Académique Documents
Professionnel Documents
Culture Documents
237-250, 1998
Copyright© 1998 Lippincott-Raven Publishers for SOM
Printed in Great Britain. All rights reserved
0962-7480/98
Key words: Burnout; health care workers; health professionals; stress; stress management.
employers to give more attention to services related was that undertaken by Northwestern National Life
to managing employee stress.4 As burnout is the end of Minneapolis.10 Telephone interviews were held with
point of stress in certain work settings, its nature, 600 American workers. It was the experience of the
development, and prevention should be clarified. respondents that they were highly stressed, had mani-
fested burnout, and had noted an increase in physical
ailments. It was the experience of the employers that
DEFINITIONS there was a decrease in productivity, a rise in absen-
teeism, higher health care costs because of stress, and
Attempts have been made to define the term that a greater personnel turnover. In the findings among
moved from rocketry to psychiatry. A contemporary 600 workers nation-wide, it was learned that one-third
dictionary views burnout as 'exhaustion of physical or thought seriously in 1990 about quitting work because
emotional strength or motivation usually as a result of of stress; one-third expected to burn out in the near
prolonged stress or frustration'.5 Some have written future; 14% quit employment or changed jobs in the
that staff burnout among professionals and parapro- past two years because of job stress; stress levels were
fessionals in the human services is much easier to extremely or very high for nearly one-half of the
observe and to describe than it is to define — 'it is interviewees and one-third reported job stress as the
many things and many people . . . '6 During the same greatest stress in their lives.10
period, a decade-and-a-half ago, strict defining of the Significant burnout occurred when employee
term was skirted — 'What do we mean by the term, benefits were cut; when corporate ownership changed;
are more often the object of complaints about the presumed by all sides to be the enemy. We have become
interpersonal care they provide, even by their patients targets of all who would criticize, victims of needing
who do not sue. to follow a course through a mine field of risks. We
Threats of suits lead to changes in practice, including constantly dodge assaults. We bleed from many wounds
more accurate records, a greater number of tests, a of constant skirmishes with insurance companies. We
negative attitude toward patients, and a defensive mode cower in the trenches, stirring to fight disease, but
of practice which tends to narrow the physician-patient struggling more to stay alive in the battle zone. How
relationship. can we be asked for compassion, sympathy, empa-
There is great pressure on physicians, particularly thy?'21
in light of today's pace in technologic developments, While physicians may still hold authority positions
to 'keep up'. This effort has to be balanced against in medical schools, in the wider society and within the
family life. non-medical school portion of the health sector, they
Further, there is genuine fatigue as a by-product of occupy a smaller proportion of positions of authority.22
a busy practice; most practitioners share 'on-call' duty Finally, the words of the recent president of the
— which means contact with patients whose progress American Medical Association, Dr Lonnie Bristow,
or treatment plan is unknown; work loads are heavy; echo the same refrain: 'Sure, physicians are frustrated,
there is a daily dealing with life and death situations; confused, even angry about the reform movement.
decisions concerning the maintenance of impaired One reason for their edgy mood is the implication by
living vs. 'do-not-resuscitate' orders are difficult to reformers that doctors are somehow dishonourable,
or, at the very least, profligate and wasteful. And they
Significant in the findings were the role of the dentist who are providing care to children with malignant
in society and the need to be useful in the community; disease. Even the most optimistic provider soon
primary in the prediction of stress was the quality of experiences burnout.
working life. The authors concluded that, 'The results
suggest [ed] that the communality of work charac-
teristics [led] to significant stress patterns among Health care providers and patients with AIDS
dentists which need to be considered in [the] future Possibly the most difficult professional challenge to
if dentistry is to maintain its prestige as a profession.'53 care givers is in those situations where patients with
Certain work hazards have been noted in dental AIDS, or those who are seropositive, are receiving
offices. Dental hygienists have experienced muscu- daily attention. Much has been written about sustained
loskeletal problems in general, and carpal tunnel care among these patients since the AIDS epidemic
syndrome in particular. Attention should be directed struck in the beginning of the 1980s. Maj59 reviewed
to work station design, posture, treating patients with the literature and found that there was a wide range
heavy calculus, and the scheduling of rest periods.54 of emotional reactions, ranging from rejection and
Numerous hazards were found in an OSHA survey of refusal to provide care, to immersion in the infected
a dental office wherein it was noted that there was a person's needs and burnout. There has been fear of
lack of compliance with the hazard communication contagion, avoidance of infected patients or distancing,
standard, OSHA's current requirements for preventing unprofessional removal of patients from lists of dentists
occupational exposure to the hepatitis B virus (HBV) or general practitioners, and identification to the point
and the human immune deficiency virus (HIV) ,55 Fur- of believing that they, the providers, believe themselves
The stress encountered among emergency service psychiatrists at a large public mental hospital showed
personnel has been documented. In one study, it was that most of the events rated as highly stressful fell
shown that job stress manifested itself as work dissat- into the category of administrative and organizational
isfaction, organizational stress, and negative patient shortcomings.70
attitudes. The absence of fatigue, sickness, and other Fully agreeing that nursing is a stressful occupation,
psychophysiologic markers of stress might mislead Sullivan71 studied the specialized area of nursing prac-
supervisors into believing paramedics are not stressed. tice that involves daily dealing with the psychological
In this population, stress was seen in what the indi- distress and suffering of the mentally disordered. He
vidual said about the organization, co-workers, and steers away from the profession's belief that stress is
patients.64 an individual problem, claiming that both the individ-
In an effort to understand the dynamics underlying ual and the organization must accept some
a high turnover rate, over 100 EMT union members responsibility regarding the control and management
were studied. The samples had high stress, strain, and of stress, chiding executives for their style of manage-
burnout scores, but normal coping skills. These various ment, he asks that the difficulties of nursing be
elements were related significantly to job satisfaction, recognized, the climate be geared to minimizing
worry about infectious diseases, and perceptions of individual stress, and individual performance be maxi-
being poorly treated by emergency room personnel mized. To be fully effective, he concludes, the providers
and firefighters. In addition these responses were of care must be valued.
related to being upset by 'runs' related to injuries from More recently, concern has been expressed regarding
violence, drug overdoses, and exposure.65 violence against the staff in psychiatric hospitals. In
on the job); (b) emotional-fatigue manifestations co-operation can be detected by a sensitive supervisor.
(procrastination, call in sick, think of other things While a manager is usually inclined to defend a staff
during conversations); (c) time and workload manage- person when attention is directed to a work error,
ment (little time for preparation and personal patients or clients should be heard to the fullest if a
priorities, over-commitment, excessive paperwork); complaint has been raised. Not all recipients of care
(d) instructional limitations (students poorly moti- are to be dismissed as unknowing of, or insensitive to,
vated, do not improve and present discipline problems; inadequate treatment or harried inattention. Every
inflexible scheduling); (e) biobehavioural manifesta- grievance must be given a hearing, for behind some
tions (respiratory, cardiac, and gastrointestinal of the dissatisfaction felt may be a worker in the process
problems; use of drugs and alcohol) and (f) lack of of undergoing emotional loss or behavioural flattening,
professional supports (lack of recognition, alienated and no longer able to provide effective care.
from school staff, misunderstood by public, lack of
consultation opportunities).
Prevention and treatment
Other professionals It is difficult to distinguish readily between measures
Burnout has been experienced by health care workers preventive of burnout and efforts taken to treat the
in other speciality areas. Nurses employed in relatively disorder. If preventive measures are in place, burnout
small nursing homes, where there is a high probability will not occur; if the behavioural disorder is already
of the residents' deaths, are under stress.77 Job stress in place, the same preventive moves may be used
are to be performed. The worth lies in there being directing the Residency Program in Occupational
teams rather than groups; the workplace team may not Medicine at a large university, the writer encouraged
be recognized formally, and its members may change the graduate students to enrol in on-campus Sensitivity
from week to week, but if the group is organized to Training, in addition to the technical master's degree
achieve a common goal, then it is a team84 and the requirements, so that personality aberrations could
team can reconfigure jobs, for its members are those undergo straightening and interactions with future
persons closest to, and most knowledgeable of the work employees and patients would be productive and burn-
practice components. The increased control of a job out would be averted. A difference in the lives of those
by its incumbent adds purpose to the conduct of the undertaking the additional experience was seen as the
job and new value is seen in what had previously been years progressed. In keeping with this sense of growth
a ritualistic execution of functions. is the role of managers in encouraging teaching,
Jobs can be redesigned, even in health care, so that writing, and research by staff members. Offers to teach
new duties may be assigned, functions may be rotated, should be made to institutions of higher learning and
and responsibilities increased or diminished, thus the preparation of articles for the appropriate profes-
freshening the daily set of tasks. sional literature should be fostered. While the
While recognition is accorded work teams, individu- appearance of a piece in a journal by a seasoned
als can receive approbation in a more subtle way and medical scribe may not be too personally exciting, it
be given the realization that their participation in the can be an unbelievable joy to a staff member who has
organization is of special meaning. Visitors to health never attempted such publication.
care facilities — who are members of the medical New members of a health service staff should be
skilled counselling can be obtained. Irrespective of the institutional goals and can begin work free of any
source of the referral, either the supervisor or the feelings of role ambiguity; the development of family
OHS, there must be an explanation for the recom- policies and certain leave procedures so that conflicts
mendation — impaired work performance, disinterest between home and work can be resolved; informal
in patients, repeated negative outcomes — and some staff and family events such as picnics, retreats, or
clarification of the counselling process, so that the potluck suppers; and, probably most important, the
affected employee will be prepared for the aid to be encouragement of some kind of activity between work
offered by the EAR A 'cold' referral without some and home, be it exercise, walking, swimming or other
introductory discussion may deepen the burnout, for sports participation. Many companies now have work-
the employee may feel that he or she is a true 'mental out facilities, gymnasia, or paths or roof-top tracks for
case', stigmatized and beyond rehabilitation. walking or jogging. There can be other activities, as
This mode of providing professional help is one determined by an individual's interest, such as music
method of managing stress, but if the emotional or even meditation. The alternative to work can be
flattening is extant among many workers, then a group anything else: the study of Sanskrit, a plan for perma-
nent peace in Bosnia, or the collection of old
may be formed for Stress Management sessions
buttonhooks — anything that demands an attention
conducted by an outside firm. One such group, known
other than that devoted to work requirements.
as the Balint group method,87 provides health profes-
sionals with a sympathetic and accepting forum in Conferences of the type indicated earlier ('Physician
which to present instances of the client-professional Heal Thyself) can be suggested activities of various
professional health care societies, or burnout content
out on the day or night shift? Health Care Sup 1993; 11: 47-52. dealing with people infected with human immunodeficiency
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