Nearly ubiquitously, the factors related to Healthcare Practitioner burnout were: high workloads, shift work, excessive work hours, schedule inflexibility, time pressures, communication overload and interruptions, value incongruence, low control over the job, low safety levels, negative and uncivil and toxic professional relationships and work / social environments, and poor leadership and unsupportive management.145679101520 (also see 3). Any relations / effects from personal or demographic factors were mixed and slight to none.28

Flynn et al.12 found that younger nurses were more prone to burnout, specifically due to not having developed resilience or sufficient situational coping skills. They suggested the counter-intuitive findings merited further investigation.14. Basu et al.5 observed that workplace stressors were primarily responsible for burnout that resulted in a high “intention to leave”; and noted that with high attrition the workplace situation only got worse for those remaining.(also see 7). Koontalay et al. 19 also found regarding the advent of the COVID-19 pandemic that inadequate preparedness and psychological distress (i.e., fear, anxiety, frustration, and stigma) increased substantially as a response to the pandemic, feelings of unpredictability, lack of resources and infrastructure, a perceived unsafe workplace, and lack of competent leadership or leadership’s support, and resulted in high levels of burnout in Healthcare Practitioners. They also noted frontline Healthcare Practitioners, which naturally would include a higher proportion of nurses, suffered more from the precipitants of burnout.10121320

Sabitova, Hickling, Priebe3 found that working conditions—particularly hospital constraints, poor infrastructure, deficient equipment, lack of supplies and medications, especially in the Third World—were sources for poor morale (aka burnout). Additionally, poor financial and non-financial rewards (e.g., career development, advancement, teaching / learning), job security, and excessive workloads also were contributing factors to low morale and a potential for burnout.(also see 4) Elliott et al. 4 found that shift work across an array of health professions was related to poor sleep, exhaustion, and emotional exhaustion—precipitants for burnout.20

Bronkhorst et al.1 noted that a “good organizational climate” was significantly related to positive outcomes such as low psychological distress and burnout; logically, the opposite was the case. Specifically, they found that collegiality between Healthcare Practitioners, mutual co-worker support, and constant civil communications were the hallmarks of good organizational culture with less risk for distress and burnout.3 Flynn et al. 12(also see 4) observed that increased demands of acute care settings, such as in Emergency Departments or the Intensive Care Units, especially excessive communications and interruptions, severely worsened psychological distress and burnout.

Finally, Li et al.8 detected no difference in burnout levels according to Healthcare Practitioner demographics, experience, geography, and specialties, except in the case where there were slightly lower rates in advanced Health Practitioners and single Health Practitioners.2.

Healthcare Practitioner Burnout (e.g., “low morale”, “occupational weariness”) has been depicted as emotional exhaustion, depersonalization, and decreased worker accomplishment deriving from constant and chronic psychological distress.2 Burnout has been reported at epidemic proportions among Healthcare Practitioners in the U.S. and worldwide.12 Few demographic factors are significant; burnout’s source is rooted in work environment co-factors.2 Bronkhorst et al. 1 observed that is often accompanied by depressive symptoms and general psychological malaise / fugue. Li et al.8 characterized workplace burnout in the literature as evidence by emotional exhaustion, low sense of personal accomplishment, low self-esteem, cynicism, low professional efficacy, occupational stress, and poor sleep.4, also see 20

Di Ora et al.20 noted in the Health Practitioner literature the concept of burnout includes overlap between symptoms and outcomes. Work disengagement, intention to leave the job, job abandonment, early retirement, medical miscommunication, process errors and subsequent mishaps and accidents are sometimes considered surrogate measures of workplace burnout.20 They also found a high degree of Health Practitioner value incongruence with their jobs and incivility were signs of burnout. Worse, Elliott et al.4 found that burnout includes negative attitudes towards patient care and safety.

Undeniably, Health Practitioner burnout unchecked has detrimental medical care quality and safety implications for patients, co-workers, and the Health Practitioners themselves; but the nature and the extent of that relationship is sketchy and questionable.589122 According to Hall et al.9 higher Health Practitioner burnout significantly results in more medical errors. Research unequivocally has shown that Healthcare Practitioner burn-out related inattention increases the risk for medication errors, infection precaution non-observance, failure to recognize life threatening signs /symptoms and delayed reaction, missed patient falls, needle sticks, and other critical safety issues and risky harm scenarios, including mortality.24820 These burnout situations were not related to personal or demographic factors. 9 Hall et al.9 found a direct and consistent relationship between workload (i.e., substantial numbers of patients), burnout, poor quality of patient care, and a high number of medical mistakes, which were actually underreported due to the high workload.

Health Practitioner burnout by whatever means is significantly related to poor patient care and safety, though there may be more “near misses” than actual adverse events.9 Flynn et al. 12 found that Health Practitioner burn-out, when organization-wide, can contribute to an unsafer organizational climate creating a detachment from workload, incomplete safety procedures (especially infection control), and decreased patient engagement. Nevertheless, that link between burnout and safety is tenuous at best due to under-or-over-reporting: under reporting seemed the result of punitive measures for reporting; whereas, over-reporting seemed to be caused by rewarding or encouraging reporting.17 Ironically, Flynn et al. and Hall et al 812 observed that the very act of reporting errors also can exacerbate burnout in Healthcare Practitioners. These findings have led some to conclude there is no direct correlative link between Health Practitioner burn-out and safety.81217 The ambiguous nature and link of that supposed relationship warrants definitive prospective research.2812

Another interpretation of Jun et al.’s2 and Flynn et al.’s12 mixed findings regarding major surrogate safety measures of burnout, specifically, near misses and intention to leave / leaving, suggest that Healthcare Practitioners are opting out of work situations conducive to poor mental health and burnout in the interest of patient care and safety. That is, ironically, intention to leave, leaving the job, and job abandonment actually may be a tribute to Healthcare Practitioners’ professionalism—if they are suffering burnout and prone to safety breaches—they would rather leave than risk the health and well-being of their patients and colleagues. This is worthy of further investigation.

Along with the permanent psychological harm of burnout to Healthcare Practitioners, Whitcombe, Cooper, and Palmer 15 identified other physical hazards resulting from burnout. such as cross-infection, manual hand injuries, slip-trip-and-falls, soft-tissue back injuries, chemical-substance-medication exposure, solo work and violent or abusive patients (especially for mental health workers6), and the most prominent dangerous medical work-related injury, namely, non-attentive needle sticks.115 In sum, Healthcare Practitioner burnout adversely affects Health Practitioners, patients, health organizations, and society worsening safety, quality of care, and Health Practitioners’ commitment.2

Additionally, burnout was cited consistently as a cause for Health Practitioners intent to leave their jobs, leave, or abandon their jobs, and seek early retirement.27121520 This increases recruitment and training costs to health organizations, further increases workloads and risk of burnout for those remaining, and reduces morale and quality of patient care. Overall, the financial loss to the entire healthcare system is staggering.2

In a perfect world, ideally workloads would be lowered, organization / worker values forged congruently , consistent civility would be maintained in the workplace, flex schedules would prevail, shift work would be abolished, time pressures would be dissipated, work would be inherently interesting and rewarding, and Health Care Practitioners would be supported 100% by informed, stellar, altruistic leadership, while burnout levels would bottom out. Presumably, burnout-related safety hazards and harms would then just disappear. As improbable as that seems, research suggests that interventions that address , fix, or even just tweak one or more fundamental and “tangible” organizational aspects precipitating burnout, are very effective in decreasing burnout.5 However, they also may be unrealistic, impractical, and most likely unaffordable.35 For example, research shows that Health Practitioner psychological distress, a precursor to burnout, can be greatly reduced simply by improving civility and communication in the workplace or scheduling better or reducing workloads even a little.21

Most psychologistic interventions designed to help fight Health Practitioner burnout fall under the theoretical rubric of Cognitive Behavioral Therapy (CBT), which is designed to replace negative thought patterns and behaviors contributing to psychological distress and burnout, rather than change workplace conditions.8 The two most prominent components are Mindfulness and Resilience.

Mindfulness programs train Health Practitioners in groups over a period of time with the aim of increasing their ability to contemplatively pay attention and be “in the present moment” non-judgmentally to facilitate relaxation and calm the body and mind.10 Research has shown that these programs are effective in reducing Health Practitioners’ stress levels and improving their attention and concentration to minimize workplace safety mishaps.10

These programs aim to improve Health Practitioners’ equilibrium under stress by training them to keep a sense of control and continue to forge onward positively despite adversity and emotional distress.17 Early research reported that web-based resilience burnout prevention / intervention programs significantly improved resilience to psychological distress / burnout, improved well-being, work engagement, and improved overall emotions on par with didactic in-person ones; however, these claims have since been hedged substantially.161719 However, by reducing burnout psychologically, these programs may improve the safety of the health organization, while preserving the mental health and well-being of staff. also see, 18. Regarding the value of on-line resilience training in general, Henshall et al. 17 found its benefits to be convenience and accessibility, though the downside was that it failed to capture support in the workplace that seems crucial to warding-off burnout. This suggests that both online and in-person burnout programs have benefits depending on the target audience and situation; a multi-modality approach is probably optimal.

Regardless of theoretical underscoring of psychological interventions addressing burnout, what appears to work are interventions incorporating participative leadership, an organizational culture facilitating interdisciplinary teamwork with civility, and feedback that emphasizes the positive aspects of the work in a safe, supportive environment.16

An intervention that has shown great promise in terms of addressing burn-out and related safety mishaps is the eponymous implementation of a Culture of Safety.11 Though varied and complex, a major feature of it is advancing the quality of healthcare and reducing patient and worker harm through focusing and learning from events / incidents and translating that into best practices and policy involving staff support in the learning process.11 Research has shown that a functional culture can be replaced with a socially supportive one through teamwork aimed at improving safety and communication; this is psychologically beneficial to Healthcare Practitioners and crucial to reducing / eliminating psychological distress and burnout.111 Since health organizations managers are directly involved in promoting safety and caring for workers, worker perception and attitudes improves.11 In a Culture of Safety, frontline workers are also considered leaders too, thus, their feelings over control of their work improves, and their self-efficacy improves—reducing psychological stress and burnout, while improving job satisfaction.11

Overall, research has shown that implementing a Culture of Safety results in dramatic drops in Health Practitioner attrition and improvements in attitudes; there are improvements in working conditions, since communication and collaboration improves as Healthcare Practitioners are involved in planning of safety and even staffing, which have been sore points resulting in burnout.112468912 Studies have shown that when frontline Healthcare Practitioners felt management supported them and were concerned for their well-being, there was a reduction of psychological stress, low morale, and burnout, and quality of patient care increased—by-products of a Culture of Safety. 171112. Most importantly, a Culture of Safety strives for value congruence between the organization and the Healthcare Practitioner, ultimately reducing Healthcare Practitioner psychological stress and burnout.

Note: In the literature, there was mention of a burn-out reduction intervention for a hospital Emergency Department consisting of aromatherapy combined with massage sessions over a 12-week period that resulted in a slight reduction in short term anxiety levels. Also, the final verdict on Mentorship programs is that they do not affect workplace psychological distress and burnout.5

There was a discordance between the methodology of grounded iterative thematic enumeration of all variants and the aim of the study to produce a purer synthesis of already synthesized materials.242526 Nevertheless, the method ensured a comprehensive identification, organization, and solid descriptive accounting of what is currently known, and the state of the science and best practices regarding the study’s subject matter. Another inherent limitation of the grounded methodology is the possibility of some extreme obscure variant escaping detection or being overlooked.2526 Nevertheless, the final product represented a staggering number of original peer-reviewed research study reports and probably nearly exhausted variants. Although this study only included peer-reviewed articles, missing the “grey” literature reviews (e.g., in-house program evaluations or trade journal articles), there was a degree quality control assurance regarding findings in terms of scientific merit. Another methodological limitation was that, as the study was a descriptive / qualitative inventory and not quantitative, findings were given equal weight; so there could be no effect size comparisons.14. Future research should consider meta-analysis. Similarly, there was no formal estimate of the quality of research articles included. Nevertheless, 16 of the 21 studies (77%) specifically adhered to PRISMA guidelines ensuring literature review quality.

It would be expected that restricting the key words for search articles would exclude journals using synonyms or foreign journals using different words; but this did not appear to be the case, as there was diversity of different terms and different nations from which articles came. Though most articles did come from the Western world, they represented a variety of Western nations, and even a Third World comparison nation was included in one of the journal articles. Of course, there is the issue to limiting the reviewed articles’ language to either English or translated English. Future research should similarly explore non-English speaking literature reviews as a comparison. Furthermore, treating Health Practitioners in the aggregate created a lack of heterogeneity, making generalizability to sub-groups difficult, but not impossible. This is another area that could benefit from future research. However, recent research reports indicate that all Health Practitioner sub-groups are more or less similarly affected by burnout and are at risk for making medical mistakes, and could benefit from programmatic interventions. 145691118

Probably the most profound recommendation derived from this work is that, before a healthcare workplace plunges in a downward spiral and that devolves into an overwhelming morass of Health Practitioner burnout and related problems, leadership / management must act quickly and follow the scientific research based best practice blueprint contained in this research report and reach for that near “200 proof.”* Preventive intervention is generally less expensive than curative remediation.

Besides gaps in knowledge already identified in this review, other similar systematic literature reviews should be conducted on other high stress occupations where safety is a premium as a comparison to verify the universality of this study’s findings. For the same reason, cross-national literature review studies of literature reviews should be conducted too.

*Note: “Moonshiners” commonly refer to double-distilled near 200 proof spirits in common parlance as “White Lightening.” 27

Non-applicable, this was a commentary accompanied by a review of supporting open-source documents.

Yes.

Yes, publications and sources are available on-line or provided or by author upon request.

None declared.

The author gratefully acknowledges UT-MDACC for in-kind support.

Non-applicable, there is one sole Author.

Acknowledgements

The Author wishes to gratefully acknowledge in-kind support of the Department of Lymphoma and Myeloma, UT-MD Anderson Cancer Center, Houston, TX. in the preparation of this manuscript. Also, the author thanks Mr. Jasper Olsem for the concept and his encouragement in pursuing the subject matter. The author also expresses appreciation Ms. Aileen “Acey” Cho freelance-copy editor for proofing and copyediting drafts. The opinions expressed are solely those of the Author. Reprints and correspondence should be addressed to the author at rjjohnson@mdanderson.org or, UT-MDACC, Dept. of Lymphoma / Myeloma, Unit 429, 1515 Holcombe, Houston, Texas, 77030-400, U.S.A.. (832-372-3511)