‘Burnout’ occurs when ‘…people give too much for too long and receive too little in return’.1 It was first described amongst clinical staff, and the expression itself was borrowed from a colloquial description of end-stage drug abuse.
People who are burnt out have reduced morale, are indifferent to - or resentful of - their work. Work that was once meaningful becomes a meaningless stream of tasks, with the negatives looming larger than the positives. Emotional control may be reduced, leading to bursts of anger.
Thinking may be more rigid, or escapist, or filled with hostility towards colleagues and patients. Burnout has been shown to have a negative impact on the doctor’s relationship with their patients.2
Those who are burning out may further withdraw from contact with colleagues, patients and family. The surly partner sat on the edge of the practice meeting could be suffering from burnout, and suffering from the triad of:
- Emotional exhaustion – feeling unable to ‘give’ any more
- Depersonalisation – not used in the normal psychiatric sense, but referring here to cynical attitudes towards patients and colleagues
- Lack of personal accomplishment – a tendency to evaluate one’s work negatively
It must be stressed that burnout a description of a psychological state emerging from prolonged work strain, not a clinical diagnosis. Burnout is a useful concept in that it points us away from thinking about an individual who is coping or not, and towards considering the work setting.
What increases the risk of burnout?
There are many features of contemporary general practice that increase the risk of burnout, including reduced connectedness, both with colleagues and patients; increased workload – both emotional and intellectual; increased time intensity; reduced autonomy; role ambiguity and conflict; and increasing patient needs and expectations.
In the large-scale, influential Whitehall studies, Marmot and colleagues demonstrated the robustness of the job demand-control-resource model, in which strain is a result of the mismatch between demands and resources.3 An imbalance in demands and resources leads to strain and common mental disorders.4,5
According to the job demands-resources model, demands are aspects of the job that require considerable energy, and resources are those aspects of the job that facilitate the work process.
Demands and resources
Demands that are relevant to general practice include workload, complexity, fast pace, stressful events, responsibility, interpersonal conflict, emotional labour of care, and the hindrances of bureaucracy.
These need to be carefully balanced with adequate resources, including social support, opportunities for development, participative decision-making and autonomy. Job resources are especially helpful in engaging staff when demands are high.6
Research with GPs shows that a mismatch between demands and resources lead to mental distress, health problems, exhaustion and reduced wellbeing,7 dissatisfaction, intention to leave and actual turnover of GPs.8 These findings have been corroborated this month in a report by the King’s Fund.
Such studies included work control and peer support as key resources. So if we seriously want to protect and enhance or psychological and physical health, we need to be doing all that we can to call for changes within our practices, and general practice more broadly, that reduce the demands placed on us, and increase the resources open to us.
What can we do in practice?
The General Practice Forward View may go some way towards this, but we also need to keep thinking about how to make time for peer support within our working day.
Some of the most sustainable practices I have worked at were ones where there was a shared coffee or lunch break, and a proper Christmas bash. It helped me feel more like a human being myself, not just a worker.
We also need to find ways of continuing to grow professionally, possibly through a special interest, new roles in the practice or a portfolio career. Those I’ve spoken to who take on appraising, leading or medical politics often describe how the roles reciprocally enrich one another, and keep them thinking and learning.
Within practices there are some decisions that could be shared amongst staff. Even if it takes longer to hear everyone’s view, giving the team a voice may be a wise investment, showing that colleagues and their views are valued.
Please feel free to post comments about initiatives you have used in supporting morale within your teams and practices. This could be a valuable space for swapping ideas and best practice.
- Dr Jennifer Napier is a GP with special interest in occupational medicine. She has researched wellbeing and workforce issues, and works through Contextualyse to train and consult on how to create healthy, productive workplaces.
- Schaufeli W & Enzmann D. The burnout companion to study and practice: a critical analysis. London: Taylor and Francis, 1988.
- Bakker AB, et al (1997) cited in Schaufeli, W & Enzmann, D (1998)
- Siegrist, J. & Marmot, M. () Health inequalities and the psychosocial environment – two scientific challenges. Social Science and Medicine, 2004; 58: 1463-73.
- Stansfeld, S. & Candy, B. () Psychosocial work environment and mental health—a meta-analytic review. Scand J Work Environ Health 2006; 32(6): 443-62.
- Lee RT & Ashforth BE. A meta-analytic examination of the correlates of the three dimensions of job burnout. Journal of Applied Psychology, 1996; 81: 123–33.
- Demerouti E, et al. The job demands–resources model of burnout. Journal of Applied Psychology, 2001: 86; 499–512.
- Houkes I, et al. Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study. BMC Public Health 2011; 11: 240
- Heponiemi T, Kouvonen A, Aalto AM, et al. Psychosocial factors in GP work: the effects of taking a GP position or leaving GP work. Eur J Public Health 2012; 23: 361-66