Addressing Health Worker Burnout to Improve the Quality of Patient Care

Ian Batanda

Senior Orthopedic Officer and the palliative care focal person, Fort Portal Regional Referral Hospital

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Abstract

Burnout can contribute to poor health worker functioning, although its true impact on the quality of patient care is not well understood. The demanding nature of the healthcare environment necessitates health workers to make cognitive and behavioral efforts to cope with and ensure longevity in service. Thus, this review explored the available evidence on the mechanisms involved in addressing work stress and burnout in the healthcare workplace. Several individual coping mechanisms and institutional interventions have been identified. Further studies are needed to establish the effectiveness of documented interventions in reducing burnout and improving job performance and quality of care.

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Introduction

Burnout of varying levels is prevalent among health workers, and studies have shown that it contributes to poor health worker function and a lower quality of patient care. However, its actual impact on job performance and the quality of patient care is not fully understood^1,2.

Quality healthcare services involve providing safe, timely, equitable, and efficient patient-centered      care, with patient safety as the cornerstone^1,2. Embracing these broad aspects of care requires a physically and psychologically healthy workforce of motivated, self-driven medical professionals who can continuously implement, measure, and monitor the tasks involved. For example, timely patient-centered care involves responding to individual patient preferences, needs, and values while minimizing waiting times and harmful delays³. This involves impeccable patient assessment, effective, empathetic communication between patients and the medical team, prompt decision-making, and the implementation of appropriate interventions, which may include physically and emotionally demanding tasks and procedures for health workers.

Over time, and as the workload increases, all these components of care can become repetitive, tedious, and difficult to sustain when faced with other individual and systemic challenges, such as chronic staffing shortfalls, inefficiencies, interpersonal and moral conflicts, and institutional climates that limit career advancement^4–6. They can thus cause chronic work-related stress, especially in high-volume settings. In facilities that handle numerous patients with chronic or life-limiting illnesses that are emotionally draining, emotional exhaustion can arise⁷. If such stress is not addressed, the result is burnout of varying levels. In the healthcare work environment, the resulting depersonalization, as highlighted in the Maslach Burnout Inventory (MBI)⁸, may manifest as suboptimal practices such as incivility, not answering patients' questions, reduced compassion, discharging patients early, and not communicating important handoffs^6,9, which may compromise patient safety. These can result in poor patient outcomes, poor patient satisfaction, and poor job satisfaction for health workers.

Therefore, it is essential to develop mechanisms for identifying and measuring work-related stress among healthcare providers alongside job performance to inform support strategies and interventions that enable workers to cope with demanding repetitive tasks to ensure continuous and sustainable quality patient care.

Thus, this mini-review explored the impact of burnout on the quality of patient care and the available evidence on mechanisms for addressing work stress and burnout in the healthcare workplace.

Methods

A literature search was conducted on the PubMed database for free full-text systematic reviews published in the last 10 years using the search phrases (burnout) AND (quality patient care), (burnout) AND (health worker coping), and (burnout) AND (workplace interventions). Additional papers were obtained from the reference lists of the identified articles. Only original research articles, reviews and systematic reviews published in English that focused on health worker burnout were included. Papers that did not report the impact of burnout on the quality of patient care or the mechanisms for addressing healthcare work stress and burnout were excluded.

Results

Impact of health worker burnout on the quality of patient care

The evidence of the true impact of health worker burnout on patient care is contentious, with some studies reporting compelling associations between physician burnout and a reduction in the quality of patient care, whereas others downplay the overall impact.

A recent systematic review reported a significant association between burnout, increased medical errors and lower patient safety¹⁰. Similarly, another study reported that burnout was associated with a small but significant decrease in productivity and a doubled risk for patient safety incidents, particularly in physicians aged 20--30 years and those working in emergency medicine¹¹. The study also reported more than twofold decreases in professionalism, and this decrease was greatest among physicians in training or residency and lowest among those older than 50 years¹¹. These findings highlight the negative impact of health worker burnout on patient care, which is more likely to manifest when younger physicians are involved in stressful work environments, compared to their older more experienced colleagues. The increasing evidence of higher burnout scores among younger medical workers⁹ indicates that they experience more physical and emotional exhaustion and are more likely to experience depersonalization in the health worker–patient relationship. Thus, younger medical workers may require targeted work-stress management interventions as a patient safety improvement strategy.

In contrast, one systematic review concluded that the true effect size of health worker burnout may be smaller than reported¹². However, this review did not dispute the potential impact on the quality of patient care but highlighted the need for further longitudinal studies to understand the magnitude of the effect.

Mechanisms for addressing burnout in the healthcare workplace.

The multifactorial etiology of burnout necessitates multi pronged approaches to addressing chronic work stress. One approach is to identify individual coping mechanisms and institutional interventions that can be implemented in the workplace within available resources with minimal disruption to patient care. Various studies have outlined several coping mechanisms and interventions, which are summarized in Table 1.

Table 1: Documented health worker coping mechanisms and institutional interventions for addressing burnout (identified from various studies). Positive coping mechanisms are associated with less burnout. The effectiveness of these interventions in moderating work stress and improving job function hasn’t been extensively studied.

Individual health workers’ mechanisms of coping with burnout

Factors contributing to burnout, such as excessive workload, imbalances in workload due to staffing gaps, and absenteeism, are often beyond the individual worker’s ability to address. Additionally, in some low-income settings, healthcare professionals are compelled to work in dual, sometimes multiple, high-volume healthcare facilities to increase their earnings to manage the ever-increasing cost of living and other social demands^13,14. This means that they are chronically exposed to work stress, in addition to other social responsibilities, with little time for physical and psychological recovery.

Therefore, health workers are compelled to make cognitive and behavioral efforts to cope with the highly demanding and stressful nature of their work¹⁵, to enable longevity in service, and to minimize the harmful effects of work-related stress because coping strategies can influence staff well-being and job satisfaction¹⁶. In many settings, health workers must individually recognize their stressors and symptoms of burnout and look for coping strategies to enable them to continue their work responsibilities¹⁷.

Studies have identified various positive and negative strategies that health workers use to cope with work stress.

Positive mechanisms include utilizing others’ ways of dealing with similar problems, physical activity, physical self-care, passion for one’s work, setting boundaries, engaging in healthy hobbies, seeking social and emotional support from colleagues and friends and setting realistic work expectations^18–20.

The negative or avoidant coping mechanisms include emotional and physical distancing from work, procrastinating, relying on others, binge eating, social withdrawal, alcohol use and trying to forget about everything^18,20,21.

In a study on promoting resiliency among palliative care clinicians, the participants proposed training in mind-body skills such as breathing, yoga, meditation, education about the effects of stress, and cognitive strategies to help reduce ruminative thoughts and negative self-talk¹⁹. They further proposed that these interventions should be brief enough to integrate into the workplace¹⁹.

Some interventions, such as yoga and meditation, are impractical in a busy hospital workplace but can be useful after work alongside engaging in physical exercise and other aspects of physical and emotional self-care. On the other hand, education about the negative effects of stress, utilizing others’ ways of dealing with similar problems, and setting realistic work expectations can be incorporated into hospital continuous medical education (CME) schedules.

Positive coping mechanisms are associated with less burnout¹⁸ and may improve job performance, whereas negative coping mechanisms may increase stress²¹. A study among nurses in China revealed a positive correlation between positive coping mechanisms and job performance and a negative correlation between negative coping mechanisms and job performance²⁰. However, the scales used to derive these correlations were self-reported, with potentially subjective responses. The study concluded that positive coping strategies reduce the negative effects of work stress on job performance, whereas negative strategies increase the negative effects²⁰.

These findings suggest that positive, self-driven coping by individual workers is an essential strategy that could be promoted in the healthcare workplace to address work stress and prevent or minimize burnout. Furthermore, avoidance coping strategies such as disconnecting from work, procrastinating, and trying to forget everything should be discouraged owing to their potential adverse effects on job performance and staff well-being¹⁶. However, the extent to which these mechanisms impact job performance has not been extensively examined.

Therefore, further studies with objective measures of impact on job performance are needed to evaluate the effectiveness of these coping mechanisms in moderating work stress and improving job performance within context-specific settings across various healthcare systems and to understand their overall impact on burnout syndrome.

Institutional interventions for addressing burnout

Understanding the true magnitude of burnout's impact on patient care quality can enable healthcare institution managers and policymakers to make evidence-based decisions on resource allocation for interventions that minimize burnout and improve care quality¹². Unfortunately, the heterogeneity of burnout definitions, the lack of standard assessment tools for work-related stress and quality of care, and the multifactorial nature of burnout syndrome⁹ hinder objective, generalizable measurements of burnout’s impact on patient care quality to inform appropriate institutionalized interventions.

However, several practical interventions have been proposed. These include workload or schedule rotation, training programs in stress management and communication skills, Balint training, encouraging teamwork, leadership through team meetings, and debriefing sessions^7,15. A randomized controlled trial revealed that biweekly self-facilitated discussion groups involving reflection, shared experience, and small-group learning reduced the rate of overall burnout by 12.7%²².

A bundled approach that combines organisational and individual interventions has been proposed to address burnout effectively. In a meta-analysis evaluating individual and organisational interventions for reducing physician burnout, combined interventions were found to have a small but statistically significant reduction in burnout⁷. Individually, organisational and physician-directed interventions were found to have a medium and moderate reduction, although the difference was not statistically significant⁷. Organization-directed interventions were more effective than physician-directed interventions in the depersonalization domain of the Maslach Burnout Inventory ⁷.

In contrast, a systematic review revealed no evidence to support the effectiveness of organizational-level interventions in reducing burnout²³. Furthermore, one study reported no significant relationship between support from superiors and improvements in the mental well-being of staff and that team-based and participatory programs had a nonsignificant effect²⁴. The study, however, reported that workplace appreciation significantly increased performance and reduced depression and burnout among nurses and physicians²⁴. This suggests that workplace appreciation is an essential factor in job performance and that it could be more beneficial than supervisor support in addressing staff mental well-being and burnout. These contrasting findings also indicate a need for further studies.

Many of the proposed interventions can be implemented in busy healthcare workplaces with minimal disruptions in work schedules and service delivery. The process of developing interventions should be viewed as part of creating a healthy workplace, and interventions should be responsive to local needs and the context from development to implementation²⁵. A systematic review of whole-system approaches to improve the health and well-being of healthcare workers revealed that greater participation in developing interventions showed greater benefits in staff well-being and that staff who actively participated in improvement activities did not deteriorate in coping with work pressure during the follow-up period²⁵.

Addressing workload imbalances requires careful evaluation of complex contributing factors such as understaffing and absenteeism, consideration of the heterogeneity of the healthcare workforce in hospitals, and understanding the multishift nature of work^26–28. Abseintism, for example, is reportedly high in healthcare, particularly among public sector workers, and may result from physically demanding procedures, poor working conditions and the high emotional burden associated with daily exposure to illness and death, which can lead to emotional exhaustion and sickness absence^29,27. However, absenteeism can also result from holding multiple concurrent jobs^13,14. Allowing health workers to supplement their income as a strategy to retain them is an enabler of dual practice,³⁰ which often leads to workers spending less time in their public sector jobs, causing workload imbalances. However, interventions to stop the dual practice, such as total prohibition, financial restrictions, and the restriction of professional practice licensing, are not well studied for effectiveness^30,31.

Targeted interventions are also necessary for nurses, younger health workers, and junior doctors since burnout appears to be more prevalent in these groups of the healthcare workforce, possibly because they bear most of the workload^9,32.

limitations:

A limitation of this review is that the literature search was not comprehensive since it was conducted in a single database".

Conclusion

Several studies have identified individual coping mechanisms and institutional interventions to address burnout. Combining both approaches could be a more beneficial practical strategy for many healthcare institutions, with minimal disruptions to work activities. Many individual coping mechanisms are implemented outside work, and institutional interventions can be incorporated into work schedules.

However, additional studies are needed to measure work stress and its true impact on job performance. Further studies are also needed to establish the effectiveness of documented interventions in reducing burnout and improving job performance and quality of care across various groups of health workers and settings. Policymakers and managers of healthcare institutions should acknowledge burnout as a potential barrier to delivering quality patient care and devise targeted evidence-based mechanisms to identify and address work stress to foster a healthy, efficient, and resilient healthcare workforce.

Funding

The study received no funding from sources other than the authors.

Competing interest

The author has no competing interests to declare.

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