Burnout is a complex phenomenon. This article will discuss how stress and burnout is defined and what are the symptoms of burnout. It will then discuss the factors that contribute to stress and burnout, namely the individual characteristics, the client characteristics, and work-related factors. It will conclude by offering some suggested strategies to reduce stress and burnout in the workplace.
Defining stress and burnout
Stress has been defined as the effects produced by an interaction between an individual and the environment and is caused by stresses intrinsic to the job, role-based stress, relationships with others, career development, and organizational structure. Stress is not necessarily all bad as it has been found to assist in motivating individuals, growth, development and change. But stress can be counterproductive when it continues to be present and becomes chronic (Sutherland and Cooper 1990). When this happens it can be very costly both in human and economic terms for the individual and society (Cushway 1995). Burnout is related to stress.
Burnout is increasingly being recognized as being a serious problem affecting many people, particularly those in the human service industry. Job burnout is a prolonged response to chronic emotional and interpersonal stressors on the job (Maslach 2003). More specifically, it involves the chronic strain that results from an incongruence, or misfit, between the worker and the job. In the multidimensional model of the burnout phenomenon there are three key dimensions. These include exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. According to Maslach, Jackson, and Leiter (1996), burnout differs from occupational stress in that it is specific to work that requires intense involvement. Burnout is a state of physical, emotional fatigue, and it is caused by a long-term commitment to demanding situations. It has been described as a sense of helplessness and hopelessness, low energy levels, chronic tiredness, fatigue, and a feeling of being trapped. There are also evident negative feelings for self, work and life (Sorgaard et al. Dawson 2007).
Burnout has been associated with absenteeism, ineffectiveness, interpersonal conflicts, lower productivity, job dissatisfaction, reduced organizational commitment, and turnover. The emotional exhaustion component of burnout has been associated with stress-related health outcomes. Emotional exhaustion predicts increased rates of illness, fatigue, substance misuse, depression, anxiety, and irritability (Ducharme et al. 2008). Turnover among human service occupations has adverse implications not only for the organization, but also for the clients. Clients may suffer setbacks such as loss of trust when their clinical services are disrupted by their therapist's departure. Turnover can intensify stress among the remaining therapists whose caseloads increase. Then there is the issue of temporary staff or newer less-experienced staff being hired into vacant positions (Ducharme et al. 2008). Replacing staff is time consuming and costly. There are costs associated with recruitment, training, and supporting new employees until their performance reaches a satisfactory level. Turnover causes a disruption in service provision and in the client-provider relationship (Blankertz and Robinson 1997).
Certain specific occupations are at risk of the development of burnout. These include positions in the human services, particularly in health care (Felton 1998). Various occupations in health care have been studied, for example, psychiatrists (Kumar et al. 2007), nurses (Lee and Akhtar 2007), psychologist, social workers (Evans et al. 2006) and occupational therapists (Lloyd and King 2004). While strain levels vary across the different health professions. People in these professions regularly experience stress that is to some extent attributable the job.
Following the consistent findings that their research yielded, Maslah et al. (1996), developed a specific syndrome of burnout, and devised an instrument to assess it. The most widely used instrument to measure burnout is the Maslach Burnout Inventory (MBI) (Maslach et al. 1996), which was designed to assess the three aspects of the burnout syndrome. It provides scores on three subscales. These include depersonalization, emotional exhaustion and personal accomplishment. Respondents are asked to indicate how frequently they experience a particular aspect of burnout (22 statements) on a scale of 0-6. The higher the respondent's score on depersonalization and emotional exhaustion, the higher their levels of burnout. The lower the score on personal accomplishment, the higher the burnout level. This tool has been found to be reliable, valid and easy to administer.
Factors that contribute to burnout
In the work and organizational context, burnout often has a social origin and is sustained by social and organizational stress experiences (Peiro et al. 2001).
Higher levels of burnout are generally observed in younger people (e.g. Cushway and Tyler 1996). There are different patterns found in the relationship between stress and burnout and gender. For example Kumar et al. (2007) found that women respondents reported lower levels of personal accomplishment. Whereas other studies, for example, Cushway et al. (1996) found that male mental health nurses had a poorer mental health outcome, as well as being less satisfied with their work than their female counterparts. Length of tenure in a position or place within the organization's hierarchy has an equivocal impact on levels of burnout and job satisfaction. Kumar et al. (2007) found that longer duration of practice was associated with lower levels of depersonalization. Leary and Brown (1995) found that nurses who undertook additional training after their initial qualifications, were less likely to be emotionally exhausted than those who did not complete further training. Various aspects of personality have been found to contribute to the degree of stress and burnout experienced by individuals. For example, research clearly implicates Type A behaviour observed in people who are excessively time conscious, competitive, ambitious, and hard-driving as predictor of stress and burnout (Moore and Cooper 1996). When a perceived lack of control is felt by individuals over events important to them, the greater the perception of stress and level of emotional exhaustion they experience (Moore and Cooper 1996). In a study of the predictors of components on the MBI (Maslach et al. 1996), Rowe (1997) identified that stress and a lack of control best predicted emotional exhaustion; stress and a lack of effective coping predicted depersonalization; and a lack of challenge and commitment and ineffective coping predicted lack of personal accomplishment. The interface between home and work where stressors from each may spill over clearly impacts on a person's psychological well-being in both environments. Maslach et al. (1996) reported there was a relationship between burnout and difficulties with families and friends. Poor working relationships amongst co-workers in an organization is a potential source of stress. Lee and Akhtar (2007) found that co-worker support significantly increased the respondent's sense of personal accomplishment while supervisory support reduced emotional exhaustion.
Client characteristics and contact are a defining factor in burnout among human service providers. In human service occupations the worker must deal directly with people about issues that may be problematic. Maslach et al. (1996) suggested that as a consequence of this, strong emotional feelings are likely to be present in the workplace and this chronic emotional stress can induce burnout. Studies of mental health workers have focused on caseload, case type, and contact level.
Higher rates of emotional exhaustion and depersonalization and lower rates of personal accomplishment are related to having a larger caseload (Maslach et al. 1996). In the study conducted by McLeod (1997) community nurses reported that having too many referrals and a large caseload were the most significant stressors. The higher percentage of people with schizophrenia in the client population, the less job satisfaction staff members expressed. In McLeod's (1997) higher levels of stress were experienced by community mental health nurses working with severely mentally ill people than those working with people with a range of diagnoses. Potentially threatening clients were found to be a major source of stress for mental health nurses, with staffing shortages putting them at physical risk because of the nature of their client group (Cushway et al. 1996). The type of client problems has an effect on staff stress and burnout. Some clients may have problems that are far more emotionally stressful for staff than others. It also be more difficult for staff to work with people and see few changes over time. Another stressor has been fond to be client's reaction to staff. It is common in many of the human services to receive more negative feedback from clients than positive. Client contact is important in predicting the job stress of helping professionals. Maslach et al. (1996) reported that physicians who spent most of their working time in direct contact with clients scored high on emotional exhaustion.
Work environments associated with high burnout are those that demand high personal adherence to work through restrictions of worker freedom or flexibility and de-emphasize planning and efficiency for the task at hand. Other work environments related to higher levels of burnout are those in which job expectations are vague or ambiguous, in which management imposes extensive rules and regulations, and in which support and encouragement for new ideas and procedures are low. Maslach et al. (1996) suggested that reduced stability on the organizational level is likely to have an impact on burnout. According to Maslach et al. (1996), organizational settings that undermine staff members' autonomy reduce their potential for significant accomplishments and increase their tendency to become cynical and distant from their work. Key sources for mental health nurses were found to be staff shortages, health service change, poor morale, lack of consultation from management, and not being notified of changes before they occurred (Fagin et al. 1996). The most commonly cited sources of pressure found in the study conducted by Prosser et al. (1997) were lack of resources followed by work overload, bureaucracy and management. Issues relating to how clinicians spend their time are also associated with stress. For example, it was found that being unable to reach planned work targets, and other caseload factors, such as having too much administrative and paper work, appear to be strongly associated with a high measure of stress for social workers (Collings and Murray 1996). In a study of clinical mental health staff, (including nurses, psychiatrists, occupational therapists, social workers and psychologists) community staff scored significantly on the emotional exhaustion component of the MBI than hospital-based inpatient, day-care or outpatient staff (Prosser et al. 1996). A later study conducted by Sorgaard et al. (2007) found that there was no difference between inpatient and community staff on burnout. Community teams reported more organizational problems, higher work demands, less contact with colleagues, but also better social relations and more control over their work. The ward staff was more satisfied with the overall organizational structure and access to colleagues but complained about lack of control over operating conditions at work.
Within organizations, certain behaviours and demands are associated with the roles people are required to carry out. However, dysfunctions may occur, causing stress to the worker. These organizational stressors include role conflict, role ambiguity, role overload, and the responsibility associated with the role of the individual (Moore and Cooper 1996). Role conflict exists when an individual is affected by the conflicting demands of other people in the organization, when an individual is required to do tasks that are not perceived to be a part of the job, or when involved with a job that conflicts with personal values or beliefs (Sutherland and Cooper 1990). Stress is caused by the inability to meet various expectations or demands. Role ambiguity has been defined as an uncertainty in knowing which behaviours are expected in an individual's job and the extent to which needed information is available. For example, Reid et al. (1999) found that community mental health social workers expressed more concerns about role conflict and role ambiguity than any other professional.
Strategies to reduce stress and burnout
Stress represents an occupational risk to the health and wellbeing of workers. There are a number of strategies that could be used to improve working conditions. These include: redesign the task; redesign the work environment; establish flexible work schedules; encourage participative management; include the employee in career development; analyze work roles and establish goals; provide social support and feedback; build cohesive teams; establish fair employment policies; and share the rewards (Cooper and Cartwright 1997).
Work load and work pace
It is necessary to avoid under load as well as overload. Provision should be made to encourage workers to have recovery time from demanding task or for increased control by workers over characteristics such as work pace of demanding tasks (Bassett and Lloyd 2001). It may also be necessary to negotiate for a reduced caseload.
Having flextime, a compressed work week, and job sharing are all ways of trying to reconcile the demands and responsibilities the individual has outside the job (Cooper and Cartwright 1997). Time-outs are opportunities for staff under high stress to choose less stressful work while other staff take over their more stressful responsibilities (Zastrow 1984).
Employees need to be clearly informed if any organizational changes that my affect their employment or how they do their jobs (Cooper and Cartwright 1997).
Jobs need to provide opportunities for social interaction, both for purposes of emotional support and for actual help in completing the assigned task (Cooper and Cartwright 1997).
Job tasks need to be designed to have meaning and provide stimulation, and an opportunity to use skills (Cooper and Cartwright 1997).
Relationship with clients
Additional training in communication would be useful as would supervisory practices. Public relations departments should use appropriate media to promote awareness of the rights as well as responsibilities of clients and the key roles that staff play in the health care system (Lee and Akhtar 2007).
Clarifying job duties
It is critical that job duties be identified clearly and specifically. Job descriptions and orientation programs should be utilized at the beginning of employment. They should be reviewed and updated regularly. Regular team meetings may also help clarify role conflicts and role ambiguity between work units (Lee and Akhtar 2007).
It is important that supervisors are adequately trained so that they are able to provide staff with feedback about their work performance (Lee and Akhtar 2007).
Opportunities for training should be regarded as high priority as they assist in upskilling the worker, which means that they will be able to carry out their work more effectively (Bassett and Lloyd 2001).
Supervision needs to be seen as an integral part of working practice. It is important that staff are able to talk about their practice, and what they have gone through. Supervisors are meant to provide useful advice and strategies to improve practice (Bassett and Lloyd 2001).
Stress education and stress management training are useful in helping individuals to recognize the symptoms of stress (Cooper and Cartwright, 1997).
There are also additional strategies that individuals may use for dealing with potentially stressful situations. These include goal setting and time management, positive thinking, relaxation techniques, exercise, outside activities, treats, and humour (Zastrow 1984).
Burnout is most evident in work situations that inhibit mental health workers' capacity to realize their values through their work. In the research that has been conducted amongst various disciplines, there are differences evident in levels of burnout found, and the issues that researchers examined. Issues evident are management practices, consultation and communication, lack of control, lack of resources and, in many cases, role ambiguity and conflict. All of these factors have been identified as contributing to the development of stress and burnout. In general, predictors of stress and burnout include both the demands of the work and lack of necessary resources. Client characteristics and contact are defining factors in burnout. Burnout integrates feelings of exhaustion with staff members' involvement in their work, especially in terms of client contact and their sense of efficacy and accomplishment. Susceptibility to burnout has been found to exist in health workers with large caseloads, high levels of client contact and who have clients in their caseload with a diagnosis of schizophrenia and ongoing problems with little likelihood of change. Strategies to reduce stress include organizational ones including reducing size of caseloads, limiting hours of stressful work, increased training and supervision, and fostering the development of support systems. Individuals may also use a number of strategies to address stressful situations, including goal setting, time management, utilizing time-outs, seeking additional training, developing social support systems, and outside activities.
King R, Lloyd C. 2007. The wellbeing and professional development of the psychosocial rehabilitation practitioner. In: King R, Lloyd C, Meehan T, editors. Handbook of psychosocial rehabilitation. Oxford: Blackwell Publishing. p. 210-224.