When people experience emotional exhaustion cynicism and reduced feelings of personal accomplishment they are experiencing *?

Worker Burnout

Tracy's study of workers aboard cruise ships describes burnout as “a general wearing out or alienation from the pressures of work” (Tracy, 2000, p. 6). Burnout is generally thought to be the end result of job dissatisfaction and low morale. To be burned out is not the same as being burned up. Workers who are burned out can have renewing experiences and time-outs that bring back their motivation to work and satisfaction with their jobs. Burned up workers are so depressed and unmotivated with their jobs that it may be difficult or impossible to improve motivation and performance. Burn up happens when burnout goes untreated for too long a period of time. Think of burn up as the final stages of a long-term clinical depression.

Maslach (1993) described three dimensions of worker burnout: (a) emotional exhaustion; (b) depersonalization, defined as a negative attitude towards customers and clients, a personal detachment, or loss of ideals; and (c) reduced personal accomplishment and commitment to the profession. Farber (1990) suggests three types of burned out workers: frenetic, under-challenged, and worn out. The characteristics of each type are as follows.

Frenetic type: The frenetic type of worker is highly dedicated and committed to their work. Feelings of dissatisfaction cause them to work even harder. Frenetic workers are often tenacious, energetic, and invested in their work and might be considered highly idealistic by most colleagues. Additionally, they are often unable to acknowledge failure, and they set unrealistically high goals for themselves. When those goals are not met, they often feel great negativity about themselves, neglect their own personal needs, and respond to themselves and others with anxiety, irritability, and depression. Glicken (2010) called these workers “idealistic workaholics.”

Under-challenged type: The under-challenged worker has lost interest in his or her occupation and does their work in a superficial way. They have little motivation, see no new challenges, and lack a desire to be more involved on the job. Behaviors associated with the under-challenged worker are indifference, an unwillingness to develop as a person, obsession with finding new jobs and new careers without actually following through, and often complaining about how monotonous the work is and how bored they are.

Worn-out type: The worn-out worker has lost all optimism about his or her job, including even considering other work or new assignments. They have essentially given up, neglected their work-related responsibilities, feel no control over the situation, often feel depressed, and have difficulties performing assigned work tasks. Farber believes that worn-out workers are often the byproducts of inflexible, rigid, bureaucratic organizations where everything is done following arcane rules and procedures no one really knows or understands and that hide the fact that there is unfairness in almost all the decisions made regarding salaries, promotions, and work assignments. Workers at greatest risk of this type of burnout often work in large organizations providing little recognition, support, or appreciation for their work.

Freudenberger and North (1985) believe that burnout often shows itself in the following phases:

The need to prove oneself on the job.

Taking on increasing amounts of work to the point of work’s becoming a compulsion.

Neglecting personal needs.

Knowing they are working too hard, beginning to have physical symptoms of overwork, but being unable to do anything about it.

Being consumed by work, which leaves them isolated from others.

An increase in social isolation, sarcasm with others, and a tendency to blame the work for their increasing sense of isolation.

Withdrawal, beginning to use substances to cope, and a tendency to do the job by the book.

Obvious behavioral changes noted by others.

Behavior at work becoming mechanical and robotic.

Inner emptiness and exaggerated activities involving food, substances, and sex.

Depression.

Physical and emotional collapse.

Lorenz (2009, p. 1) provides the following signs of burnout:

Crankiness, irritability, and an inability to get along with co-workers you used to get along with just fine;

Coming to work late, wanting to leave early, dreading coming to work at all, watching the clock, and counting the minutes until you leave;

A sense of apathy and a lack of motivation; no longer wanting to be challenged;

No longer interested in interacting socially with co-workers;

Feeling exhausted much of the time, having headaches, feeling tension in all of your muscles, and having trouble sleeping.

A Personal Reflection on Worker Burnout: A Judge Confronts the Limitations of Her Job

Linda Morgan is a superior court judge in a state in the northeast. She told us that as caseloads have increased and judicial discretion has been taken away from judges because of strict sentencing guidelines handed down by legislatures, many judges are experiencing burnout and retiring early. In her own experience an example she cited was a young man charged with possession of illegal drugs. Should she impose prison time or probation on the son who is taking care of his elderly mother (who sits weepy eyed in the back of the courtroom)? He claims he is going to school to become a nurse. She doubts that he will make it since he was caught with enough marijuana to show that, although he is not a dealer, he is very likely a heavy user. Heavy drug use, she suspects with considerable past experience with drug users, will not bode well for academic work.

The guidelines for the amount of marijuana found in his possession calls for a prison sentence, but who will take care of the elderly mother? If she sentences him to probation, she faces judicial scrutiny and possible sanctions in her appointed job because her decision would be contrary to the guidelines imposed by a strongly anti-drug-use legislature.

She told me that “His face reflected what so many others tell me in their eyes: A pleading to be released, a desire to do better for themselves, if only in this moment. I, of course, have heard it all before. I know of all the jobs that are starting “tomorrow,” of all the children that need them to be “out” so they can provide for their families, and even the ones who just look at me as only a shell of the person they once were. But for today, at this hour, at this time, I believe him and yet I must sentence him to jail time. It eats away at me. I go home and look at the calendar and wonder if I can make it for three more years until I can retire. I’m not sure that I can.”

Key Facts on Burnout

•

Burnout is not recognized as a formal diagnosis.

It is often referred to as a syndrome of emotional exhaustion, cynicism, and low professional efficacy resulting from long-term work stress.

Research shows that burnout is more prevalent among younger people, females, singles, and highly educated people.

Risk situations involve a long-term gap between individual skills and resources on one side and work demands and load on the other, especially when the worker experiences low degrees of control/influence and autonomy in the job.

Burnout has been linked to workaholism.

Psychological Burnout

Research attention has increasingly focused on psychological burnout, a common reaction to stress among police officers. Maslach and Leiter defined burnout as a syndrome of emotional exhaustion, depersonalization, and low personal accomplishment. Jackson and Maslach studied the effects of levels of self-reported psychological burnout on police officers' interactions with their spouses and children. Police officers reporting higher levels of psychological burnout were more likely to display anger, spend time off away from the family, be uninvolved in family matters, and have unsatisfactory marriages.

Empirical studies of psychological burnout among police officers have attempted to identify both individual difference characteristics and job conditions associated with higher burnout levels. Relationships of burnout with individual demographic characteristics are sometimes found but tend to be both inconsistent and weak. However, there is considerable evidence that work setting characteristics, particularly chronic work stressors, influence levels of psychological burnout. Such characteristics have included features of the job itself, quality of supervision, unmet expectations, and constraints in one's organizational environment.

Police forces are concerned when their officers use excessive force toward citizens. Recent research has shown a relationship between officer burnout levels and both attitudes toward the use of force and the actual use of force. Burned-out officers were more likely to advocate and use force and violence. Cynicism toward the general public lowers the threshold for using force or violence. Exhaustion and low professional efficacy reduce problem-solving skills while increasing use of force and violence.

Physician Burnout

Physician burnout has been the subject of numerous studies over the past 10 years.9 Physician burnout is a term that is used to describe a condition of emotional exhaustion related to overwhelming and/or chronic stressors present in many physicians' lives. However, burnout has also been found to occur when there is a high level of cynicism and depersonalization, as well as when there is a lack of efficacy or a feeling of being unable to have influence or make a difference. Although it is ultimately people who “burn out,” burnout is not a deficiency or a mental illness. Burnout is often created by our systems and the excessive demands placed on us as caregivers—demands to do more than we can humanly do (witness the increase in clerical work now being demanded of caregivers on top of demands to provide care to an increasingly sick group of patients). In general, burnout often comprises numerous emotional, cognitive, social, and physical distress experiences, leading to a collection of conditions such as depression, anxiety, depersonalization, fatigue, loss of relationships, impaired decision making, and health impairment.

Physicians treating patients with life-threatening diseases are continuously exposed to patients and families in distress. Our bodies are designed to monitor and respond to both internal and external demands. We can maintain a balanced and healthy response to these demands if we have adequate internal and/or external resources with which to manage them. Some examples of resources contributing to internal or biologic/physiologic support include a healthy diet, exercise/yoga, sleep, meditation, and centering prayer. Examples of external resources leading to healthy psychosocial experiences are work cultures that invite autonomy, mastery, and relatedness, including collaborative colleagues and adequate professional resources to do one's job. Other psychosocial influences include adequate financial resources and living conditions, as well as connected and secure relationships with family and friends. If any of the internal physical demands or external social and contextual demands exceeds an individual's capacity to manage them, then their biologic and social systems begin to break down. This may take the form of illness, impaired cognitive and technical functioning, safety violations at work, and damage to relationships. In addition to the many demands of their professional context, physicians have personal lives, which also have demands that must be supported in order for the physician to be able to be present and fully functioning at work. (To think that physicians are immune to the influences of their lives apart from work would be to imply that they are not human, and depersonalization—lack of acceptance of their humanness—not only is a fast track to burnout, but also is associated with an 11-fold increase in medical errors, as well as unprofessional/immoral acts and lack of empathic connection with others.) Some factors contributing to an underresourced work environment include the following demands: long work hours, not enough sleep and disrupted sleep patterns, demands of keeping abreast with the latest research for current medical practice, being present to gravely ill and dying patients, interpersonal conflicts, excessive paperwork, and pressure to see increasing numbers of patients in a limited time frame.

In addition to the numerous stressors just mentioned, the medical culture with its demands for perfectionism and its propensity to punish errors, as opposed to understanding them and learning from them, can easily overwhelm a physician's capacity to manage the demands of his or her professional context, leading to burnout and illness. Cultures of perfectionism and blame have been linked to toxic shame and secondary victimization,10 which interferes with the physician's emotional well-being and also contributes to the increased likelihood of physician error.

One can imagine the inherent difficulties built into a stressful situation when a physician is not adequately resourced and is also in the grip of burnout as the physician tries to engage a teenage mother, who also may not be adequately resourced, to make a meaningful and difficult decision regarding the care of a child with complex congenital heart disease. Both individuals are most likely at the ends of their internalized windows of tolerance, which has the potential to impact their capacities for mindsight, abstract thinking, temporal integration, empathic responsiveness, and ability to engage in wise decision making. Add to this the factors of sleep deprivation, poor nutrition or physical health, and outside stressors (marital discord, issues with their own families, financial stressors), and it compounds the complexity of decision making. The first important step to managing these varying demands is simply becoming aware that they exist. Although that awareness does not abolish them or change them, acceptance of their presence reconnects us with our humanness and invites us to be able to connect with our patients, who have their own extraordinary demands, as humans and not simply as “diseases.”

SPECIAL POPULATIONS

Compared to 50 years ago, the stigma of having cancer has been reduced. However, many cancer patients still feel stigmatized. If depression coexists, it produces an extra barrier to treatment.

Patients with cancer have a 1.5-fold increased suicide risk over that of the general population. Passive suicidal thoughts are common (8% in terminal phases).

Men are at increased risk for suicide. Other risk factors include advanced stage of disease, poor prognosis, delirium with poor impulse control, inadequately controlled pain, family history of suicide, previous suicide attempts, physical and emotional exhaustion, and social isolation. Hopelessness and extreme need for control also increase risk. Patients with cancer in the head, neck, or gastrointestinal system have a higher risk of suicide and alcohol disorders.16

Summary

Chronic medical illness challenges patient's coping skills.

The effectiveness of coping is determined by premorbid (baseline) coping strategies, current illness burden including comorbid psychiatric disorder(s), and availability of support mechanisms.

Common indicators of ineffective coping include nonadherence to treatment, denial or minimization of illness, substance abuse, and high use of health care.

In addition to empathic listening and support, the physician should mobilize other sources of support including ancillary medical staff, family, religious, and illness-oriented support groups.

Motivational interviewing holds promise for primary care specialists aspiring to help patients discover their own ambivalence and who have a desire to change unhealthy ways.

Abstract

Burnout constitutes a serious health concern in the modern working environment. It is a stress-related condition that has developed as a result of a prolonged psychosocial stress exposure causing a persistent mismatch between demands and resources. The main symptom is emotional exhaustion, but physical fatigue, diminished professional efficacy, cynicism, and cognitive impairments are also associated with this condition. Burnout has been used both as a psychologic term in occupational settings and as a clinical diagnosis in patient populations, and there is currently no universally accepted definition and diagnostic criteria of burnout. It has been hypothesized that the two main stress response systems, the autonomic nervous system (ANS) and the hypothalamus–pituitary–adrenal axis (HPA axis), are involved in the pathogenesis of burnout. A common hypothesis is that in the early stages of chronic stress, the HPA axis and sympathetic ANS activity tend to be higher, while it will decrease with a longer duration of chronic stress to ultimately reach a state of hypoactivity in clinical burnout. The current research in this field shows many contradictory results. Thus there is no compelling evidence of either ANS or HPA dysfunction in burnout. However, there is partial support for the hypothesis of HPA and sympathetic hyperactivity in early stages, and HPA hyporeactivity and low vagal activity in more severe burnout cases, but high-quality studies investigating the causal links are still lacking.

Family Communication

The nature and quality of family communication significantly influences the caregiving experience. Conversations about illness and death can be painful, difficult, and laden with emotion. The level of open communication has been related to caregivers’ emotional reactions (e.g., emotional exhaustion, depression), feelings of self-efficacy, and the length of time spent in the caregiving role.38 The intense energy that is required to cope with the physical, psychological, social, and spiritual aspects of a loved one's illness also generates stress and fatigue that can cause conflict within families and with providers.39

Communication about serious illness can generate dissimilar responses in caregivers and care recipients. Fried and colleagues40 found that disagreement about communication preferences is frequent in caregiver–patient pairs. In a sample of responding caregivers who desired more communication, 83.1% of the patients did not. In a sample of responding patients who desired more communication, 66.7% of the caregivers did not. More communication was desired by 39.9% of caregivers, and 37.3% reported that communication was difficult. Caregivers who wanted more communication had higher burden scores.40 The level of openness is influenced by personality traits, the history of the relationship, the duration and intensity of caregiving, and the emotional responses to the experience.38

Family caregiving for people with serious illnesses occurs within the network of complex social and family relationships. Providers may encounter various patterns of care, three of which have been identified as (1) care dyads who are aging, who are chronically ill, and who compensate for each other's deficits; (2) people who are cared for by a constellation or system of multiple family members; and (3) family care chains in which one person functions as a caregiver for one but the care recipient of another (e.g., older spouses with adult children).41 Families also respond to the advanced stages of serious illness in varied modes or styles. Family response styles can be reactive when the illness generates intense emotional responses, fused when the illness and decline are seen as shared or “we” experiences, dissonant when family members have diametrically opposed and conflicting viewpoints, resigned when death is anticipated, and assertive or advocative when the patient's vulnerability ignites responses. Providers who can recognize, acknowledge, and engage families with varying responses to serious illness can ease patients’ suffering and help families manage the often unknown terrain of dying and prepare for life without the loved one.

Family–provider communication is also central to caregiver adaptation over the course of a serious illness. Cherlin and colleagues42 investigated caregivers’ perceptions of physicians’ communication and found that there is little concordance between families’ and providers’ perceptions of their communication. Caregivers reported that physicians did not tell them the patient's illness was incurable, they were not given life expectancy information, and hospice was not introduced.43 To ascertain patient–clinician and caregiver–clinician concurrence about prognostic discussions, Fried and colleagues44 gathered and subsequently matched independent reports. In 46% of patient–clinician and 34% of caregiver–clinician pairs, the clinician reported saying the patient could die of the underlying disease, but the patient or caregiver said this was not discussed. In 23% of patient–clinician and 30% of patient–caregiver pairs, the clinician reported discussing an approximate life expectancy, but the patient or caregiver reported there was no discussion.44

Caregivers typically overestimate cancer patients’ symptom burden, and accuracy does not improve over time. Improving caregiver accuracy may boost the positive effects of cognitive-behavioral interventions designed to improve cancer patients’ quality of life.45 Greater attention toward a coordinated approach to discussing options in the setting of serious illness is needed.46 Communication about the nature of illness, symptoms, terminality, life expectancy, and prognosis is a major issue in family communication and encounters with providers. Open, honest, direct, and frank discussion of a poor prognosis, end-of-life needs, and goals of care can be difficult to initiate and to participate in, but their importance cannot be underestimated.

Burnout as a Process

Increasingly, research has focused on the examination of burnout as a process that develops over time. As such, researchers have been interested in discovering the paths through which burnout develops. Some researchers have demonstrated the existence of two separate paths to burnout: a cognitive path, manifested in personal and professional feelings of lack of accomplishment, and an emotional path, reflected in a sense of overload and emotional exhaustion. It is generally held that the process begins to develop with external stressors, such as disruptive students, excessive paper work, and conflicting demands, which lead to emotional exhaustion. Emotional exhaustion is considered the aspect of burnout that is most responsive to the nature and intensity of work stressors. Some researchers refer to emotional exhaustion as the prototype of stress. In general, various job conditions are more strongly related to emotional exhaustion than to the other two subscales, depersonalization and lack of personal accomplishment. Emotional exhaustion is predicted mainly by occupational stressors, such as work overload, inadequate use of skills, and interpersonal conflicts. In addition, emotional exhaustion is considered the affective component of burnout that leads to depersonalization or cynicism. Through depersonalization, individual teachers attempt to cease the depletion of their emotional energy by treating their students as objects rather than people. Emotional exhaustion can also lead to reduced feelings of personal accomplishment in the teaching role, which may be seen as indicative of an impoverishment of people's perceptions of themselves in their work role, particularly as teachers. Findings suggest that depersonalization contributes to lower feelings of accomplishment as well. Because effective teaching is contingent on teachers' communicating with students on a personal level, teachers may be particularly vulnerable to low feelings of accomplishment when perceiving that they are treating their students impersonally, as in the process of depersonalization. Other findings point to the consistency of each of the burnout components over time. Emotional exhaustion, depersonalization, and lack of personal accomplishment predict significantly the scores on the same scales 1 year later, according to Greenglass and co-workers. Researchers agree that burnout levels are fairly stable over time.

One of the advantages of viewing burnout as a process over time is that it allows the investigation of the antecedents of burnout, particularly those associated with the school, the teachers' interpersonal relationships, and their workload. Being able to specify the antecedents of burnout in teachers has both theoretical and applied value. By specifying variables that contribute to burnout, theoretical knowledge of the process of the development of stress and burnout is advanced. On a practical level, it is valuable to the school's administration to be able to specify just what causes burnout. Examining the development of stress and burnout over time offers the possibilities of changing the processes involved and grappling with the complex causal relationships. This presumably can lead to the development of better and more effective intervention techniques, which can improve teacher morale and prevent the harmful consequences of further burnout.

Values

People might feel constrained by their job to do something unethical and not in accord with their own values. Alternatively, there may be a mismatch between their personal career goals and the values of the organization. People can also be caught in conflicting values of the organization, as when there is a discrepancy between a lofty mission statement and actual practice, or when the values are in conflict (e.g., high-quality service and cost containment do not always coexist). Staffing problems can lead to not being able to do the job properly, a decrease in quality patient care, and decreased staff morale.24 Gynecologic oncologists had high EE and high job stress if their expertise was not being put to good use.54 Burned out oncology surgeons64 were less satisfied with their career choice. Surgeons in private practice were less likely to say that they would become a physician again, and were less likely to say that they would become a surgical oncologist again. Devoting less than 25% of one's time to research was associated with burnout in that study.64

In a national study (n = 3213) exploring the interaction between workload and value congruence (personal and system) among Canadian family physicians, researchers found that both workload and value congruence were strong predictors of emotional exhaustion and cynicism (P = .01) for both genders, whereas value congruence was found to be a strong predictor of personal efficacy (P = .01).65 Similarly, an article providing strategies to reduce burnout among oncologists reported that optimization of career fit (balance between personal and professional goals/values) led to increased job satisfaction.66

6 Burnout

Cooper et al. describe burnout as “a special form of strain.” These authors point to the concept of burnout as reflecting a state of psychological strain initially associated with those working in the human service professions. Since the early studies on burnout, researchers have extended their investigations of the phenomenon to working life in general, considering in detail the consequences of burnout for individuals and their organizations. In the early 1980s, Maslach provided a description of burnout involving three major elements: emotional exhaustion described in terms of not having the emotional energy to sufficiently manage the encounter; depersonalization, in which individuals simply become seen as objects and are treated in a detached way; and a lack of personal accomplishment, in which the tendency is to devalue performance in negative ways. Since this three-dimensional view of burnout was first proposed by Maslach, much discussion has centered on whether emotional exhaustion is the essential feature of burnout, with the roles played by the other two dimensions being disputed.

Cordes et al. describe burnout as a developmental process. These authors go on to describe burnout as a gradual eroding process and note that by emphasizing the process of burnout, researchers and organizations are provided with a mechanism for understanding what to look for and the types of interventions that may be necessary. Their work supports a process in which the onset of burnout is marked by emotional exhaustion. Depersonalization follows, as Ashforth and Lee suggest, because it is a “means (albeit futile) of staunching the flow of emotional energy, of coping with growing exhaustion.” The issue of whether, as depersonalization occurs, the individual begins to sense a loss of accomplishment and hence a degrading of achievements is less clear. Cordes et al. note that one possible reason for this is that a lack of personal accomplishment may also be explained in terms of a range of constraining organizational factors and hence depersonalization may develop somewhat independently of the other two dimensions.

Correlates of burnout are many and varied, and researchers have explored these at a number of levels, including the individual level (e.g., gender, age, commitment, and individual differences), the job level (e.g., work role demands, client relationships, and autonomy), and the organizational level (e.g., organizational culture, management style, and communications). In general, it is clear that a range of individual, job, and organizational level factors influence the experience of burnout. However, it is also clear that more work is still needed to understand where in the process these different factors have their most significant effect, how far their effect can be generalized, and what this means in terms of the development of intervention strategies.