The hierarchy of burnout prevention for healthcare

Burnout is a big problem in healthcare. It’s a hot topic in the press right now, highlighted by the pressures of the pandemic, but it’s nothing new to those in medicine. Burnout symptoms have been experienced by – I’m taking a leap here – everyone who has worked in a healthcare setting, at least in training and probably beyond: Severe exhaustion? Insomnia or disturbed sleep? Cynicism? Feelings of helplessness? Trouble concentrating? Irritability? Sounds like half of medical school. Working insane hours and being stressed is so normal and accepted that it’s been turned into a source of perverse pride by doctors, in which they compete to see who wins by suffering the most. It’s a bizarre martyrs’ game of one-upmanship in which the winner is really the loser: “You actually get a lunch break? I haven’t taken a lunch break in years!”

While burnout itself is nothing new to healthcare, calling it out and actually trying to do something about it is trending, as the phrase goes. As a result of this newfound focus, wellness committees, burnout seminars (or the more positive version, “joy in medicine” seminars), and countless articles have sprung up on the topic. My cynicism may be showing through, but in truth, this is a good thing. It’s an issue that deserves some serious attention, because burned out healthcare workers are not good healthcare workers, and that affects all of us.

I attended one such seminar with a group of other doctors. With the help of peer facilitators, we started off by discussing the definition and symptoms of burnout. We transitioned to the solutions-focused part of the curriculum, first telling stories about why we went into medicine (presumably to reconnect us to our sense of purpose), then breaking out into small groups to share ideas of how to increase personal resilience (exercising, hobbies, eating healthy) and tips on how to be more efficient in the office (using templates and macros in the EMR). All good things, and plenty of handy suggestions. And yet, I kept thinking about how most of these doctors are going to leave this seminar feeling energized about change, but tomorrow will face 9-11 hour days of broken processes, overstuffed schedules, and frustration, with any spare minutes filled with desktop medicine – answering messages, filling prescriptions, and writing notes. And here they are, walking out of the seminar armed with a hot lead on a meal delivery service. They don’t have a chance.

Many burnout prevention sessions, articles, and programs share some common flaws:

  • Emphasizing understanding the problem over taking action to fix it
  • Focusing on personal resilience over systemic change
  • Focusing on large scale problems rather than issues that might be solved in the short term
  • Treating burnout as an extracurricular problem, solved by what individuals do outside of work or by a team separate from operations (e.g. wellness committees)
  • Focusing on high level abstract concepts (e.g. finding meaning in work) and ignoring concrete actionable problems (e.g. 24 hour shifts)

The overarching themes are ones of thought over action and individual responsibility rather than systemic change.

As someone who used to run operations as the Chief of a department, I know how those who directly oversee the workplace have a lot of power over everyone’s day-to-day well being. Small-seeming decisions like planning for breaks, back-filling for sick leave, or just trying to be helpful rather than critical can dramatically affect the entire functioning of a department. These leaders, who have the most direct control of the work environment, should be “first responders” to burnout. They can buy time for others to understand and address the higher level issues.

Of course, operational leaders are always drowning in daily details, even more so with COVID outbreaks and supply chain problems. It’s hard to know where to start, and there is precious little reserve with which to do it. It would help to organize the effort, so that we can be at least somewhat methodical and make sure that we focus on achievable changes that will have the biggest impact in the shortest amount of time.

To do this, we need a hierarchy, similar to Maslow’s Hierarchy of Needs – a Healthcare Burnout Prevention Hierarchy. Such a hierarchy can help us focus on issues that have more leverage, since it’s arranged so that the factors closer to the base have more power to effect the higher levels than the reverse. It doesn’t mean that your wellness program should ignore things like the pride that comes from mastering a skill, for example, but it shows that no one is going to be thinking about taking pride in their work if they’re exhausted after a 24 hour shift. Or that, while you can try to balance the lack of proper PPE with paid bonuses, it’s going to take a lot of money, if it works at all.

healthcare burnout prevention hierarchy

There are a few points to note about this hierarchy. One is that it is specific to healthcare and may need adjustments to apply to other fields. It assumes, for example, that most healthcare workers are paid well above the poverty level, putting Job Fundamental factors like salary and schedule higher, acting more as proxies for esteem and issues of convenience. If the pay scale were generally lower (and they may be, even for some healthcare workers), then Job Fundamentals would be closer to the Safety level. Another point is that the hierarchical arrangement doesn’t mean that these factors should be tackled in order, from bottom to top. The reality of the workplace is that all of the levels need to be addressed at once, to varying degrees. But keep in mind that a weak base will dilute any efforts on the upper levels.

Other points:

  • The hierarchy is focused at the system level. Individuals will have differing personal priorities.
  • The lower levels can often be addressed directly with daily habits, while the upper levels ensue indirectly as a result of many actions over time
  • The upper levels, once established, are more robust than the lower levels. If you feel proud about your work, a single bad day is unlikely to change that. But one instance of verbal abuse can completely disrupt someone’s feeling of safety, making it hard to think of anything else.

The time to address burnout is right now. We can’t just talk about personal resilience, putting the burden of solving the problem on those experiencing the pain. And while we do need to design studies and gain more understanding, just because we don’t understand everything doesn’t mean we can’t do something. At each level in the hierarchy, leaders can find something to improve, shrinking the change until they reach a goal that can be achieved quickly. Every little improvement will chip away at the problem. We don’t know the complete answer to preventing burnout, but we certainly know some things make it worse. We need to start there.

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