Psychiatric Annals

CME Article 

Organizational Approaches to Burnout

Gregory Couser, MD; Gaurava Agarwal, MD

Abstract

Burnout is a problem that takes its toll on health care practitioners and organizations, as well as the patients they serve. People and health care organizations both have a role to play in preventing burnout. However, increasing research suggests that burnout interventions targeted at the organizational level may be more effective than interventions targeted at individual well-being and resilience. Thus, the mental health practitioner who is well-versed in organizational consultation models of addressing burnout may be best positioned to assist leadership at these institutions. [Psychiatr Ann. 2019;49(11):476–481.]

Abstract

Burnout is a problem that takes its toll on health care practitioners and organizations, as well as the patients they serve. People and health care organizations both have a role to play in preventing burnout. However, increasing research suggests that burnout interventions targeted at the organizational level may be more effective than interventions targeted at individual well-being and resilience. Thus, the mental health practitioner who is well-versed in organizational consultation models of addressing burnout may be best positioned to assist leadership at these institutions. [Psychiatr Ann. 2019;49(11):476–481.]

In this article, we review the recent literature about physician burnout in health care organizations. Organizational models are discussed that can help diagnose the drivers of burnout and suggest interventions. We discuss the importance of engaging leadership early in a consultation. We review measurement of burnout and provide sample organizational interventions that have been used to address burnout in health care organizations. Effective organizational psychiatry consultation could be the ultimate solution to burnout.

Burnout Defined

Burnout is a syndrome of depersonalization (detached and not caring even to the point of viewing people as objects), emotional exhaustion, and low personal accomplishment that leads to decreased effectiveness at work.1 Although the syndrome is not officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition,2 it affects 28.1% of the general population and 39.8% of physicians (including a slightly lower percentage of psychiatrists).3 Organizations are feeling the downstream impact of burnout, which include medical errors, dissatisfied patients, malpractice suits, reduced clinical work hours, and staff turnover.4–6 These can be economically quantified with various calculators in terms of return on investment to help convince organizational leadership that it is the fiscally correct way to proceed.7 Thus, it is shown that improving wellness of health care providers not only is an admirable goal but also the financially responsible choice.

Christina Maslach, author of the decades-tried Maslach Burnout Inventory (MBI), has stated that “Burnout develops in response to problematic relationships between employees and their workplaces, and is therefore a social and organizational issue.”8 Mental health practitioners are the best trained medical professionals to understand interpersonal dynamics and tend to see burnout in people as a symptom of a greater public health problem of suboptimal organizational health. As psychiatrists understand the latest evidence about tackling burnout within an organization, they can potentially take on consulting roles as organizational psychiatrists.

Occupational Health Models

Three early occupational models described factors that influence the experience of occupational stress. These three models propose that organizations could potentially be successful in intervening by thoughtful design of jobs that include reasonable demands, appropriate resources to meet demands, some degree of autonomy on the job, built-in positive teams for good support, and work for which workers' efforts have meaning and tangible result.

First, the demand-control (-support) model suggests that people experience strain and subsequent ill effects when the demands of their job are high.9 On the other hand, increasing control over their job functions and social support from supervisors and colleagues can decrease job strain. Second, the Effort-Reward-Imbalance model suggests that high-effort, low-reward occupational conditions are considered to be particularly stressful.10 Finally, the Job Demands-Resources model proposes that burnout can occur from too many job demands leading to exhaustion, whereas resources (ie, aspects of the job that help employees reach work goals, reduce job demands, and/or stimulate personal growth and development) can help mitigate the negative impact of job demands leading to greater engagement at work.11

Organizational Models for Addressing Burnout

Although there are many organizational conceptual models for addressing burnout, four are presented here. Having a conceptual model in mind is crucial for the organizational psychiatrist to shape thinking and data when consulting for organizations. Conceptual models are useful in identifying the likely drivers of burnout and in creating a common language in conversations with leadership. Ultimately such conversations motivate leaders to create change within the organization and prioritize their interventions.

The National Academy of Medicine developed a comprehensive “Factors Affecting Clinician Well-Being and Resilience” conceptual model that reflects the factors affecting clinician well-being and resilience. The model focuses on patient well-being at the center, with the next layers being the clinician-patient relationship and clinician well-being. This is critical because it is important to address well-being to improve the care we can deliver to our patients, and any intervention that risks patient care is a nonstarter. Other individual factors (health care role, personal factors, and skills and abilities) and external factors (sociocultural, regulatory, business and payer environment, organizational, and learning/practice environment) affect the entire dynamic.12 The latest model is also available.13

Another model, developed by the Mayo Clinic, identified seven driver dimensions that influence whether an individual physician is more likely to be engaged or burned out. These driver dimensions include (1) efficiency and resources, (2) workload and job demands, (3) control and flexibility, (4) work-life integration, (5) social support and community at work, (6) organizational culture and values, and (7) meaning in work. There are individual, work unit, organization, and national factors that influence each driver. This highlights both that everyone has a role to play in addressing burnout and the potentially transformative effect of everyone working together on this problem. See Figure 1 for the complex array of solutions for burnout that are presented at all different levels.14

An illustration of drivers of burnout and engagement with examples of individual, work unit, organization, and national factors that influence each driver. Reprinted with permission of Elsevier from Shanafelt and Noseworthy.14

Figure 1.

An illustration of drivers of burnout and engagement with examples of individual, work unit, organization, and national factors that influence each driver. Reprinted with permission of Elsevier from Shanafelt and Noseworthy.14

A third model by the American Medical Association StepsForward Program lists nine steps to creating the organizational foundation for joy in medicine. The first six steps are to create a culture of wellness to (1) engage senior leadership; (2) track the business case for well-being; (3) resource a wellness infrastructure; (4) measure wellness and the predictors of burnout longitudinally; (5) strengthen local leadership; and (6) develop and evaluate interventions. The next two steps relate to efficiency of practice: (7) improve workflow efficiency and maximize the power of team-based care; and (8) reduce clerical burden and tame the electronic health record. The final step relates to personal resilience: (9) support the physical and psychosocial health of the workforce.15

A fourth model called Total Worker Health was developed by the National Institute for Occupational Safety and Health. Total Worker Health is defined as “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.”16 This program comprehensively evaluates issues relevant to advancing worker well-being, including control of hazards and exposures, organization of work, built environment supports, leadership, compensation and benefits, community supports, changing workforce demographics, policy issues, and new employment patterns. The full model16 gives specific examples to help reduce work-related stress (eg, policies for more worker flexibility, supervisor training, worker stress reduction interventions).

Engaging Leadership

Although there are many other potential frameworks for addressing burnout at the organizational level, an organizational psychiatry consultation is unsuccessful without fully engaging leadership. Leadership sets the tone that can either set the work group trend toward burnout or toward engagement. A study of more than 2,800 physicians at the Mayo Clinic found that each 1-point increase in composite leadership score (60-point scale of physician's immediate supervisor) was associated with a 3.3% decrease in the likelihood of burnout (P < .001) and a 9% increase in the likelihood of satisfaction (P < .001) of the physicians supervised.17 It logically follows that focusing on developing sound physician leaders could broadly and positively impact organizations. It is also important to note that this study defined leaders as direct work-unit supervisors. This highlights the various levels of leadership, and not just senior staff, that one can engage to make a meaningful difference.

Specific aspects of leadership could also be considered when working to improve organizational culture. A 2017 study18 found that across health care, industry, service, and public sectors, role conflict was the most important predictor of burnout. Surprisingly, cognitive demands were unrelated to burnout and correlated positively to work engagement. Intuitively leaders may use this information to recognize that team members must have clearly defined roles and appropriate cognitive challenges to keep them engaged.18 Additional work has demonstrated evidence suggesting that physicians who spend at least 20% of their professional effort focused on the dimension of work they find most meaningful are at dramatically lower risk for burnout.19 Leaders who understand this can serve another important role in helping individual physicians craft meaningful careers.

Good leaders are also mindful of team factors. A 2015 systemic review20 of organizational climate and mental health outcomes indicated that group relationships between coworkers are important in explaining the mental health of health care workers. The review showed evidence that aspects of leadership and supervision affect mental health outcomes.20

Measuring Progress

Before implementing an intervention, it makes sense first to measure baseline data for burnout, wellness, or another chosen target. There are many valid and reliable tools for this purpose. Pragmatic considerations to measurement have included finding the dimensions of well-being important to organizational stakeholders, keeping costs low, simplicity of interpretation, benchmarks with actionable measures, sensitivity to change, and broad applicability.21 Although a comprehensive discussion of measurement is beyond the scope of this article, The National Academy of Medicine22 gives many suggested tools.

A popular tool to consider for burnout is the MBI that has been used for decades to measure emotional exhaustion, depersonalization, and personal accomplishment.1 There are different versions of the MBI and there is usually an associated fee. There is a companion Areas of Worklife Survey (AWS) that considers employees' perceptions of fit with their work setting and explores the match between people and their work environment.23 For an organizational psychiatrist, a comprehensive assessment with both MBI and AWS (or similar comprehensive instruments) may allow one to provide targets for interventions to reduce the risk of burnout.

Additional measures that are freely available and more specific to physician burnout include the Mini-Z Burnout survey,24 the free Well-Being Index (7–9 items that are simple to analyze),25 and the Stanford Professional Fulfillment Index.26

Organizational Intervention Principles and Ideas for Consulting Psychiatrists

After choosing measurement tools, an organization can then implement an intervention. The three levels of change to reduce burnout risk can be focused on (1) modifying the organizational structure and work processes; (2) improving the fit between the organization and the individual physician, including professional development programs to facilitate better adaptation to the work environment; and (3) individual-level actions to reduce stress and poor health symptoms through effective coping and promoting healthy behaviors.27

An example of an organizational intervention to address the first two levels of change is how an organization deals with a major source of stress for physicians, such as administrative burden and the electronic medical record (EMR). A 2014 study showed that primary care physicians working in clinics with many EMR features and who had been experiencing time pressure for visits had more stress, burnout, dissatisfaction, and intent to leave when compared to physicians working in clinics with fewer EMR features under similar time pressures.28 Therefore, recent research has focused on recognizing the important part of the EMR in a physician's practice. A 2018 study of three-day advanced hands-on EMR trainings with 3,500 physicians indicated the trainings were well received, and most physicians reported time savings (4–5 minutes or more per hour), increased efficiency, fewer errors, and potential to help reduce physician burnout.29 Thoughtful scribe implementation may be another organizational solution to the EMR and administrative burden problem.

Additional interventions that address the second and third levels of change can leverage psychiatrists' knowledge that meaning in work is derived from people—not only patients, but also colleagues and teamwork. A National Academy of Medicine discussion article30 proposed that high-functioning teams have potential to increase clinician well-being. Principles of high-performing teams included shared goals, clear roles, mutual trust (eg, feeling safe enough to admit a mistake or make a suggestion without fear of embarrassment), effective communication, and measurable processes and outcomes.30 Psychiatrists can help develop these high-functioning teams that allow all team members to work at the top of their license and decrease the overall demands of care to a more manageable level and also returning joy to practice. Meanwhile, psychiatrists are quite familiar in helping people with effective coping, healthy behaviors, and finding meaning in each person's unique situation.

Conclusion

Burnout is a complex problem with symptoms felt by one person, but it has consequences that ripple throughout the organizations in which people work. Many organizational models have been developed that suggest solutions to move employees from burnout to engagement. Successful organizations have strong values and a compelling mission, leading to meaningful work and engagement of their employees. These organizations typically have strong leadership that creates the culture that leads to success.

Psychiatrists are well-versed at helping people develop coping skills and resilience, and we can make a difference on a larger scale by using our unique skill set to benefit organizations. Organizations are in and of themselves complex “patients.” It takes a thoughtful approach and experience to help “treat” organizations. Effective organizational psychiatry consultation starts with engaging leadership in a process that includes selecting an organizational model for intervention, choosing tools to take baseline data, developing a specific intervention, and then using the chosen tools to measure progress. Using our clinical skills to treat our organizational “patient” could be the ultimate solution to burnout.

References

  1. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clinic Proc. 2019;94(9):1681–1694. doi:10.1016/j.mayocp.2018.10.023 [CrossRef]
  4. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714–1721. https://doi.org/10.1016/S0140-6736(09)61424-0 PMID: doi:10.1016/S0140-6736(09)61424-0 [CrossRef]19914516
  5. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91(4):422–431. https://doi.org/10.1016/j.mayocp.2016.02.001 PMID: doi:10.1016/j.mayocp.2016.02.001 [CrossRef]27046522
  6. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. 2007;32(3):203–212. https://doi.org/10.1097/01.HMR.0000281626.28363.59 PMID: doi:10.1097/01.HMR.0000281626.28363.59 [CrossRef]17666991
  7. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826–1832. https://doi.org/10.1001/jamainternmed.2017.4340 PMID: doi:10.1001/jamainternmed.2017.4340 [CrossRef]28973070
  8. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160–163. https://doi.org/10.1080/0142159X.2016.1248918 PMID: doi:10.1080/0142159X.2016.1248918 [CrossRef]
  9. Johnson JV. Collective control: strategies for survival in the workplace. Int J Health Serv. 1989;19(3):469–480. https://doi.org/10.2190/H1D1-AB94-JM7X-DDM4 PMID: doi:10.2190/H1D1-AB94-JM7X-DDM4 [CrossRef]2753580
  10. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1(1):27:41. doi:10.1037/1076-8998.1.1.27 [CrossRef]9547031
  11. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499–512. https://doi.org/10.1037/0021-9010.86.3.499 PMID: doi:10.1037/0021-9010.86.3.499 [CrossRef]11419809
  12. Brigham T, Barden C, Legreid Dopp A, et al. A journey to construct an all encompassing conceptual model of factors affecting clinician well-being and resilience. https://nam.edu/journey-construct-encompassing-conceptual-model-factors-affecting-clinician-well-resilience/. Accessed October 2, 2019.
  13. National Academy of Medicine. Factors affecting clinician well-being and resilience–conceptual model. https://nam.edu/clinicianwellbeing/resources/factors-affecting-clinician-well-being-and-resilience-conceptual-model/. Accessed October 2, 2019.
  14. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129–146. https://doi.org/10.1016/j.mayocp.2016.10.004 PMID: doi:10.1016/j.mayocp.2016.10.004 [CrossRef]
  15. American Medical Association. StepsForward. Redesign your practice. Reignire your purpose. https://edhub.ama-assn.org/steps-forward. Accessed October 2, 2019.
  16. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health (NIOSH). Total worker health. https://www.cdc.gov/niosh/twh/totalhealth.html. Accessed October 2, 2019.
  17. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432–440. https://doi.org/10.1016/j.mayocp.2015.01.012 PMID: doi:10.1016/j.mayocp.2015.01.012 [CrossRef]25796117
  18. Van den Broeck A, Elst TV, Baillien E, et al. Job demands, job resources, burnout, work engagement, and their relationships: an analysis across sectors. J Occup Environ Med. 2017;59(4):369–376. https://doi.org/10.1097/JOM.0000000000000964 PMID: doi:10.1097/JOM.0000000000000964 [CrossRef]28157768
  19. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990–995. https://doi.org/10.1001/archinternmed.2009.70 PMID: doi:10.1001/archinternmed.2009.70 [CrossRef]19468093
  20. Bronkhorst B, Tummers L, Steijn B, Vijverberg D. Organizational climate and employee mental health outcomes: a systematic review of studies in health care organizations. Health Care Manage Rev. 2015;40(3):254–271. https://doi.org/10.1097/HMR.0000000000000026 PMID: doi:10.1097/HMR.0000000000000026 [CrossRef]
  21. Dyrbye LN, Meyers D, Ripp J, Dalal N, Bird SB, Sen S. A pragmatic approach for organizations to measure health care professional well-being. https://nam.edu/a-pragmatic-approach-for-organizations-to-measure-health-care-professional-well-being/. Accessed October 2, 2019.
  22. National Academy of Medicine. Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions. https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/#purpose. Accessed October 2, 2019.
  23. Leiter MP, Maslach C. Six areas of worklife: a model of the organizational context of burnout. J Health Hum Serv Adm. 1999;21(4):472–489. PMID:10621016
  24. Dolan ED, Mohr D, Lempa M, et al. Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med. 2015;30(5):582–587. https://doi.org/10.1007/s11606-014-3112-6 PMID: doi:10.1007/s11606-014-3112-6 [CrossRef]4395610
  25. Dyrbye LN, Satele D, Shanafelt T. Ability of a 9-item well-being index to identify distress and stratify quality of life in US workers. J Occup Environ Med. 2016;58(8):810–817. https://doi.org/10.1097/JOM.0000000000000798 PMID: doi:10.1097/JOM.0000000000000798 [CrossRef]27294444
  26. Trockel M, Bohman B, Lesure E, et al. A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians. Acad Psychiatry. 2018;42(1):11–24. https://doi.org/10.1007/s40596-017-0849-3 PMID: doi:10.1007/s40596-017-0849-3 [CrossRef]5794850
  27. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: a meta-analysis. Hum Resour Health. 2013;11:1–16. https://doi.org/10.1186/1478-4491-11-48 PMID: doi:10.1186/1478-4491-11-48 [CrossRef]
  28. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100–e106. https://doi.org/10.1136/amiajnl-2013-001875 PMID: doi:10.1136/amiajnl-2013-001875 [CrossRef]3957395
  29. Robinson KE, Kersey JA. Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Medicine (Baltimore). 2018;97:38:e12319. doi:10.1097/MD.0000000000012319 [CrossRef]
  30. Smith CD, Balatbat C, Corbridge S, et al. Implementing optimal team-based care to reduce clinician burnout. https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout. Accessed October 2, 2019.
Authors

Gregory Couser, MD, is the Medical Director, Employee Assistance Program, Mayo Clinic. Gaurava Agarwal, MD, is the Director of Physician Well-Being, Northwestern Medical Group; and an Assistant Professor, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine.

Address correspondence to Gregory Couser, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; email: Couser.Gregory@mayo.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20191002-01

Sign up to receive

Journal E-contents