Caring for underserved populations is an inevitably challenging endeavor. While health-care providers throughout medicine struggle with issues of burnout and compassion fatigue, providers of underserved populations are confronted with a greater burden than most. The difficulties unique to this work are numerous: the work environment is often unfavorable, institutional barriers to providing quality care seem insurmountable, financial limitations are frequent, and colleagues can appear “burned out” or unhelpful. Worse, providers regularly find themselves witnessing the injustices, traumas, and tragedies suffered by their patients. A provider who remains sensitive to the human struggles of his or her patients will experience a steady stream of complex emotions that require attention. Self-care becomes essential.

A common misunderstanding of the notion of self-care is that self-care requires engaging less with work or distancing oneself from one’s patients. While adequate rest and time away from work are important, distancing, or “depersonalization,” is in fact one of the features of burnout and rarely leads to a happier, more satisfied health-care provider.¹ In trying to protect themselves from the pain associated with their difficult work, many providers unintentionally depersonalize their work to the extent that they no longer take pleasure in it or engage wholly in it. Besides being miserable for the provider, this shift has been shown to lead to increased errors and worse patient outcomes.² Particularly in a population that is already subject to marginalization, a provider who is disengaged and uninterested can be genuinely harmful.

The task, then, is to find a way to engage deeply in one’s work, to confront the struggles associated with it, and to continue to feel empathy for patients, all while remaining healthy and satisfied as a provider. In this chapter, we explore the features of burnout and what is known about its causes and cures. We will also explore a newer concept, compassion satisfaction, and discuss its impact on the provider and patient experience.

DEFINITION

Herbert Freudenberger³ first mentioned the term “burnout” in 1974. In his original conception, burnout was the last in a series of 12 stages that began with the “compulsion to prove oneself” and ended with “inner emptiness,” followed by “depression” and then “burnout syndrome.” In this conceptualization, burnout syndrome was described as a physical and emotional collapse, often involving suicidal ideation.³

Our understanding of burnout has evolved from this somewhat dramatic description, and we now understand it to encompass a spectrum of experiences, from mild burnout to severe burnout. Burnout is understood as a composite of three related psychological states: depersonalization/cynicism, emotional exhaustion, and a sense of inefficacy or helplessness. The Maslach Burnout Inventory is designed to measure these features and can allow employers or employees to monitor the effectiveness of interventions designed to limit or prevent burnout.¹

The term “burnout” implies that something that was once present has been burned away, and that the sufferer of burnout has lost his or her capacity for engagement, efficacy, and energy. This is not the case. Burnout is extraordinarily common among health-care providers, with estimates of prevalence ranging from 25% to 70% depending on the population studied.⁴ The majority of providers will experience burnout at some point in their careers, often multiple times, and most will recover. Burnout, for most providers, is a temporary state. For this reason, some researchers suggest that we find a different, more descriptive term that does not imply such a drastic, unsalvageable situation.

Compassion fatigue is one example of an alternative formulation that acknowledges its normal and temporary nature. Compassion fatigue is described as the gradual lessening of compassion over time. It is understood that repeated exposure to suffering will naturally lead to periods of compassion fatigue, but that this state is recoverable.

A third term, secondary traumatic stress, describes a similar experience in which providers are repeatedly stressed by their exposure to patient traumas. These repeated micro-traumas lead to a state of depersonalization and fatigue that is considered unfortunate but normal and temporary.

IMPACT ON PROVIDER

The impact of burnout, compassion fatigue, and secondary traumatic stress on the health care provider is obvious. Studies confirm increased rates of depression, anxiety, and suicidality among providers with high burnout scores on the Maslach Burnout Inventory.⁵ Nurses and physicians with burnout are more likely to consider leaving their jobs, and burnout contributes to increased turnover, sick days, and attrition from medicine.⁶ In addition, there is evidence of increased inflammatory markers and increased rates of cardiovascular disease among those who suffer burnout.⁷

The consequences of burnout spread beyond the provider. Studies show a significant increase in medical and surgical errors, higher postoperative recovery times for patients with burned out surgeons, increased rates of wound infection among patients with burned out nurses, increased self-report of suboptimal care by burned out providers, and consistently worse patient satisfaction when providers are experiencing burnout.⁸ From the perspective of a manager or system leader, there is no question that burnout leads to increased waste and worse patient outcomes.

RISK FACTORS AND PROTECTIVE FACTORS

An awareness of one’s own modifiable and unmodifiable risk factors for burnout can help a health-care provider manage these risks more actively. Known risk factors for burnout can be divided into work-related factors, demographic factors, life stress–related factors, and psychological or temperamental factors (see Table 45-1).

Workplace Factors

Both employers and employees can improve working conditions and prevent burnout by attending to a number of specific features that have been shown to correlate with burnout among health-care workers.

Control

Primary among work-related predictors of burnout is a sense of control at work.⁹ Health-care providers who work in underserved settings are particularly vulnerable to a sense of being overwhelmed, inefficient, or, worse yet, ineffective. They often have little control over the services and treatments that are available to their patients and, more importantly, over the social determinants of health that have an impact on their patients’ lives. Finding ways to maintain a sense of control at work is a powerful and important strategy for preventing burnout. A sense of increased control can derive from placing health-care workers in leadership positions, encouraging their participation in projects with a clearly defined purpose and concrete results, and allocating time for creative or administrative endeavors beyond the daily work of patient care. Management styles that allow employees a voice and the opportunity to make change in the workplace can support employees in cultivating a sense of control. Regular meetings in which employees have the opportunity to contribute to management decisions or retreats that allow for creative group thinking about work-related issues are another way to build a culture of self-efficacy.

Shared Mission and Meaning

The health of an organization is dependent upon coherent alignment with a shared mission.¹⁰ Providers who work with underserved populations are more likely to continue if they feel their work aligns with their personal mission.¹¹ Provider satisfaction is best in settings where organizational values and mission are clearly stated, frequently discussed, and evident in the work at all levels.¹² The simple but critical experience of being surrounded by colleagues who share values and commitment to a joint mission can be extraordinarily supportive and nourishing.

Systems of Care

Care-related administrative tasks might add hours of uncompensated time and suffocates contentment with meaningful work. Research on this phenomenon is minimal, but many health-care providers complain that increasing emphasis on business tactics and checkbox-driven care undermine a sense of meaning or mission, and can deflate a provider’s sense of competence and efficacy.

Providers note increasing frustration with electronic medical records that dictate the priorities of care and interfere with meaningful interaction with patients. Because the current generation of electronic medical records are not generally optimized for use by providers and patients but are instead optimized for collecting uniform data and billing information, they contribute to an overall sense that medicine is moving away from its origins as a profession rooted in compassion, and is moving toward a commercialized entity divorced from humanistic values. This need not be the case, as most providers remain essentially committed to these humanistic values. One hopes that the next generation of electronic medical records will facilitate the expression of these values by making care more efficient rather than stifling them by increasing the administrative burden on providers.

Administrative tasks such as advocating for insurance companies to provide necessary care or seeking specialists willing to accept underinsured patients can contribute to this loss of sense of efficacy and disconnection from meaning. Inasmuch as a sense of meaning keeps providers engaged and satisfied in their work, these tasks that appear less meaningful can be particularly draining and frustrating. Conversely, organizing systems of care to minimize and share less rewarding administrative duties and construct realistic productivity and time demands allows for true connections with patients and contributes to a sense of meaning and effectiveness. It is common in under-resourced environments for health-care providers to do the work of multiple employees. Physicians find themselves performing phlebotomy, taking vital signs, and calling in medication refills; nurses find themselves making appointments for patients and administering vaccines; and social workers find themselves performing very basic case management tasks. In all of these instances, health-care providers are not working at the tops of their licenses and are likely to become frustrated by the inefficiencies of their system. Workers are unlikely to meet their productivity goals and may work long hours in an attempt to keep up.

Team-based care, in which every person on the team works at the top of his or her level of training, can improve efficiency, distribute responsibility, and create opportunities for everyone on the team to feel valued. Furthermore, providers are most likely to flourish systems with fewer administrative barriers, such as coordinated care systems with clear and functional referral mechanisms, shared medical records, protocols for transfers of care, and rational payment systems that reward quality outcomes and allow innovative systems of care. Reimbursement for telephone or e-mail-based medicine and for nurse, medical assistant, and group visits can allow a care system to become more streamlined and utilize the skills of its team members to best effect.

Teaching and Leadership Roles

Research shows that health-care workers who have administrative or educational roles have lower rates of burnout than those who practice only clinical care.¹³ While still serving the primary function of patient care, institutions can offer all health-care workers the opportunity to work with students, teach colleagues or other learners, and participate in special projects. Working with learners often serves as a reminder of the core values that inspired one’s entry into the health-care professions and can reinvigorate workers who are struggling to stay connected to those values.

Compensation and Reward

An employee who perceives compensation to be inadequate or unfair is at elevated risk of burnout. Compensation can come in the form of pay or benefits. Often, nonprofit or government organizations have difficulty providing competitive pay for their employees. Expanded employee benefits such as flexible work schedules, generous vacation time, family leave, paid sabbaticals, reimbursement for conferences or continuing education, robust retirement plans, daycare, gym memberships or onsite exercise facilities, workplace wellness activities, employee assistance programs, healthy meals at work, employee-matched retirement plans, overtime compensation, and commuting cost reimbursement are other ways to help employees feel appreciated and well compensated.

In addition to formal compensation, a sense of being rewarded or acknowledged for one’s work is also fundamental to work-related well-being. Workers who feel undervalued and under-rewarded have higher rates of burnout. Employers who deliberately reward excellence through public or private acknowledgement, prizes, or even informal thanks can help employees feel recognized and valued.

Flexible Schedules

Another key predictor of burnout is work schedule flexibility. Health-care providers who desire part-time schedules show significantly lower rates of burnout if they have the option to work part time than those who are required to work full time. The same is true of providers who prefer to work full time: if they are able to work the schedule they prefer, they have less burnout than if they are forced to work part time.¹⁴ Part-time health-care providers have been shown to provide the same quality of care for patients in multiple studies and tend to have higher patient satisfaction scores, likely reflecting lower levels of burnout in this population.¹⁵ Offering flexible and accommodating work schedules is an effective way for organizations to prevent burnout among employees.

Teamwork

Health-care providers who experience a high level of “teamness” at work also tend to have lower rates of burnout. Factors that seem to contribute to this experience include working with the same people regularly (e.g., a nurse practitioner always paired with the same medical assistant in clinic); having clear role definitions for each team member; explicitly sharing responsibility for patients among all the team members; and regular two-way communication with every team member. The simple knowledge that there is someone you can trust to help you is reassuring on a difficult day.¹⁶

Supportive Culture

The ability to discuss difficult cases in a supportive environment is particularly important for people providing care to vulnerable populations. These health-care providers often witness extreme distress and unimaginable tragedies. While they will need to develop strategies outside of work to process the vicarious trauma accumulated at work, they also need support within the workplace. In some settings, regular case conferences can serve this function. In others, encouraging a culture of sharing stories and supporting one another through difficulty is more appropriate. It is particularly important to create an environment in which errors can be discussed thoughtfully and safely. A workplace in which emotions about patient care, fears about bad outcomes, and the joy of good outcomes are given time and attention protects its employees from burnout caused by the difficulties of patient care.¹⁷

Demographic Factors

Gender

Most studies on gender and burnout demonstrate no difference in rates of burnout between men and women. While women, on average, seem to have higher rates of empathy, which is protective against burnout, they also report feeling less valued by patients, colleagues, and superiors, and they report higher rates of conflict between their work and home life.¹⁸ Men report a greater sense of control at work than women, a protective factor against burnout, but also have higher rates of alexithymia (difficulty identifying their emotions), an independent risk factor for burnout.¹⁹ Altogether, rates of burnout appear similar in men and women, but burnout may take different forms and have different sources in the two groups. For this reason, workplace changes designed to address provider well-being should seek to address the varied needs of different employees.

Marital Status