes that improve the alignment of people with their as a target for interventions designed to alleviate and pre-
worksetting hold potential for positive change. A powerful vent burnout. This approach fits well with the AW model in
part of the framework arises from its diverse options, that it calls upon both individuals and their workgroups to
because any of the six areas – workload, control, reward, develop. The process goes beyond one side accommodat-
community, fairness, values – may provide the leverage for ing the demands of the other, to facilitating both groups
improvement. Surveying employees’ evaluations of the six and their individual members finding a better fit from all
areas provides valuable information for diagnosing both perspectives. Improving the social culture of a workgroup
the strains and strengths of a worksetting. This information has positive implications for other AW, in that an improved
indicates what needs development. A close familiarity with community advances members’ capacity to fulfill their val-
the worksetting indicates the practical options: where does ues, treat one another fairly, and to express appreciation
the worksetting have the resources and the flexibility that for one another’s contributions.
permit meaningful change?
Improving civility to alleviate burnout
Prevention and alleviation of burnout
The Veterans Health Administration of the USA developed
Addressing burnout includes both alleviating burnout when the CREW intervention (Civility, Respect, and Engagement
it arises and preventing it before it occurs. In the most at Work) as a method to improve the social climates of
severe situations, alleviation interventions focus on efforts workgroups (Osatuke et al. 2009). The efficacy of this pro-
to facilitate employees’ return to work after they have gone cess has been demonstrated in a controlled study of
on disability leave. Alleviation interventions may also occur Canadian hospitals (Leiter et al. 2011, 2012). Leiter (2016)
with individuals or workgroups experiencing levels of burn- has subsequently developed a more focused civility inter-
out that, although elevated, are not sufficiently severe to vention, CARAWay (Civility and Respect at Work). These
prevent them from working. Prevention strategies tend to approaches share an essential quality of addressing a work-
focus on employees who are generally in good shape, and setting issue (quality of social encounters among col-
to help them to not become at risk for burnout. These pre- leagues) through employees gaining insight into and
vention strategies can also be important elements of pro- expanding their repertoire of positive social behaviors.
fessional education. First, participants deepen their awareness of the quality
There has never been a shortage of ideas for what to do of their social behavior and its impact on others, not
about burnout, which has led to a large array of work- through passive listening but through active conversation
shops, self-help books and pamphlets, as well as thera- with their peers. The process enhances important dimen-
peutic and coaching programs. Many of these options have sions of their emotional intelligence. Second, the process
been adapted from other work done on stress, coping, and conveys that all workgroup members share responsibility
health. The most popular proposals have focused on for contributing to improving its culture. A workgroup level
changing work patterns (e.g. working less, taking more process locates the solution among the people who make
breaks, avoiding overtime work, balancing work with the up the workgroup, thereby empowering the workgroup
rest of one’s life); developing coping skills (e.g. cognitive and strengthening its culture. The approach assumes that a
restructuring, conflict resolution, time management); heartfelt allegiance to the concept of civility is not enough
obtaining social support (both from colleagues and family); to bring about meaningful change. Workgroups only
utilizing relaxation strategies; promoting good health and become enhanced through people interacting with one
fitness; and developing a better self-understanding (via another in new ways. Changes in social behavior inevitably
various self-analytic techniques, counseling, or therapy). bring discomfort along the way. The process notes that if
Most of these proposals have been person-oriented; in people feel perfectly comfortable in their social encounters,
other words, it is up to the individual person to follow that means that they are behaving as they usually behave.
these recommendations, and to do so on one’s personal The CREW intervention has demonstrated that not only
time and at one’s own personal expense. Furthermore, can the process improve workgroup civility, but improved
most of these person-oriented strategies are only focused civility alleviates burnout. Further, the change remained in
on helping the person to cope more effectively with a effect at a one-year follow-up. A close link of workplace
stressful job, and to become more resilient in the face of social dynamics with burnout (Leiter et al. 2011, 2012) is
such work challenges. not surprising, but designing a process to address burnout
In contrast, job-oriented proposals focus on the workplace through improved relationships required a full appreciation
and try to change the conditions that are actually causing of the importance of both individual and workplace dynam-
the stress. This kind of strategy is relatively rare, both in ics to effect lasting change.
terms of ideas and implementation, but can include such
things as redesigning job tasks, improving recognition of
Recommendations for medical education
notable work by both teams and individuals, and developing
more fair and equitable policies. It is here that the AW model Burnout in health care is clearly an important issue, and
can be especially useful. First, it focuses on the job–person needs to be addressed not only within the workplace, but
 MEDICAL TEACHER 163

in the educational process that prepares people for a individuals with their worksettings in terms of the key areas
health career. “For physicians, burnout is the inevitable con- of workload, control, reward, community, fairness, and val-
sequence of the way that medical education is organized ues. Identifying these important AW helps to focus action
and the subsequent maladaptive behaviors that are for prevention and alleviation. We provided an example of
reinforced in healthcare organizations via the hidden cur- improving workgroup civility as an intervention approach.
riculum. Thus, burnout is an important indicator of how This strategy has the benefit of being evidence-based, as
the organization itself is functioning.” (Montgomery 2014, its efficacy has been established in controlled intervention
p. 50) studies. In addition, community has spillover benefits for
other AW. But any of the six AW have a potential role to
play in preventing burnout. Accurate evaluation of workpla-
Know the problem
ces can identify areas that are both problematic and
Put burnout on the educational agenda – students need to important for the professionals involved. The second major
know about it, discuss it on a regular basis, work with consideration is identifying where change is possible.
others on how to deal with it (i.e. burnout needs to be a Effective action requires the active participation of both
legitimate, ongoing part of the educational curriculum). individual professionals and organizational leadership. The
primary message is that burnout is a manageable hazard at
work: burnout deserves concerted action and burnout
Enhancing teamwork perspective
responds to well-designed interventions.
Increasing prospective physicians’ teamwork skills helps in
two ways. First, these skills allow physicians to make full
use of a valuable resource that increases their capacity to Disclosure statement
meet the demands of practice. Second, the most stressful The authors report no conflicts of interest. The authors alone are
part of any leader’s day arises from conflicts and confronta- responsible for the content and writing of this article.
tions with people. These encounters flip the primary
resource into a primary demand. The capacity to lead team
Notes on contributors
initiatives in healthcare increase physicians’ capacity to
address demands as they arise. Christina Maslach, PhD, is a Professor of Psychology at the University
of California at Berkeley, USA. She is one of the pioneering researchers
on job burnout, and the author of the Maslach Burnout Inventory (MBI),
Build a culture of appreciation the most widely used research measure in the burnout field as well as
definitive books and research articles on the topic.
Receiving recognition for one’s contributions engages peo-
Michael P. Leiter, PhD, previously held the Canada Research Chair in
ple in their work. However, waiting around for others to
Occupational Health and Wellbeing at the Department of Psychology,
notice is a weak method for prompting recognition. A Acadia University. He is currently with the School of Psychology,
more fruitful strategy occurs through modeling a culture of Deakin University, Geelong, Australia. His current research addresses
appreciation through explicitly thanking colleagues for their the social environments of work units, especially the design of inter-
contribution. Ideally, mentors and instructors model appre- ventions to alleviate burnout through improving collegiality.
ciation during physicians’ education, establishing an For details visit: www.workengagement.com
ongoing habit.

Realistic recovery References

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