Local and Regional Anesthesia

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Burnout in Healthcare Workers: Prevalence,

Impact and Preventative Strategies

Stefan De Hert

To cite this article: Stefan De Hert (2020) Burnout in Healthcare Workers: Prevalence,
Impact and Preventative Strategies, Local and Regional Anesthesia, , 171-183, DOI: 10.2147/
LRA.S240564

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© 2020 De Hert.

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Burnout in Healthcare Workers: Prevalence,

Impact and Preventative Strategies
This article was published in the following Dove Press journal:
Local and Regional Anesthesia

Stefan De Hert Abstract: Approximately, one in three physicians is experiencing burnout at any given time.
This may not only interfere with own wellbeing but also with the quality of delivered care.
Department of Anesthesiology and
Perioperative Medicine, Ghent University This narrative review discusses several aspects of the burnout syndrome: prevalence, symp­
Hospital, Ghent University, Ghent, toms, etiopathogenesis, diagnosis, impact, and strategies on how to deal with the problem.
Belgium
Keywords: burnout, healthcare worker, prevalence, impact, symptoms, prevention

Never overestimate the strength of the torchbearer’s arm, for even the strongest arms
grow weary.

AJ Darkholme, Rise of the Morningstar

Introduction
Burnout is a work-related stress syndrome resulting from chronic exposure to job
stress. The term was introduced in the early 1970s by psychoanalyst Freudenberger
and has subsequently been defined by Maslach et al as consisting of three qualita­
tive dimensions which are emotional exhaustion, cynicism and depersonalization,
reduced professional efficacy and personal accomplishment.1–4 Burnout can occur
in any kind of profession.5
Healthcare workers, and especially perioperative clinicians seem to be at parti­
cular risk for burnout.6,7 This may have significant negative personal (substance
abuse, broken relationships and even suicide),8,9 but also important professional
consequences such as lower patient satisfaction,10−12 impaired quality of care,13,14
even up to medical errors,15–18 potentially ending up in malpractice suits with
substantial costs for caregivers and hospitals.19
Therefore, alertness for the phenomenon with prompt recognition together with
the development of adequate coping personal and organisational strategies is
essential in dealing with this important problem in contemporary healthcare. The
last 10 years have witnessed an increasing interest in the topic with an exponential
growth in the number of papers published on the topic (Figure 1).

Correspondence: Stefan De Hert Prevalence

Department of Anesthesiology and Because of the absence of a generally accepted definition of the syndrome of
Perioperative Medicine, Ghent University
Hospital, Ghent University, Corneel burnout, its multifactorial origin and the vagueness and subjectivity of the diag­
Heymanslaan 10, Ghent B-9000, Belgium nostic criteria, it is difficult to get a clear and correct overview of the prevalence of
Tel +32 9 332 32 81
Email [email protected] burnout in a general population. Estimations report values up to 20% of the

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De Hert Dovepress

2500
2,145

2000
1,680

1,330 1500
1,171
985
1000

578

311 500

145
0 27
0
1970 1980 1990 2000 2010 2015 2016 2017 2018 2019
Figure 1 Overview of the number of PubMed hits for the search term “burnout” between 1970 and 2019.

working population but the number is strongly dependent care access such as family medicine, general internal med­
on the cut-off values to define severe burnout.20 icine, and emergency medicine seem to be at greatest risk.
Interestingly, the results of a Finnish study, looking at The 2020 Medscape National Physician Burnout and
the relation between the level of burnout and socio- Suicide Report reported a burnout rate of about 43%,24
demographic factors found only small differences between which remains quite similar to the 46% reported in 2015
the different population groups studied. There was and 39.8% in 2013. While most studies agree on the fact
a slightly higher incidence with increased age and some that there is no real gender effect in the incidence of
gender-specific features. For instance, in women burnout burnout,25,26 the data from the Medscape National
was related to education and socio-economic status while Physician Report indicate that women physicians reported
for men, a relation to marital status was observed.21 more commonly symptoms of burnout (in 2015, 51%
The reported incidence of burnout varies worldwide. female vs 43% male and in 2020, 48% female vs 37%
For instance, in Europe, a difference is observed between male).24 Interestingly, there seem to be gender differences
the European Union countries (10%) and the non- in the presence of the different symptoms: exhaustion,
European Union countries (17%). Within the European depersonalization, and lack of efficacy. A study in general
Union countries, the incidence of burnout ranges from practitioners showed that exhaustion and fatigue occur
4.3% in Finland to 20.6% in Slovenia and within the non- equally in both sexes. On the other hand, the feeling of
lack of efficacy seems more common in women. It seems
European Union countries from 13% in Albania to 25% in
that male physicians are less likely to doubt the quality of
Turkey.22 This study also indicated that burnout at the
their work than women.26
country level seemed positively related to the workload.
It is difficult to have an exact estimation of the inci­
dence of burnout in physicians. A recent systematic review
Burnout in Physicians including 182 studies published between 1991 and 2018
Burnout has been shown to occur in all kinds of jobs. and involving 109,628 individuals in 45 countries
However, the incidence seems to be higher in physicians. observed a substantial variability in prevalence estimates
In a study comparing incidences of burnout between US of burnout among physicians, ranging from 0% to 80.5%.
physicians and a population control sample, Shanafelt et al This appeared to be related to important differences in
observed an incidence of symptoms of burnout of 37.9% definitions of the syndrome and of the assessment methods
in physicians compared to 27.8% in the control population applied. There were no relevant associations between
(p < 0.001).23 Physicians in specialties at the front line of burnout and demographic factors.27

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Burnout in Anesthesiologists Symptoms

The 2020 Medscape National Physician Burnout and Burnout has been defined as a syndrome of emotional
Suicide Report ranked the incidence of burnout on 29 exhaustion, depersonalization, and a sense of low personal
medical specialities. The top three medical specialisms accomplishment that leads to decreased effectiveness at
for burnout are urology (54%), neurology (50%), and work.29 Burnout seems to occur mainly in professions
nephrology (49%). The lowest incidence of burnout is involving an interaction with people, such as physicians,
reported in general surgery (35%), psychiatry (35%), and nurses, social workers, and teachers but meanwhile, the
orthopedics (34%). Anesthesiology comes on the 16th syndrome has been described in other professions.30
place with 41%, emergency medicine on place 14 with The symptomatology of burnout appears to be rather
43%, and critical care on place 10 with a reported inci­ complex as the syndrome seems to develop in several con­
dence of burnout of 44%.24 secutive stages. Initially, Freudenberger described its devel­
During the last decade, several studies have been pub­ opment in a 12-stage model31 (Figure 2). Later on, this model
lished specifically looking at burnout in the anesthesiology has been simplified, and currently, a 5-stage model is most
community. A recent systematic review identified a total frequently used (Figure 3). This 5-stage model starts with the
of 167 papers on the topic, from which finally 17 were honeymoon phase and is characterized by enthusiasm.
included to assess the prevalence and initiating factors for However, inevitably, after time this becomes associated
burnout.28 From this study, it appeared that the occurrence with experiencing the stresses of the job. If at this stage, no
of burnout varied substantially among the different reports, positive coping strategies are implemented, the process of
ranging from 10% to 59%. It seems to occur in all career burnout risks to become initiated. This is followed by a stage
stages and is related to a stressful work situation. No of stagnation characterized by the onset of stress. This second
specific relationship was observed between burnout and stage begins with an awareness of some days being more
gender, or marital status. However, the authors underscore difficult than others. Life becomes limited to work and taking
that the small number of studies included together with the care of business, while family, social life and personal prio­
large differences in their methodology and reporting rities are neglected and suffer and common stress symptoms
approach make reliable conclusions difficult and warrant appear, which affect the person emotionally, but also physi­
further research.28 cally. Then a stage of chronic stress develops which leads to

BURNOUT compulsion
SYNDROME to
prove
depression working
harder

neglecting
emptiness
own needs

depersonalisation displacement
of conflicts

behavioral revision
changes of values
denial of
emerging
withdrawal
problems

Figure 2 12-stage model for the development of burnout as described by Freudenberger.31

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STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5

HONEYMOON ONSET of STRESS CHRONIC STRESS BURNOUT HABITUAL BURNOUT

enthusiasm stagnation frustration apathy intervention

PHYSICAL EXHAUSTION

MENTAL and EMOTIONAL EXHAUSTION

Figure 3 Simplified 5-stage model for the development of burnout which is most frequently used.

frustration. Individuals get the feeling of failure and a sense control model focuses on the job task profile (job demand
of powerlessness. Efforts do not visibly pay off and the vs control),32 the effort-reward imbalance model focuses
impression or fact of not receiving enough acknowledgement on the work contract (effort vs reward),33 and the organi­
leads to one feeling incompetent and inadequate. This then zational injustice model focuses on organizational justice
leads to the stage of apathy, where despair and disillusion­ (unfair procedures and their interactions).34
ment occur. People do not see a way out of the situation and
become resigned and indifferent. The final stage is habitual Job Demand-Control Model
burnout. Symptoms of burnout cause a significant physical or The job demand-control model was introduced by Karasek
emotional problem and ultimately these may prompt one to in 1979 and focuses on the balance between the magnitude
look for help and intervention. of the demands (height of strain) and the level of control
The list of symptoms is long and most of them are not (decision latitude) in a person’s work situation.32 The
very specific (Figure 4). Symptoms are related to the height of strain represents the requirements that are set at
different stages of the syndrome and have been divided work which may cause for stress. This includes all aspects
into different clusters.30 These include warning symptoms of the workload of a particular job such as work rate,
in the early phase (increased commitment to goals and availability, time pressure, travel time, difficulty of the
exhaustion), followed by a phase of reduced commitment tasks, etc. The decision latitude refers to the possibilities
(towards patients and clients, towards others in general, and freedom of an employee to organise and manage the
towards work, towards increased demands), emotional workload. Based on these concepts a diagram has been
reactions and blaming (depression, aggression), finally proposed representing four different job situations, where
leading to reduction in cognitive performance, motivation, both the stress imposed by the work situation and the
creativity, and judgement, flattening of emotional, social, personal attitude and engagement of the employee are
and intellectual life, psychosomatic reactions and despair. incorporated. These are the low- and high strain jobs and
the passive and active jobs (Figure 6).
Etiopathogenesis The low strain job rectangle represents the combination
The etiopathogenesis of burnout is multifactorial. of a job without important demanding tasks but with where
Different etiological factors are summarized in Figure 5. the employee has some job decision latitude for instance
These factors have been taken into account in the devel­ some freedom to decide on own schedules and targets. This
opment of the different psychological explanatory models section represents a majority of the routine jobs. Persons in
for the etiopathogenesis of burnout. The job demand- this category may progressively get bored in their work

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Figure 4 Symptoms in the different stages of burnout.

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Figure 5 External (environmental) and internal (personality-related) etiological factors for burnout.

situation. A high strain job, on the contrary, refers to very Passive jobs are simple jobs but with very little
demanding and/or complex jobs with little control about decision latitude, typically repetitive production jobs.
working conditions and targets by the employee. As Such jobs present very little stress but also no substan­
a consequence, the risk of stress is very high. tial challenge to the employees. Active jobs, on the

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motivation to
develop new
high behavioral patterns

LOW STRAIN ACTIVE

job JOBS JOBS
decision
latitude

PASSIVE HIGH STRAIN

JOBS JOBS
risk for
psychological and
low physical stress

low job demands high

Figure 6 The job demand-control model, introduced by Karasek in 1979 focuses on the balance between the magnitude of the demands (height of strain) and the level of
control (decision latitude) in a person’s work situation.32

other end, represent highly demanding jobs but where In fact this model focuses on the balance between the
the employees have a high level of decision requirements of a job and the level of control the employee
latitude. has in his/her professional situation.

Figure 7 The effort-reward imbalance model, proposed by Siegrist in 1996 defines threatening job conditions as a mismatch between high demand (high workload) and low
control over long-term rewards.35

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Effort-Reward Imbalance Model (MBI).29 Others include the Tedium Measure (later
Another theoretical explanatory model for the etiopatho­ renamed the Burnout Measure),49 the Shirom Melamed
genesis for burnout is the effort-reward imbalance model. Burnout Questionnaire (SMBQ), the Oldenburg Burnout
It was proposed by Siegrist in 1996 and defines threaten­ Inventory (OLBI), the Copenhagen Burnout Inventory
ing job conditions as a mismatch between high demand (CBI), and the School Burnout Inventory (SBI).30,48 These
(high workload) and low control over long-term rewards.35 different questionnaires are adapted for the specific popula­
An additional point in the model is the concept of over­ tion studied, in terms of language and culture and of specific
commitment to the job, which may negatively impact the occupations. They all share a similar approach of looking at
balance between effort and reward (Figure 7). burnout as a multi-dimensional construct consisting of the
main three components, emotional exhaustion, depersona­
lization, and reduced personal accomplishment (or dissatis­
Organizational Injustice Model
faction with personal accomplishment). The problem is that
A third model is the organizational injustice model. In
all value for the diagnosis of burnout, and when such a value
1987 Greenberg introduced the concept of organizational
is used, it is determined arbitrarily. In addition, while the
justice. This refers to how an employee judges the beha­
dimension emotional exhaustion appears to be a constant
vior of the organization.36,37 There are four components of
feature of burnout, this seems to be less the case for the
organizational justice: distributive, procedural, interperso­
dimensions depersonalization and personal accomplish­
nal, and informational justice. Several models have been
ment, which appear heterogeneous, thereby reducing the
proposed to explain the structure of organizational justice
significance of the latter two dimensions.30,48
perception including a two factor, a three factor, and a four
Following its publication in 1981,4 several new adapted
factor model. It is beyond the scope of this review to
versions of the MBI were progressively developed to fit
discuss these. The interested reader is referred to specific
different groups and different settings.29 There are currently
articles on the topic.37–41
five versions: Human Services Survey (MBI-HSS), Human
Services Survey for Medical Personnel (MBI-HSS (MP)),
Other Proposed Models Educators Survey (MBI-ES), General Survey (MBI-GS),
Additional proposed models include the person- and General Survey for Students (MBI-GS (S)). The ques­
environment fit model, the job characteristics model, the tionnaires look at the different dimensions of burnout. The
diathesis stress model, and the job demands resource 9-item emotional exhaustion (EE) scale measures feelings
model.42–45 The multitude of explanatory models proposed of emotional overextension and exhaustion. The scale is
indicates the complexity of the syndrome of burnout and used in the MBI-HSS, MBI-HSS (MP), and MBI-ES ver­
no single model is capable of incorporating all the aspects sions. The MBI-GS and MBI-GS (S) use a shorter 5-item
of its etiopathogenesis. As a consequence, the different version. The 5-item depersonalization scale assesses the
potential causative factors need to be explored when deal­ degree of impersonal response towards the recipients of
ing with an individual case of burnout (Figure 5). An one’s care, treatment or service. This scale is used in the
integration model of personality-related and environment- MBI-HSS, MBI-HSS (MP) and the MBI-ES versions. An
related etiological factors has been proposed by Fisher46 8-item personal accomplishment scale measures feelings of
and has been considered plausible and practicable.30 In competence and achievement in one’s work and is used in
this model, the precondition for the development of burn­ the MBI-HSS, MBI-HSS (MP), and MBI-ES versions. The
out is a complementary interplay of factors in the employ­ MBI-GS and MBI-GS (S) additionally score cynicism
ee’s personality and environmental triggering factors.47 (indifference towards one’s work) on a 5-item scale and
professional efficacy (feelings of competence and achieve­
Diagnosis ment) on a 6-item scale. All items are scored on a 7-level
A health technology assessment report from 2010 commis­ frequency scale: never (0), a few times a year or less (1),
sioned by the German Institute for Medical Documentation once a month or less (2), a few times a month (3), once
and Information concluded that to date there is no standar­ a week (4), a few times a week (5), and every day (6).
dized and generally valid procedure to diagnose the burnout Currently, none of the assessment tools for burnout
syndrome.48 A number of screening tools are now available. provides instruments for differential diagnosis. In particu­
The most frequently used is the Maslach Burnout Inventory lar, the association between burnout and the chronic

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fatigue syndrome and burnout and depression is relevant, minor and slight, measures such as changing life habits
as all entities share quite some common symptoms and and optimizing work–life balance are recommended.
burnout is a risk factor for the development of These measures concentrate on three important pillars:
depression.48 relief from stressors, recuperation via relaxation and
Burnout seems to be associated with musculoskeletal sport, and “return to reality” in terms of abandoning the
diseases among women and with cardiovascular diseases ideas of perfection.30
among men. These associations are not explained by socio­ Various wellness strategies can be applied by physi­
demographic factors, health behavior, or depression.49 cians in order to cope with the symptoms of
Other studies have suggested that chronic burnout might burnout.6,15,67,68 A first strategy focuses on relationships.
be a risk factor for the onset of type 2 diabetes,50 and It refers to an understanding of the importance of spending
hyperlipidemia.51 The underlying neurobiological mechan­ quality time with family, friends and significant others.
isms for the physical effects of burnout are still unknown. This strategy also includes actively developing connec­
Several studies have investigated the association between tions with colleagues, to share and reflect with them on
burnout and functioning of the hypothalamic-pituitary- emotional and existential aspects of being a physician.
adrenal axis, but the results are not consistent and the A second element that seems to promote well-being in
clinical implications of these findings remain to be some people is religious belief and/or spiritual practice.
established.52 Currently, there is no hard evidence for the This refers to a personal attentiveness to nurturing own
clinical usefulness of any specific biomarker for burnout.53 spiritual aspects.68,69 It has been reported that up to 34%
of persons mentioned this aspect to be important and even
Impact essential.15,68 A third element deals with work attitudes.
Consequences of burnout are decreased job satisfaction,54 This has two components. The first one refers to finding
absenteeism,55 turnover in personnel,54,56 and cynicism.15,57 meaning and fulfillment in work, the second one to
These effects at work frequently have repercussions on per­ actively choosing and limiting the type of medical practice
sonal life such as feeling unhappy, anxiety, depression, iso­ such as working part-time, being involved in education
lation, substance abuse, frictional and broken relationships and/or research, managing schedule and discontinuing
and divorce.58–66 Burnout in physicians may have more unfulfilling aspects of practice. A fourth strategy consists
serious professional implications than in other professions. of self-care practices, in which an individual actively
Indeed, physician burnout has been linked to suboptimal cultivates personal interests and self-awareness in addition
patient care [8] resulting in lower patient satisfaction,8−12 to professional and family responsibilities. This also
impaired quality of care.13,14 This may eventually lead up implies actively seeking professional help in case of per­
to medical errors,15–18 with potential malpractice suits and sonal physical and psychological problems or illness.
subsequent litigation, with substantial costs for caregivers Examples of such practices are, among others, exercise,
and hospitals as a consequence.19 self-expression activities, adequate nutrition and sleep,
regular medical care, professional counseling, etc.
How to Deal with Burnout? Finally, the fifth component is adapting a specific life
The complexity of the interaction between all the pre­ philosophy. This is developing a philosophical approach
viously discussed external and internal factors in the to life that is based on a positive outlook where one
development of burnout underscores the importance of identifies own values and acts accordingly with emphasis
a multifactorial approach in the prevention and the treat­ on the balance between personal and professional life. It is
ment of the syndrome. This means that both the work likely that such strategies are also the designated tools to
environment and the person’s own personality and attitude be implemented in the prevention of the development to
towards the work situation need to be addressed. This burnout.
implies not only the implementation of measures at the Although each individual is in the end responsible for
level of the professional employers and work environment his/her own wellness, organizational and institutional
but also developing and implementing individual coping awareness, attention to and recognition of the problem can
strategies. play a crucial role in promoting physicians’ well-being.6,70
Approaches to treating burnout syndrome should be Job characteristics and institutional factors that contribute
guided by the severity of the symptoms. If these are to wellbeing include promoting autonomy,71–82 providing

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adequate office resources and support staff,83,84 and facil­ being may depend on different variables and therefore
itating a collegial work environment.75,77 Giving physicians studies specifically focusing on different subpopulations
the ability to influence their work environment, to partici­ are needed.72,73,75,78,87–90 Staff working in critical care
pate in organizational decisions that affect medical practice, settings may be particularly affected.91 This situation
and to have more control over their time schedules seem to may aggravate when the flow of critically ill patients starts
have a substantial positive effect regardless of practice to exceed available capacities, as is for instance the case
type.71–81 Efforts to minimize work-home interference by with the recent COVID-19 pandemic.92
providing flexible scheduling, childcare adapted to irregular Also the efficacy of therapies for the treatment of
work hours, etc., are also important for increasing the burnout syndrome is insufficiently investigated. There is
employees’ well-being.59,81,84 evidence from meta-analyses that organisational issues
If the symptoms of burnout are severe, psychothera­ need to be addressed as well as individual ones,93,94 but
peutic interventions are recommended. There may also be the exact most effective strategies to apply in each indivi­
a place for antidepressants, preferably combined with dual remain to be established. Further studies are needed
psychotherapy.30 There are several therapies for the treat­ to evaluate the efficacy of the different therapeutic options.
ment of burnout but all with unclear evidence. In 2012,
a health technology assessment analyzed the usage and
Disclosure
efficacy of different burnout therapies.85 In this systematic
The author reports no conflicts of interest in this work.
review, 17 papers were included. Thirteen of them (partly
in combination with other techniques) deal with the effi­
cacy of psychotherapy and psychosocial interventions for References
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