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Best Examples of PSAs: Why PSAs Work and Why They Don't

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PSAs build awareness or encourage people to take, but what makes them effective? Learn about the best PSAs from the award-winning experts at RaffertyWeiss.

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Abstract

The experience of burnout has been the focus of much research during the past few decades. Measures have been developed, as have various theoretical models, and research studies from many countries have contributed to a better understanding of the causes and consequences of this occupationally‐specific dysphoria. The majority of this work has focused on human service occupations, and particularly health care. Research on the burnout experience for psychiatrists mirrors much of the broader literature, in terms of both sources and outcomes of burnout. But it has also identified some of the unique stressors that mental health professionals face when they are dealing with especially difficult or violent clients. Current issues of particular relevance for psychiatry include the links between burnout and mental illness, the attempts to redefine burnout as simply exhaustion, and the relative dearth of evaluative research on potential interventions to treat and/or prevent burnout. Given that the treatment goal for burnout is usually to enable people to return to their job, and to be successful in their work, psychiatry could make an important contribution by identifying the treatment strategies that would be most effective in achieving that goal.

Keywords: Burnout, work engagement, psychiatric staff, health care, depression, exhaustion, cynicism, burnout measures, burnout interventions

For many years, burnout has been recognized as an occupational hazard for various people‐oriented professions, such as human services, education, and health care. The therapeutic or service relationships that such providers develop with recipients require an ongoing and intense level of personal, emotional contact. Although such relationships can be rewarding and engaging, they can also be quite stressful.

Within such occupations, the prevailing norms are to be selfless and put others' needs first; to work long hours and do whatever it takes to help a client or patient or student; to go the extra mile and to give one's all. Moreover, the organizational environments for these jobs are shaped by various social, political, and economic factors (such as funding cutbacks or policy restrictions) that result in work settings that are high in demands and low in resources. Recently, as other occupations have become more oriented to "high‐touch" customer service, the phenomenon of burnout has become relevant for these jobs as well 1.

DEFINING BURNOUT

Burnout is a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. The significance of this three‐dimensional model is that it clearly places the individual stress experience within a social context and involves the person's conception of both self and others.

The initial research on burnout was exploratory and relied primarily on qualitative techniques. Because the earliest researchers came from social and clinical psychology, they gravitated toward relevant ideas from these fields. The social perspective utilized concepts involving interpersonal relations, i.e. how people perceive and respond to others; these included detached concern, dehumanization in self‐defense, and attribution processes. It also brought in concepts of motivation and emotion (and especially coping with emotional arousal). The clinical perspective also dealt with motivation and emotion, but framed these more in terms of psychological disorders, such as depression. Subsequent researchers came from industrial‐organizational psychology, and this perspective emphasized work attitudes and behaviors. It was also at this point that burnout was conceptualized as a form of job stress, but the primary focus was on the organizational context and less on the physical characteristics of the experienced stress.

What emerged from this descriptive work were the three dimensions of the burnout experience. The exhaustion dimension was also described as wearing out, loss of energy, depletion, debilitation, and fatigue. The cynicism dimension was originally called depersonalization (given the nature of human services occupations), but was also described as negative or inappropriate attitudes towards clients, irritability, loss of idealism, and withdrawal. The inefficacy dimension was originally called reduced personal accomplishment, and was also described as reduced productivity or capability, low morale, and an inability to cope.

Assessment of burnout

As the characteristics of burnout became more clearly identified, the next step was to develop measures that could assess them. Various measures were proposed, based on different assumptions about burnout, and many of them relied on the face validity of the measurement items or statements. The first burnout measure that was based on a comprehensive program of psychometric research was the Maslach Burnout Inventory (MBI) 2, 3. The MBI was specifically designed to assess the three dimensions of the burnout experience which had emerged from the earlier qualitative research. It has been considered the standard tool for research in this field, and has been translated and validated in many languages 4. In contrast, other initial measures of burnout focused only on the dimension of exhaustion 5, 6.

This distinction between measures that assess several dimensions of burnout, and those that assess the sole dimension of exhaustion, continues to the present day, and reflects different conceptualizations of burnout. For example, the Bergen Burnout Inventory (BBI) 7 assesses three dimensions of burnout: exhaustion at work, cynicism toward the meaning of work, and sense of inadequacy at work. The Oldenburg Burnout Inventory (OLBI) 8 assesses the two dimensions of exhaustion and disengagement from work. Other burnout measures focus on exhaustion alone, although they differentiate between various aspects of exhaustion. For example, the Shirom‐Melamed Burnout Measure (SMBM) 9 distinguishes between physical fatigue, emotional exhaustion, and cognitive weariness; and the Copenhagen Burnout Inventory (CBI) 10 makes a distinction between physical and psychological exhaustion.

There have been other changes and modifications of burnout measures over the years. Because the initial concern about burnout emerged from caregiving occupations, such as health care and human services, the measures developed in the 1980s tended to reflect the experience of those professions. Later, however, other occupational groups became interested in the occurrence of burnout, but had some difficulties in adapting the existing measures to their work situation. For the MBI, the solution was the development of a General Survey that could be used within any occupation (MBI‐GS) 11. Not only were various items revised to be more "occupation‐neutral", but the dimension of depersonalization (which was more specific to human services) was broadened to refer to a negative detachment from work and was renamed cynicism, and the dimension of personal accomplishment was broadened and renamed professional efficacy. More recent burnout measures utilized more occupation‐neutral wording from the outset.

However, some measures also added some new dimensions to the concept of burnout. For example, the Spanish Burnout Inventory consists of four dimensions: enthusiasm towards the job, psychological exhaustion, indolence, and guilt 12. Meanwhile, some researchers were concerned that the more neutral wording meant a loss of the specific interpersonal issues for human service workers, so they developed a new measure of interpersonal strain 13. It remains an open question whether these additional elements are essential components of burnout per se, or whether they assess experiences or conditions that often accompany the experience of burnout.

Engagement

An important development, at the beginning of the 21st century, has been that researchers have tried to broaden their understanding of burnout by extending their attention to its positive antithesis. This positive state has been identified as "engagement". Although there is general agreement that engagement with work represents a productive and fulfilling state within the occupational domain, there are differences in its definition.

For some burnout researchers, engagement is considered to be the opposite of burnout and is defined in terms of the same three dimensions as burnout, but the positive end of those dimensions rather than the negative. From this perspective, engagement consists of a state of high energy, strong involvement, and a sense of efficacy 14. By implication, engagement is assessed by the opposite pattern of scores on the three MBI dimensions.

However, a different approach has defined work engagement as a persistent, positive affective‐motivational state of fulfillment that is characterized by the three components of vigor, dedication, and absorption. In this view, work engagement is an independent and distinct concept, which is not the opposite of burnout (although it is negatively related to it). A new measure, the Utrecht Work Engagement Scale (UWES) 15, was developed to assess this positive state, and extensive research has been carried out in the last decade 16.

The relationship between burnout and engagement continues to be debated, however, and a recent approach has been to use dialectical theory to synthesize conflicting views on the two constructs, and to develop an alternate model 17.

Conceptual models

There have been various conceptual models about the development of burnout and its subsequent impact. At first, the focus was on the relationship between the three dimensions of burnout, which was often described in sequential stages. Exhaustion was assumed to develop first, in response to high demands and overload, and then this would precipitate detachment and negative reactions to people and the job (depersonalization or cynicism). If this continued, then the next stage would be feelings of inadequacy and failure (reduced personal accomplishment or professional inefficacy).

More recently, burnout models have been based on theories about job stress, and the notion of imbalances leading to strain. The first such model was the transactional one, which served as the conceptual bridge between sequential stages and imbalances 18. Its three stages are: a) job stressors (an imbalance between work demands and individual resources), b) individual strain (an emotional response of exhaustion and anxiety), and c) defensive coping (changes in attitudes and behavior, such as greater cynicism).

Subsequently, two developmental models of the demands‐resources imbalance have emerged: the Job Demands‐Resources (JD‐R) model and the Conservation of Resources (COR) model. The JD‐R model focuses on the notion that burnout arises when individuals experience incessant job demands and have inadequate resources available to address and to reduce those demands 19. The COR model follows a basic motivational theory assuming that burnout arises as a result of persistent threats to available resources 20. When individuals perceive that the resources they value are threatened, they strive to maintain those resources. The loss of resources or even the impending loss of resources may aggravate burnout. Both the JD‐R and the COR theory of burnout development have received confirmation in research studies.

A different variation of an imbalance model of burnout is the Areas of Worklife (AW) model, which frames job stressors in terms of person‐job imbalances, or mismatches, but identifies six key areas in which these imbalances take place: workload, control, reward, community, fairness, and values. Mismatches in these areas affect an individual's level of experienced burnout, which in turn determines various outcomes, such as job performance, social behaviors, and personal wellbeing. The greater is the mismatch between the person and the job, the greater the likelihood of burnout; conversely, the greater the match, the greater the likelihood of engagement. Initial empirical support for the AW model has been provided by both cross‐sectional and longitudinal studies 21.

CAUSES AND OUTCOMES

Most models of burnout make explicit the causal theorizing that has always been implicit in burnout research: certain factors (both situational and individual) cause people to experience burnout, and once burnout occurs, it causes certain outcomes (both situational and individual). However, these causal assumptions have rarely been tested directly. Most research on burnout has involved cross‐sectional designs or studies using statistical causal models. This correlational database has provided support for many of the hypothesized links between burnout and its sources and effects, but it is unable to address the presumed causality of those linkages. The recent increase in longitudinal studies is beginning to provide a better opportunity to test sequential hypotheses, but stronger causal inferences will also require appropriate methodological designs (and these are often difficult to implement in applied settings). One other critical constraint is that many of the variables have been assessed by self‐report measures (rather than other indices of behavior or health).

Over two decades of research on burnout have identified a plethora of organizational risk factors across many occupations in various countries 22, 23. Six key domains have been identified, as mentioned earlier: workload, control, reward, community, fairness, and values. The first two areas are reflected in the Demand‐Control model of job stress 24.

Work overload contributes to burnout by depleting the capacity of people to meet the demands of the job. When this kind of overload is a chronic job condition, there is little opportunity to rest, recover, and restore balance. A sustainable and manageable workload, in contrast, provides opportunities to use and refine existing skills as well as to become effective in new areas of activity.

A clear link has been found between a lack of control and burnout. On the contrary, when employees have the perceived capacity to influence decisions that affect their work, to exercise professional autonomy, and to gain access to the resources necessary to do an effective job, they are more likely to experience job engagement.

The area of reward refers to the power of reinforcements to shape behavior. Insufficient recognition and reward (whether financial, institutional, or social) increases people's vulnerability to burnout, because it devalues both the work and the workers, and is closely associated with feelings of inefficacy. In contrast, consistency in the reward dimension between the person and the job means that there are both material rewards and opportunities for intrinsic satisfaction.

The area of community has to do with the ongoing relationships that employees have with other people on the job. When these relationships are characterized by a lack of support and trust, and by unresolved conflict, then there is a greater risk of burnout. On the contrary, when these job‐related relationships are working well, there is a great deal of social support, employees have effective means of working out disagreements, and they are more likely to experience job engagement.

The area of fairness emerges from the literature on equity and social justice. Fairness is the extent to which decisions at work are perceived as being fair and equitable. People use the quality of the procedures, and their own treatment during the decision‐making process, as an index of their place in the community. Cynicism, anger and hostility are likely to arise when people feel they are not being treated with the appropriate respect.

Finally, the area of values picks up the cognitive‐emotional power of job goals and expectations. Values are the ideals and motivations that originally attracted people to their job, and thus they are the motivating connection between the worker and the workplace, which goes beyond the utilitarian exchange of time for money or advancement. When there is a values conflict on the job, and thus a gap between individual and organizational values, employees will find themselves making a trade‐off between work they want to do and work they have to do, and this can lead to greater burnout.

In terms of outcomes, burnout has been frequently associated with various forms of negative reactions and job withdrawal, including job dissatisfaction, low organizational commitment, absenteeism, intention to leave the job, and turnover 23. For example, cynicism has been found to be the pivotal aspect of burnout to predict turnover 25, and burnout mediates the relationship between being bullied in the workplace and the intention to quit the job 26. On the other hand, for people who stay on the job, burnout leads to lower productivity and impaired quality of work. As burnout diminishes opportunities for positive experiences at work, it is associated with decreased job satisfaction and a reduced commitment to the job or the organization.

People who are experiencing burnout can have a negative impact on their colleagues, both by causing greater personal conflict and by disrupting job tasks. Thus, burnout can be "contagious" and perpetuate itself through social interactions on the job 27, 28. The critical importance of social relationships for burnout is underscored by studies that show that burnout increases in work environments characterized by interpersonal aggression 29, 30. Such findings suggest that burnout should be considered as a characteristic of workgroups rather than simply an individual syndrome.

Burnout has a complex pattern of relationships with health, in that poor health contributes to burnout and burnout contributes to poor health 31. Of the three burnout dimensions, exhaustion is the closest to an orthodox stress variable, and therefore is more predictive of stress‐related health outcomes than the other two dimensions. Exhaustion is typically correlated with such stress symptoms as headaches, chronic fatigue, gastrointestinal disorders, muscle tension, hypertension, cold/flu episodes, and sleep disturbances. These physiological correlates mirror those found with other indices of prolonged stress. Parallel findings have been found for the link between burnout and substance abuse 32.

A ten‐year longitudinal study of industrial workers found burnout to predict subsequent hospital admissions for cardiovascular problems 33. Other research found that a one‐unit increase in burnout score was related to a 1.4 unit increase in risk for hospital admission for mental health problems, as well as a one‐unit increase in risk for hospital admissions for cardiovascular problems 31. Other studies have provided a more detailed examination of the link between burnout and cardiovascular disease, noting the role of high‐sensitivity C‐reactive protein and fibrinogen concentrations in the link 34.

BURNOUT IN PSYCHIATRY

To a large extent, the research literature on burnout in psychiatry echoes those previous themes. Workplace variables have been found to be more stressful for psychiatrists than other factors, and thus may be more likely to perpetuate burnout 35. These variables include too much work, long working hours, chronic staff shortages, an aggressive administrative environment, and lack of support from management. Poor relationships with management and supervisors have also been identified as related to burnout among psychiatry residents 36. However, research has found mixed results with regard to the role of job satisfaction in burnout, with some studies reporting no relationship 37, 38, and other studies reporting that job satisfaction did play a role 39, 40.

The rate of burnout among those employed in the health care field tends to be reported in the moderate to high levels, and it is generally believed that the burnout risk in health care is higher than in the general working population. Reported burnout rates for psychiatrists are quite similar to this overall trend 41, 42, 43. Some studies have raised the possibility that psychiatrists show an even more negative risk profile for burnout than do other health care employees 36, 43, 44. For example, one study found that 89% of psychiatrists had either thought about or experienced a clear threat of severe burnout 45.

There are other critical risk factors that may be more unique to the field of psychiatry. Chief among these is the working relationship that psychiatrists, and other mental health professionals, have with clients who are experiencing psychological trauma. The challenging demands posed by these and other difficult clients can lead to greater stress and frustration among psychiatrists, which in turn can fuel the exhaustion, cynicism, and inefficacy of burnout. This process has also been described in terms such as compassion fatigue, secondary traumatic stress, and vicarious traumatization 46, 47, 48. The burnout experience can become especially overwhelming when the psychiatrist becomes the target of anger, hatred, and even violence, as a result of negative transference 49. Violent incidents with patients can be emotionally draining and difficult to manage, and can lead health providers to psychologically distance themselves from their work. The occurrence of violence can also make providers feel that they lack control over their job, and thus challenge their sense of professional efficacy.

Higher levels of burnout are correlated with more negative feelings about patients 50 and a poorer quality of patient care 51. This link between burnout and poor care is supported by research on how burnout is manifested in psychiatrists, by changes in appearance (e.g., look of fatigue), behavior (e.g., becoming avoidant, making less eye contact), and mood (e.g., becoming more irritable and agitated, communicating poorly). In addition, perfectionist and obsessive traits may perpetuate burnout, particularly when the workload is heavy or stressful 52.

Working with demanding patients and working with patients' families have been found to be closely associated with psychiatrists' levels of exhaustion and depersonalization 35. These relationships reflect psychiatrists' frustrations with the limits of their craft. Contact with patients' families intensified these feelings, especially when family members expressed unrealistic expectations for treatment. Psychiatrists are emotionally drained by their inability to meet the strenuous demands they put upon themselves, and the demands inherent in their interactions with patients and patients' families. In contrast, diminished personal accomplishment reflects problematic relationships with superiors and colleagues, rather than demands from patients. Colleagues provide the most relevant source of information regarding one's sense of efficacy in professional life. When those relationships are strained, it is difficult to find meaningful confirmation of one's job performance.

Research on burnout has always recognized a central role for social relationships in the development and resolution of the syndrome. Initially, the research focus was primarily on the therapeutic relationship between the provider and the service recipient. Over time, studies have confirmed that relationships with colleagues and supervisors are equally, if not more, relevant to the potential for providers to experience burnout. For example, recent research on attachment styles found that attachment anxiety was accompanied by more frequent incivility from colleagues, and was associated with more exhaustion and cynicism. Attachment avoidance was linked to fewer instances of positive social encounters at work, and was associated with a greater sense of inefficacy 53. In sum, negative social interactions seem to drain energy and distance people from their job, and the absence of positive social encounters is discouraging.

CURRENT ISSUES

There are many interesting questions about burnout and engagement which are being studied in many countries around the world. A few inter‐related themes should be of particular significance for the profession of psychiatry. First is the question of the relationship between burnout and mental illness. Second is the question of the value of simplifying the multi‐dimensional construct of burnout to the single dimension of exhaustion. And third is the question of how best to ameliorate burnout in terms of treatment and prevention.

Burnout and mental illness

When the construct of burnout was first proposed in the 1970s, there were arguments that it was not a distinctly different phenomenon, but rather a new label for an already known state - i.e., "old wine in a new bottle". However, there were a lot of differing opinions about what the "already known state" actually was. These included job dissatisfaction, anomie, job stress, anxiety, anger, depression, or some combination of them 54, 55, 56. For example, one psychoanalytic perspective argued that burnout was not distinguishable from either job stress or depression, but represented a failure to achieve narcissistic satisfaction in the pursuit of ideals 57. As a result of these critiques, subsequent research often focused on testing the discriminant validity of burnout by assessing whether it could be distinguished from these other phenomena. The results of many studies have established that burnout is indeed a distinct construct 23.

Much of this prior discussion has focused on depression, thus raising the question of whether burnout is a precipitating factor for depression, and thus is a predictor for it, or whether burnout is the same thing as depression, and thus is itself a mental illness. Research has demonstrated that the two constructs are indeed distinct: burnout is job‐related and situation‐specific, as opposed to depression, which is more general and context‐free.

However, a recent article has renewed debate on the distinction between burnout and depression by claiming that at high levels the two states are indistinguishable 58. This position is in contrast to the view that burnout is an occupationally‐specific dysphoria that is distinct from depression as a broadly based mental illness 22. But close examination of the new research article reveals problems with its argument.

A necessary condition to examine the distinction between burnout and depression is a set of measures that provide a complete and accurate operationalization of each construct, and the new study fell short of this criterion. Specifically, the nine‐item depression measure (Patient Health Questionnaire, PHQ‐9 59) used in this study includes five items that refer explicitly to fatigue (lack of interest, trouble sleeping, trouble concentrating, moving slowly, and feeling tired). The other four items include one referring to loss of appetite and three referring to negative thoughts (suicidal thoughts, feeling depressed, negative self‐evaluation). The measure produces a single factor score; clearly that factor is heavily weighted towards fatigue (Cronbach alpha of .88). It may be argued that these nine items fail to capture the full complexity of clinical depression. In any case, the depression construct operationalized in this measure is one dominated by fatigue, accompanied by negative thoughts. To measure burnout, the study used the SMBM 9, which is a one‐factor fatigue scale with items referring explicitly to trouble concentrating, feeling tired, and thinking in a slow, unfocused, and unclear manner. Although conceptualized as representing three distinct factors of cognitive, physical, and emotional fatigue, the measure consistently reduces to a single factor of fatigue (Cronbach alpha of .96). Given the overlap in the explicit reference of the two measures to fatigue in the majority of their items, it is not surprising that the two scales are correlated highly (r=.77) 58.

The high correspondence of burnout and depression in this new study reflects a large level of concept redundancy between the SMBM and PHQ‐9. The two instruments primarily measure exhaustion, leading to a strong correspondence between them, especially at high levels of exhaustion. The correlation was especially high in this study; earlier research that used these identical measures reported correlations at three different times as .51, .53, and .54 60. These results are consistent with other research that finds that burnout and depression are inter‐related conditions.

Research using the MBI departs further from depression measures in its three‐component definition of the syndrome as exhaustion, cynicism, and inefficacy. Some studies that have used the MBI and different measures of depression have found the following range of correlations. The Profile of Mood States (POMS) depression scale correlated with the MBI ‐ Human Services Survey (MBI‐HSS) exhaustion (r=.33), depersonalization (r=.30), and personal accomplishment (r=−.14) 61. The Depression Anxiety Stress Scale (DASS‐21) depression subscale correlated with the MBI‐GS exhaustion (r=.37), cynicism (r=.47), and efficacy (r=−.21) 62. The Beck negative emotions and attitudes subscale correlated with the MBI‐GS exhaustion (r=.46) and cynicism (r=.28), and the Beck performance difficulties and somatic complaints subscale correlated with MBI‐GS exhaustion (r=.61) and cynicism (r=.36) 63.

The wide range of correlations between burnout and depression argues for a complex relationship between the two constructs. Clearly, they are linked to each other. For example, one study found that 90% of the respondents with severe burnout (i.e., daily occurrence of burnout symptoms) reported a physical or mental disease, with musculoskeletal pain and depression as the most common problems 64. A longitudinal study found that increases in burnout predicted increases in subsequent prescriptions of antidepressant medication 65.

A new understanding of this linkage comes from a recent longitudinal study in Finland, which found a reciprocal relationship between burnout and depression, with each predicting subsequent developments in the other. It was noteworthy that burnout fully mediated the relationship of workplace strains with depression: when problems at work contribute to depression, experiencing burnout is a step in the process 66.

These studies confirm that burnout and depression are not independent. Each state has implications for the other. However, that relationship is far from saying that burnout and depression are the same mental illness.

Single or multiple dimensions

Although the original construct acknowledged exhaustion as a key aspect of burnout, it argued that exhaustion is not the whole story. Indeed, if burnout were solely exhaustion, then the word "burnout" would be unnecessary, as it would not be providing any added value. "Exhaustion" would suffice. To rename "exhaustion" as "burnout" would definitely be inviting the criticism of "putting old wine in new bottles".

And yet, that simplification of burnout to exhaustion has been taking place not only among researchers, but also among practitioners. The driving force seems to be the goal of establishing a clinical diagnosis for burnout, so that health professionals can then receive reimbursement for treating individuals suffering from that condition.

This shift to defining and diagnosing burnout as an individual disorder or disability has been taking place in Northern Europe, primarily in Sweden and the Netherlands. There, burnout has been likened to neurasthenia or other syndromes with a quality of chronic fatigue. Sweden began using work‐related neurasthenia as a burnout diagnosis in 1997; soon, that was within the five most frequent diagnoses 67. Researchers developed a similar diagnosis in the Netherlands, using clinically validated cut‐off scores on the MBI 68.

To provide more precise diagnostic direction, Sweden in 2005 revised the ICD‐10 burnout diagnosis (Z73.0) as a difficulty in life management characterized by "vital exhaustion". The signs of vital exhaustion include two weeks of daily experiences of low energy, with difficulties in concentration, irritability, emotional instability, dizziness, and sleep difficulties. Additionally, these symptoms must interfere with the patients' capacity to perform their work responsibilities.

In the Netherlands, the term overspannenheid or "overstrain" is used to indicate burnout. This diagnostic approach estimates burnout prevalence at 3‐7% across various occupations, with psychotherapists at 4% 69. In terms of MBI scores, Dutch researchers recommended that a burnout diagnosis should be connected with very negative scores on exhaustion accompanied by negative scores on one of the other two subscales (cynicism and inefficacy) 70, 71.

The use of burnout as a medical diagnosis implies one‐dimensionality, and it is clear that exhaustion has emerged as that single dimension. Moreover, since 1997, the Dutch census bureau has been assessing "burnout" among the working population by using an index of work‐related exhaustion (that is based on the MBI) in its annual national survey. As a consequence, public discourse about burnout in the Netherlands is increasingly limited to exhaustion alone. The risk is that a focus on just exhaustion (and its connection to work overload) will miss the distinct quality of burnout as reflecting a crisis of meaning or values. The exhaustion dimension captures the problem of lacking sufficient energy to make a useful and enduring contribution at work. But it is the cynicism dimension that captures the difficulty in dealing with other people and activities in the work world. Furthermore, efficacy captures the core self‐evaluation people make regarding the value of their work and the quality of their contribution. To ignore these core aspects of the burnout experience would truly be a "mis‐diagnosis" that could have important ramifications for both policy and practice.

It is interesting that North American jurisdictions have been reluctant to recognize burnout as a clinical diagnosis, partially due to concerns about a flood of requests for disability coverage. The lack of an official diagnosis of burnout limits access to treatment, disability coverage, and workplace accommodations. Alternatively, disability applications have referred to depression, neurasthenia, or chronic fatigue. An unfortunate consequence is that inaccurate diagnoses may reduce possibilities for successful recovery and return to work.

New research has begun to focus on an innovative use of the three burnout dimensions, which allows for multiple distinct patterns along the burnout‐engagement continuum. In addition to the two standard endpoint patterns of Burnout (high on all three dimensions) and Engagement (low on all three dimensions), this approach can identify people who are only experiencing one of the dimensions, rather than all of them 72. A particularly relevant comparison is between people with the complete Burnout profile and those with only high exhaustion (the Overextended profile). The research findings show that these two patterns are decidedly different in terms of their workplace experience, so it is clear that exhaustion alone is not a proxy for burnout. Instead, the profile that comes closer to the negative endpoint of Burnout is the cynicism‐only one (Disengaged profile), which suggests that the experience of cynicism may be more of a core part of burnout than exhaustion. Cynicism is more clearly linked to the job environment, in terms of the poor quality of social relationships at work and the lack of critical resources, and that will lead to reduced job satisfaction and poor job performance 73.

Treatment and prevention

The personal and organizational costs of burnout have led to proposals for various intervention strategies. Some try to treat burnout after it has occurred, while others focus on how to prevent burnout by promoting engagement. Intervention may occur on the level of the individual, workgroup, or an entire organization. In general, the primary emphasis has been on individual strategies, rather than social or organizational ones, despite the research evidence for the primary role of situational factors.

Many of these individual strategies have been adapted from other work done on stress, coping, and health. The most common recommendations have included: a) changing work patterns (e.g., working less, taking more breaks, avoiding overtime work, balancing work with the rest of one's life); b) developing coping skills (e.g., cognitive restructuring, conflict resolution, time management); c) obtaining social support (both from colleagues and family); d) utilizing relaxation strategies; e) promoting good health and fitness; and f) developing a better self‐understanding (via various self‐analytic techniques, counseling, or therapy) 74.

Initiatives to moderate workload demands complemented by improvements in recovery strategies through better sleep, exercise, and nutrition have direct relevance to the exhaustion component of burnout. Cynicism, in contrast, pertains more directly to a sense of community or to the congruence of personal and workplace values. For example, an intervention that improved workplace civility among health care providers showed that cynicism declined as a function of improved civility 75, and that this change was sustained at a one‐year follow‐up assessment 76. A sense of efficacy, in contrast, could be more responsive to improvements in the forms of recognition from colleagues and leaders within an organization or the profession. An alternative proposal has been that people can make various changes in how they do their job (a process known as "job crafting"), and that such job alterations could lead to less burnout 77.

Unfortunately, there is very little research that has evaluated the efficacy of any of these approaches in reducing the risk of burnout. Especially rare are studies modeled even loosely on randomized control trials. More common are studies with a single intervention group of volunteer participants for whom there are rarely follow‐up assessments after treatment has ended 78. It is not yet clear whether burnout is generally susceptible to a range of strategies or whether it is crucial to fit the strategy to the specific context of a workplace to be effective.

The same basic points can be made about studies examining interventions specific to psychiatrists. There have been several recommendations about possible interventions, but no thorough research on whether these ideas are viable solutions. One fairly common recommendation emphasizes the importance of various forms of support, such as peer support groups, formal support via regular feedback and performance evaluation, or the use of a community‐based approach in the work environment. Interestingly, medical students and residents have also identified support as a critical factor, including support from faculty, peers, outside personal relationships, and counseling services 79.

Another suggestion involves having psychiatrists evaluate their workload frequently, to ensure they are not putting themselves at additional risk for burnout. A related recommendation is that psychiatrists should develop a more versatile lifestyle, in which they diversify their work (e.g., take on a part‐time teaching job, do some writing, or extend one's practice to other types of clients) and/or engage in activities outside of work (such as hobbies and other personal interests).

Mental health professionals who have worked in the areas of trauma and palliative care have made additional recommendations on how to deal with burnout 80, 81. Notably, one approach emphasizes the need to take care of oneself - and not only in terms of personal health and physical fitness, but also in terms of psychological wellbeing. Professionals who deal with trauma survivors are encouraged to work through their own personal traumatic experiences in order to prevent becoming "wounded healers" or secondarily traumatized therapists. Professionals working in hospice and palliative medicine are encouraged to focus on spirituality and human nature, via prayer, meditation, or religious services. Other methods for self‐care include taking regular breaks from work, advocating for better social recognition of the difficult work that is being accomplished, and focusing on the positive aspects of life, both at work and home, so that one is not overwhelmed by adversity and misery.

Although various studies have provided excellent ideas to explore as interventions, the logistics of funding, designing, implementing, and evaluating these ideas remain the primary obstacles to better knowledge about the best solutions for burnout. For example, a Swedish group contrasted two therapeutic modalities for people who had been on long‐term leave from work with a diagnosis of "work‐related depression". They found that both cognitive group therapy and focused psychodynamic group therapy were effective in facilitating their return to work, but found no difference in effectiveness between the two approaches 82. This study raises two important issues for further research. First, to what extent does "work‐related depression" map upon clinical depression, in contrast to mapping upon burnout? Second, what are the common qualities of the two therapeutic modalities that could serve as mechanisms in treatment efficacy?

CONCLUSIONS

Research to date indicates that the three aspects of burnout do present challenges for psychiatrists. Many of the issues for psychiatrists are similar to those facing other professionals providing human services to people in need of help. But additionally, psychiatric work entails close contact with people in emotional distress, and in some cases the potential for threats from some of these patients. Both of these stressors make demands on psychiatrists' energy, their capacity for involvement with others, and their sense of professional efficacy.

An issue of special significance to psychiatry is the alignment and differentiation of burnout and depression. The concept of workplace depression as a basis for workers' disability coverage in some European countries raises important issues for practitioners, which have extensive implications for employees, employers, and insurance providers. Research and conceptual development that includes multidisciplinary participation is needed for definitive progress.

Psychiatry is in a strong position to contribute to the growth of knowledge regarding burnout. The question of burnout's status as a basis for disability claims requires precise and objective assessment. Further, psychiatric‐based treatments may be relevant to burnout, especially regarding return to work for people experiencing severe burnout. Finally, effective research on preventing and alleviating aspects of burnout among psychiatrists requires giving the issue a high priority within the profession.

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Understanding the burnout experience: recent research and its implications for psychiatry

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The experience of burnout has been the focus of much research during the past few decades. Measures have been developed, as have various theoretical models, and research studies from many countries have contributed to a better understanding of the causes ...

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Talks for when you feel totally burned out | TED Talks

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Worn out? Exhausted? Bleary-eyed? If you need a little something to ease your frustration and get you back in the spirit, this collection of talks should help.

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Emily Nagoski and Amelia Nagoski: The cure for burnout (hint: it isn't self-care)

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You may be experiencing burnout and not even know it, say authors (and sisters) Emily and Amelia Nagoski. In an introspective and deeply relatable conversation, they detail three telltale signs that stress is getting the best of you -- and share actionable ways to feel safe in your own body when you're burning out.

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How to burn emotional burnout | BBC Ideas

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On lots of occasions, I've told myself - and my friends and colleagues - that I'm experiencing burnout. Making a living as a freelancer can often mean working long hours, and trying to keep a lot of very different plates spinning at once. A few times a year, I hit what feels like a creative wall: I'm fresh out of good ideas, and I just really need to nap. For a long time, I've been calling that burnout. But I've been wrong.

We tend to think of burnout as an intangible - one of those things we can't define, and we just know when we feel it. Right now, more of us may be feeling it than ever. In this stage of the pandemic, after more than a year spent trying to navigate its challenges, the general feeling is that we've all hit the wall.

But there is a scientific definition of burnout, and standards by which to measure it. And based on that criteria, a lot of folks who think they're burnt out - myself included - really aren't. That doesn't mean we aren't on the way there, though, and understanding how to really measure burnout can help individuals and organisations change course before it's too late.
What burnout is - and isn't
In 1981, Christina Maslach, a professor of psychology at the University of California, Berkeley, developed the Maslach Burnout Inventory (MBI), to define and measure the condition.

"The challenge is people use the term to mean different things," says Maslach. "It's a catchy term, so people apply it to all kinds of stuff. So, are we all speaking the same language?"

The MBI attempts to clarify the subject by evaluating burnout based on three criteria: exhaustion or total lack of energy, feelings of cynicism or negativity toward a job and reduced efficacy or success at work. Respondents get scores in all three areas along a continuum, from more positive to more negative. A burnout profile requires a negative score in all three.

"There's a tendency to think if you score negatively on one measure, you're burnt out," says Maslach, but that's an incorrect usage of the MBI. The biggest misconception about burnout, adds Michael Leiter, a Nova Scotia-based organisational psychologist and the co-author, with Maslach, of The Truth About Burnout, is that it's the same as exhaustion.

"People use burnout as a synonym for tired, and they're missing the point that there's a world of difference between those two states," says Leiter. He gives the example of obstetricians, who often work chaotic schedules. "They're delivering babies at all hours of the night, and they're totally exhausted, but they're bringing new life into the world, and making people's lives better, and they care about that work. That's overextended and exhausted, but it's not burnout."

There are plenty of others who meet one of the MBI criteria. "The second largest group, after people who are just exhausted, is people who aren't fully engaged," says Leiter. "They're going to work and it's not exciting, it just pays the bills. There's another group that are just cynical. They don't care about the clientele, or the work." Still others may have low efficacy, with careers that are stalled for one reason or another.

But fewer people can report that all three conditions apply. I can't. While I've definitely experienced exhaustion, and even some disengagement, I still love what I do and haven't become cynical about my work. It takes all three - exhaustion, cynicism and lack of efficacy - to get what's scientifically defined as burnout. The majority of us aren't there.

"It's not an epidemic; it's over-diagnosed," says Leiter. But that doesn't mean there isn't a problem, or that conversations around burnout aren't increasing for a reason. "Qualities of burnout are on the rise," concedes Leiter. "Certainly, more people are heading in that direction."
Burnout isn't black and white
Burnout is a spectrum, and most of us are on it. Early this year, when job search site Indeed surveyed 1,500 US workers across ages and industries, more than half reported that they're experiencing burnout. And more than two-thirds said the pandemic had made burnout worse.

That survey did not use the MBI, and chances are most of those respondents were using the colloquial definition of burnout, not the scientific one. But while burnout - the kind defined by three negative MBI scores - is a profile that Maslach says typically applies to 10% to 15% of people, that doesn't mean everyone else is all the way on the other end of the spectrum.

In fact, Maslach and Leiter's newer research identifies three profiles in between: overextended, ineffective and disengaged. Evidence suggests more than half of employees fall into one of these profiles, with a strong negative score in exhaustion, efficacy or cynicism. They're not yet burnt out - but they're on the way.

Many people equate fatigue with burnout, but experts say that burnout is a totally different state than just exhaustion (Credit: Alamy)

For people in many professions, says Leiter, things have only got worse as a result of the pandemic, with efficacy issues especially becoming overwhelming.

"Schoolteachers have struggled to continue teaching, and haven't felt accomplished," he says. "They just know they're not being the teacher they were before, and that's discouraging. It's the same for physicians. It's improved, but early in the game there were no protocols for dealing with Covid, and everything they were doing was wrong."

Those issues have shifted the data on burnout. A study conducted between March and June of 2020 administered a series of tests, including a burnout inventory similar to the MBI, to more than 3,500 healthcare workers in the UK, Poland and Singapore. Just under 67% measured as burnt out.

While historically the true burnout profile for employees in all professions hovers just above 10%, Maslach says "that's clearly gone up" in light of the pandemic. Now, she believes, it may be closer to 20%.

And that's a huge problem, because true burnout can't be fixed with a vacation or a wellness retreat.

"When people really get to the extreme, the vast majority can't go back to the same employer or the same kind of work," says Leiter. "They have to change careers. Burnout runs so deep - just even the feel of going into that building, or that sort of building can be a trigger. It very often prompts career change."
Why measurement matters
Avoiding true burnout on a wide scale is vital, especially because it could mean a drain of qualified people from skilled professions. That's where the MBI, and tests like it, become invaluable tools.

Learning that I was not, in fact, experiencing real burnout was helpful. I was able to evaluate what I was actually feeling (overextension), and start thinking about what was causing that and what changes I could make. That is the point of a burnout inventory; it's not really about diagnosing or ruling out burnout. In fact, says Maslach, "it's not a diagnostic tool at all. People have misused it that way, but it's a research measure."

Though it's administered to individuals, what the MBI is really designed to measure is their environment. "If there are negative scores, it doesn't mean the problem is the individual. It's what they're responding to," says Maslach. "You're not trying to figure out who it's happening to, you're trying to figure out whyit's happening. You don't use it by itself, you use it with other data to say why is the pattern of scores the way it is? Those scores should be used as warning signals."

An organisation seeing scores on the negative end of the spectrum should be acting quickly, says Maslach, and that doesn't mean offering yoga classes or mindfulness seminars.

"Work is getting tougher, longer and harder to do. People are working more hours because they're scared they won't get a promotion, or will lose their job. Doing more with less is at the heart of corporate culture, and that's not how people do the best work," she says. "There's this gigantic self-care industry out there all focused on how to cope with that stress; but to prevent, or reduce, or eliminate burnout, it's not about fixing the people. It's about fixing the job."

It's not actually about measuring how many workers are or are almost burnt out, says Maslach. It's about identifying workplaces with unmanageable workloads, and using that information to give employees more control, better tools and the discretion to figure out how to do their jobs better - without burning out.

"There's that old saying, 'if you can't stand the heat, get out of the kitchen,'" says Maslach. "The thrust of our argument is, why don't you change the heat? How about redesigning the kitchen?"

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Why we may be measuring burnout all wrong

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On lots of occasions, I've told myself - and my friends and colleagues - that I'm experiencing burnout. Making a living as a freelancer can often mean working long hours, and trying to keep a lot of very different plates spinning at once.

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When Jason Fried picks up the phone at 1000 each morning, the very first thing he says is, "I just woke up."

Fried, co-founder and CEO of US software company Basecamp, says prioritising sleep - and ensuring he's regularly getting enough hours of quality rest - is a major part of what makes him a good leader. It's a mindset that runs contrary to many other leaders, who have a tendency, says Fried, to use sleeplessness as "a badge of honour".

"Especially in the tech industry, you hear people brag, 'I only got three hours of sleep' or 'I pulled an all-nighter'. It's the whole 'sleep when I'm dead, put in the hours' thing," he says. "It's kind of gross - this idea that you 'need' to work so much, and that's the thing that'll get you ahead - putting in ridiculous hours. No one has the stamina or mental capacity to do 14 hours of work."

Instead, Fried believes in leading by sleeping more. His philosophy for himself and his Basecamp employees is "eight-eight-eight": eight hours of work and sleep each, and "eight hours of life in between", he says. "What ends up happening for most people is work takes the most; life is the stuff you try to fit in the gaps and sleep is what's left over."

This type of 'sleep leadership' is twofold, explains Tori Crain, assistant professor of psychology at Portland State University, US.

"One, it's about supporting workers in their sleep. That's things like a supervisor showing care and concern and checking in," she says. "And then there's this other component that's more around understanding and communicating the importance of sleep to doing a good job and performing in the workplace. That can mean leading in a way that helps employees get more sleep, and role modelling for employees how leaders themselves are sleeping and balancing work and sleep, and how they're thinking about sleep in relation to their work."

Basecamp's Jason Fried believes the "eight-eight-eight" method is the right approach for helping employees rest and work well (Credit: Courtesy of Jason Fried)

Since the beginning of the pandemic, companies are increasingly recognising the importance of employee wellness - especially as workers themselves demand it. Programmes such as access to better flexible working policies, increased leave and mental-health apps are among the common approaches. But less traditionally, modelling and encouraging good sleep behaviour is also emerging as another approach to support employees from burning out.

And though the rules of a more traditional corporate workplace may dictate that it's inappropriate to talk about what's happening in your bedroom, Swiss sleep neuroscientist Els van der Helm says a "younger generation of workers has changed this taboo dramatically. They want to talk about all these personal topics at work, because for them, work and personal life blend much more together".
'When you're tired, you suck'
A light sleep on the job isn't wholesale new, of course; in countries such as Spain and Italy, a mid-day break for lunch and a snooze has long been baked into company culture. Elsewhere in Europe, organisations including the National Trust, are beginning to embrace these "Mediterranean hours".

There are examples in the US, too; online retailer Zappos offers employees access to massage chairs, and staff were often encouraged by late CEO Tony Hsieh to take 20-minute daily naps. Nap rooms or pods are also available at companies including Google and Cisco.

But while a connection between napping and working has been around for a while - a 2008 survey showed more than 30% of American companies allow or encourage napping during the day, and 15% or more provide a place to do so - the concept of sleep leadership takes things a step further, prioritising policies that care for employees' sleep hygiene outside working hours.

Huffington Post founder Arianna Huffington has long been a proponent, even publishing a book (The Sleep Revolution) on the topic. Former Google executive Eric Schmidt has also written about the importance of sleep to employees and leaders alike. At health insurance behemoth Aetna, employees who can prove (using Fitbit data or other means) that they've had a good night's sleep can receive a per-night monetary incentive.

For Basecamp CEO Fried, sleep leadership is just practical.

"When you're tired, you suck," he says. "You don't think clearly or lead others well. If you run a team or are in charge of other people and you're sleep deprived, you're making their lives a lot harder. You're not pleasant to be around, you're not all there. You're short and terse and all the bad things that come from being exhausted."

Research chimes with this, according to van der Helm: studies have shown sleep-deprived leaders tend to "have less followership ", she says. "They're less inspiring. The team of a leader who's had a bad night is much less engaged at work."

On the flip side, employees who've had too little sleep aren't performing at their best. "They're interpreting workplace stressors more strongly than if they were sleeping well," adds Portland State University's Crain. "They're more likely to be reactive to stressors in the work environment, and have a harder time regulating emotions."

There's a "truly reciprocal relationship", continues Crain, between sleep and work. "If people aren't performing at work, it causes stress, and stress impacts sleep. Not sleeping well impacts work performance," she says.
Lousy sleep, lousy work
But while the problem is balanced on either side - lousy sleep translates to lousy work, and vice versa - the solution, says van der Helm, almost always lies in the workplace.

"It can be incredibly stressful to lie awake at night, knowing you have something to do the next day and worrying about it," she says. "If the topic of sleep is taboo at work, and no one ever talks about that, but work is what's keeping you from getting good sleep, there needs to be a significant cultural shift."

Sleep leadership means modelling behaviours like not sending emails after work hours, and detaching from screens late at night (Credit: Getty Images)

For Basecamp specifically, this has meant bringing conversations about sleep to the forefront, both when communicating internally as well as with employees. "We constantly talk about it internally," he says. "We share information about how to get better sleep and share how important it is. And that it has to start, I think, not with sleep but with work. Eight hours a day is enough."

To make a firm 40-hour work week possible, meetings are limited and carefully scheduled to allow large blocks of uninterrupted productive hours during the day, and employees sending emails with late-night timestamps may receive a "gentle reminder" that they aren't expected to work after hours.

Fried acknowledges, however, focusing on such a private activity as sleep can cross the line into paternalism. A few years ago, his company partnered with a start-up that used a device under a mattress to track movement and heart rate and collect data about the quality of people's sleep. "We brought in the guy to talk about the importance of sleep, and bought everybody one of these things if they wanted it," he says. "Some people became really religious about it and became better sleepers, which is great. But for me, it started to feel kind of weird [even though] we weren't actually receiving any of the data."
Starting with sleep
As conversations around employee wellness ramp up across many companies - influenced both by the pandemic and a workforce increasingly dominated by millennials and Gen-Z - healthy sleep is finding a platform, too.

"We're seeing almost, like, marketing campaigns within organisations to create awareness around the topic of wellbeing," says van der Helm. "They often start with exercise and nutrition - I think you should actually start with sleep because it's so fundamental."

While more companies follow that lead and remove the taboo from discussions about sleep, it's only the first step in sleep leadership, van der Helm emphasises. "Often, the modelling is lacking," she says. "Maybe there's support for employees, but the top leadership isn't necessarily changing anything and the culture isn't changed at all. Then people can struggle."

Ultimately, sleep leadership is about both talking, and (sleep)walking that talk.

"Really, there's power in using peers and leadership to address these problems," van der Helm says. "It can be very freeing to discuss these things. For whatever reason, once we get started, we all find it easy to admit what is keeping us up at night. The impact of sleep deprivation at work is really big, so I'm really happy there's a push for these topics to be addressed at work. In the end, if you want people to sleep better, work can be the cause and the solution."

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Can 'sleep leadership' help banish burnout?

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When Jason Fried picks up the phone at 1000 each morning, the very first thing he says is, "I just woke up." Fried, co-founder and CEO of US software company Basecamp, says prioritising sleep - and ensuring he's regularly getting enough hours of quality rest - is a major part of what makes him a good leader.

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Jourdyn A. Lawrence, 1, 2, 3 Brigette A. Davis, 2, 3 Thea Corbette, 1 Emorcia V. Hill, 1 David R. Williams, 2, 4 and Joan Y. Reede 1, 2, 5

Abstract

Keywords: Burnout, Underrepresented minority, Emotional exhaustion, Measurement

Introduction

Medical staff and faculty in academic medicine experience an alarmingly high level of stress [ 1]. Their large and expanding workload requires managing increasing institutional demands, uncertainty in research endeavors, patient care requirements, and expectations regarding student and/or trainee education and administrative tasks. These forms of occupational stress, combined with the challenges of balancing work and family responsibilities, have been associated with reports of symptoms of depression, anxiety, work strain, and discontent [ 2- 6]. Such occupational stress may negatively affect medical staff and faculty well-being and increase the prevalence of burnout [ 7- 9].

Burnout has come to be described as emotional exhaustion, loss of work interest, frustration with feeling ineffective, and the tendency to see people as objects rather than humans [ 10, 11]. Though burnout is common in a multitude of professions, it is well documented and prevalent among medical professionals and has increasingly become a topic of focus [ 6, 12, 13]. Among faculty in US medical schools, it is estimated that approximately 29% of faculty reported experiencing one or more symptoms of burnout [ 14], though there have been varying estimates of prevalence among medical students, residents, and early-career physicians [ 12, 13]. Burnout has negative effects on both work and personal life. Research suggests that burnout is associated with a decrease in professionalism, productivity and quality of medical care, as well as an increase in medical mistakes and intent to leave [ 4, 11, 15, 16]. Additionally, there are serious personal consequences to burnout, including relationship issues, alcohol dependence, and suicidal ideation [ 5, 6, 11, 17, 18].

The conditions which increase the likelihood of burnout among medical professionals, such as stress, pressure to succeed, and experiences with interpersonal discrimination, vary across populations, particularly by race/ethnicity. For instance, focus groups from a sample of medical students around the USA found that lack of cultural representation, racial discrimination, and stereotyping are perceived barriers to success among students self-identifying as Black, Latinx, and Asian [ 19]. Another nationally representative sample of medical school students found that 64% reported attending an institution with a negative racial climate, and 81% reported witnessing someone else being discriminated against [ 20]. These incidents were associated with greater distress and depression scores than individuals who did not report these events. Evidence suggests these experiences continue throughout training and into the professional setting. Non-white faculty in academic medicine report discrimination within their professional/academic environments [ 21, 22], with personal experiences of discrimination associated with lower career satisfaction [ 21].

Before June 2003, the Association of American Medical Colleges (AAMC) defined underrepresented minority (URM) as Black Americans (i.e., African American, Caribbean-American), Latinx Americans (i.e., Mexican American, Puerto Ricans), and Native Americans (i.e., American Indians, Alaska Natives, and Native Hawaiians) [ 23]. Since 2003, the AAMC utilizes underrepresented in medicine (UiM) to refer to "racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population" [ 23]. Given that the focus of this study is UiM, we will utilize UiM throughout and only use URM when used by the authors themselves.

Data from faculty responses to an AAMC survey on faculty engagement indicate that approximately 35% of URM women and 21% of URM men faculty reported experiencing symptoms of burnout [ 14, 24]. Such prevalence of burnout among UiM may have implications for intent to leave the position and work satisfaction [ 14] and suggests a need to further understand burnout among UiM to mitigate its effects and identify points for intervention. Though there are efforts to prevent, alleviate, and increase awareness about burnout, there remains little focus on URM, specifically underrepresented in medicine (UiM) [ 24].

Burnout Conceptualization

While the present study is not intended as an extensive overview of relevant theories related to burnout, an understanding of how this concept has been theorized is crucial for examining burnout's measurement, pitfalls, and areas for future work, specifically for UiM populations.

In 1975, Freudenberger defined burnout as symptoms resulting from "excessing demands on energy, strength, or resources" [ 25]. Building on this, Maslach and Jackson developed the Maslach Burnout Inventory (MBI) in 1981, describing burnout as a syndrome of "emotional exhaustion and cynicism" that is accompanied by a "tendency to evaluate oneself negatively, particularly with regard to one's work" [ 11]. The MBI includes three subscales, including depersonalization/cynicism (i.e., withdrawal and inappropriate interactions with others), personal accomplishment (i.e., self-efficacy, success), and emotional exhaustion (i.e., emotional and psychological depletion, affective aspects [ 26]). The original presentation of the MBI, and several articles that followed, found the MBI to exhibit high validity and reliability; they also found the MBI to be useful across several occupational fields [ 27] and to be associated with job satisfaction, burnout, and assessments of burnout by faculty [ 28].

Additional tools to operationalize burnout were developed after researchers observed several limitations in the MBI. For example, (1) there is little to no variation in the framing of emotional exhaustion and depersonalization items, such that all items are negatively worded in these subscales, but personal accomplishment items are all positively framed [ 29]; (2) personal accomplishment may be seen as a precursor or result of burnout, thus emotional exhaustion and depersonalization remain as key constructs of burnout; and (3) some items may not be seen as relevant to populations outside of the USA [ 30].

Demerouti and colleagues introduced the Oldenburg Burnout Inventory (OLBI) to address the issue regarding the framing of items in the MBI (e.g., only negatively worded items in the emotional exhaustion and depersonalization subscales) [ 31]. Incorporating positively and negative worded items, the OLBI was created to examine both ends of the burnout continuum. The scale examines burnout in two dimensions, focusing on measures of affective, cognitive, and physical aspects of exhaustion and disengagement from work (e.g., lack of engagement with work) in order to be applicable to a broader range of occupational workers [ 29]. The OLBI omits the concept of personal accomplishment as a separate component of burnout as presented in the MBI, due to evidence suggesting that emotional exhaustion and depersonalization develop together, while feelings of personal accomplishment (or the lack thereof) were found to develop independently [ 31]. Additionally, Demerouti and colleagues identified literature that suggested that personal accomplishment could be conceptualized as a consequence of burnout [ 32], a personality characteristic (e.g., "self-efficacy"). Additional analysis by Halbesleben and Demerouti found the OLBI to be a valid alternative to the MBI, specifically as it relates to examining a more comprehensive assessment of burnout that also encompasses engagement [ 33].

Kristensen and colleagues introduced the Copenhagen Burnout Inventory (CBI) in 2005 [ 30]. The authors developed the CBI in response to several issues noticed in the MBI, including, but not limited to, (1) an unclear definition of the MBI and burnout (i.e., the definition implies that all three dimensions [emotional exhaustion, depersonalization, and reduced personal accomplishment] constitute burnout; however, the MBI operationalizes each measure independently and the items are not combined to create a single score) and (2) the inaccessibility of the MBI questionnaires due to their commercial distribution [ 30]. The CBI conceptualizes the core components of burnout as fatigue and exhaustion, measuring "the degree of physical and psychological fatigue and exhaustion" in three domains: personal, work-related, and client-related burnout [ 30]. Similar to the MBI, the CBI only includes negatively framed items with the exception of one item in the work-related burnout domain. While the domains exhibit high reliability, issues were raised with the examination of burnout as a singular construct and the similarity of fatigue and exhaustion in the CBI to chronic fatigue [ 34].

Though emphasis is placed on the MBI, OLBI, and CBI given their frequency of use, burnout has also been operationalized using several measures including the Utrecht Burnout Scale [ 35], the Professional Quality of Life/Compassion Satisfaction/Fatigue Self-Test [ 36], the Burnout Measure [ 37], single items, and investigator-developed measures. However, the utility of these measures has not been examined among UiM specifically.

In this context, the present systematic review aims to examine literature investigating burnout among UiM. We focus on what measures are currently being utilized and among which racial/ethnic groups. Through assessment of the literature, we characterize what is known regarding the prevalence and measurement of burnout among UiM and suggest additional points of consideration regarding the unique experiences, expectations, and stressors that may distinguish factors contributing to burnout and occupational stress for UiM. When available, we also report results disaggregated by race/ethnicity.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed articles examining racial and/or ethnic differences in burnout among medical students, residents/interns, physicians, and university faculty.

Search Strategy

Articles were located using PubMed, PsycINFO, Countway Discovery Medicine, and Web of Science databases. The full list of search terms used, by database, is included in Table . Our initial search of the above databases, conducted on July 30, 2018, included all of the terms listed in Table , with the exception of clinician-educator. This initial search yielded 1774 studies upon the removal of duplicates. An updated search was conducted on August 3, 2018, including the term clinician-educator, yielding 49 additional studies after the removal of duplicate literature.

Study Selection

Our search strategy yielded 1823 studies that underwent title and abstract screening to determine their relevance to the present research. Two reviewers (J.A.L. and B.A.D.) conducted title and abstract screening independently, using an online systematic review software-Covidence [ 38]. Articles appearing relevant for full-text review were also independently screened by two reviewers (J.A.L. and B.A.D). Discordance in decisions was resolved by discussion and consensus. Bibliographies of relevant literature were also searched for additional articles.

Inclusion Criteria

Studies were considered eligible for inclusion if they were empirical quantitative analyses, assessed burnout among the above fields/roles, and were published in English. No date limits were applied. Exclusion criteria included focus on populations other than those listed above, no assessment of burnout, not a quantitative analysis, and no assessments by race and/or ethnicity.

Quality Assessment

We conducted quality assessment using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies available through the National Heart, Lung, and Blood Institute (NHLBI) [ 39]. The tool contains 14 "yes" or "no" questions that are used to examine potential sources of bias across several dimensions including sample selection, exposure and outcome assessment, and adjustment for potential sources of confounding that are used to assign a rating of good, fair, or poor. Ratings were independently assigned by two authors (B.A.D. and J.A.L) and assessed the quality of each article deemed eligible for inclusion.

Results

The initial result of our searches yielded 3540 titles of which 1717 were excluded as duplicates. This left 1823 studies that underwent title and abstract screening. Full-text review was completed among 166 studies. Sixteen studies were considered eligible for inclusion. The study selection process is illustrated in Fig. .

Studies deemed eligible for inclusion examined differences in burnout among racial/ethnic groups in varying positions (e.g., physicians, residents, students). Table provides the descriptive statistics of the studies, with a brief summary of associations observed presented in Table . All studies which met the inclusion criteria were published between 2004 and 2016. Nearly all studies were cross-sectional ( n = 15) in design and conducted among populations in North America ( n = 15). Most studies examined burnout among medical students or physicians and used the Maslach Burnout Inventory, though other instruments used included the Copenhagen Burnout Inventory, the Professional Quality of Life/Compassion Satisfaction/Fatigue Self-Test, or single-item measures. Nine of the 12 studies that reported sufficient data to ascertain racial/ethnic demographics had populations comprising ≥ 50% of white or non-Minority samples. Four studies did not provide counts or percentages of the racial/ethnic composition of the samples. Findings from eligible studies are grouped based upon the population examined.

Table 2

Table 3

Faculty

Pololi et al. [ 40]

Faculty within Academic Health Centers (AHC) affiliated with the Association of Medical Colleges

Cross-sectional

2218

Single item answered using a 5-point Likert scale: "I feel burnt out"

UiM (512, 10%) b, non-UiM (1706, 90%)

No association

Primack et al. [ 41]

Mixed (40% faculty; 23% residents/trainees; 23% medical students; 15% fellows/post-doctoral scholars)

Cross-sectional

179

Single item

Asian (31, 21%), white (95, 65%), other (20, 14%)

Positive association

Physicians

Meredith et al. [ 43]

Physicians

Cross-sectional

515 (191 PCCs; 324 staff)

Maslach Burnout Inventory-EE subscale

PCCs-Latinx (9, 5.1%); non-white, non-Latinx (74, 38.7%)

Negative association

Cossman and Street [ 47]

Physicians

Cross-sectional

1449

Single item answered using the following scale: persistent, occasional, stressed (but no burnout), and no burnout

Black, white, other b

No association

Keswani et al. [ 46]

Physicians

Cross-sectional

410

Maslach Burnout Inventory

African American, white, Hispanic, Asian, other b

No association

Residents/trainees

Afzal et al. [ 48]

Residents

Cross-sectional

115

Maslach Burnout Inventory-Human Services Survey

Caucasian (18, 15.7%), Asian or African (34, 29.6%), Hispanic (63, 54.8%)

No association for EE and D compared to Hispanic for both groups

Negative association for higher PA Hispanic/white; no association for Asian or African/Hispanic

Medical students

Cook et al. [ 49]

Medical students (year 3)

Cross-sectional

564

Two-item version of the Maslach Burnout Inventory-EE and D subscales

Asian (128, 23%), Black (48, 9%), Hispanic (28, 5%), white (329, 58%), other (31, 5%)

No association

Dyrbye et al. [ 50]

Medical students (years 1-4)

Cross-sectional

1689

Maslach Burnout Inventory

Minority (410, 24%)-including African American (61), Hispanic (50), Asian (186), Native American (23), Pacific Islander (8), non-Caucasian other (82)

Negative association

Among minority students, student reporting race as an adverse effect on MS experience, positive association

Non-minority (1279, 76%)

Dyrbye et al. [ 51]

Medical students (years 1-4)

Cross-sectional

538

Maslach Burnout Inventory

Minority (84, 15.6%)-including African American (8), Hispanic (9, Asian (40), Native American (11), Pacific Islander (3), non-Caucasian other (13)

No association

Positive association for low PA

Non-minority (454, 84.4%)

Dyrbye et al. [ 55]

Medical students (years 1-4)

Cross-sectional

1701

Maslach Burnout Inventory

Non-white, white b

Negative association

Premedical students

Fang et al. (2014)

Premedical students

Cross-sectional

2059 (618 pre-med; 1441 non-pre-med)

Maslach Burnout Inventory-Student Survey

Asian (1141, 55.4%), Caucasian (539, 26.2%), Hispanic (203, 9.9%), other (176, 8.5%)

Positive association among pre-med Hispanic students compared to non-premed Hispanic students

Faculty

Of the 16 studies, only one study focused specifically on racial/ethnic differences in burnout among faculty in academic medicine. The cross-sectional analysis, conducted by Pololi and colleagues among a sample of 2218 faculty (512 UiM) identified from the AAMC list of academic health centers, found no statistically significant difference in faculty vitality (i.e., perceptions of being energized by work, looking forward to work, feeling satisfied by work, being proud to work at the institution or feeling burnt out [reverse coded]) by UiM status [ 40]. Additionally, there was no statistically significant difference in vitality by rank (i.e., professor, associate professor, or assistant professor) or role (i.e., clinician, researcher, administrator, or educator).

Two studies examined racial/ethnic differences in burnout among university faculty. Primack et al.'s analysis of racial differences in burnout found early-career, URM clinical investigators to have higher prevalence of burnout (30%) compared to white (18%) and Asian (3%) investigators ( p = 0.02) [ 41]. In a study among full-time university faculty at one university on the west coast, Lackritz found no statistically significant differences in burnout among faculty by race/ethnicity when collapsed across non-white categories (Black, Asian, Latinx, South Asian, Middle Eastern, and American Indian); however, these findings were not further disaggregated by type of school or departmental affiliation to disentangle specific effects among faculty within medical fields [ 42].

Physicians

Several studies ( n = 5) assessed burnout among physician populations. An analysis among primary care physicians found that Latinx physicians reported significantly less emotional exhaustion compared to white and non-Latinx non-white physicians [ 43]. Separate analyses among neonatologists found Hispanic physicians reported greater compassion satisfaction, though no statistically significant racial/ethnic differences in compassion fatigue or burnout [ 44]. Other analyses found no statistically significant differences in burnout by race/ethnicity. Work by Kroll and collaborators found there was no evidence of significant differences in emotional exhaustion, depersonalization, or personal accomplishment by race among a sample of pain physicians [ 45]. In an assessment among gastroenterologists, Keswani and colleagues found no statistically significant differences in burnout by race/ethnicity [ 46]. Similarly, no differences were observed in burnout among a sample of physicians in Mississippi [ 47].

Residents/Trainees

One study examined racial/ethnic differences in burnout among residents in one academic health center [ 48]. Differences in burnout were assessed from white, Asian or African, and Hispanic residents from several specialties (i.e., emergency medicine, general surgery, family practice, internal medicine, pediatrics, and obstetrics/gynecology). Findings suggested that there were no statistically significant differences in emotional exhaustion and depersonalization for white or Asian and African residents compared to Hispanic residents; however, the authors observed a significant increase in lower personal accomplishment scores among white residents compared to Hispanic residents in fully adjusted models.

Medical Students

Studies examining racial/ethnic differences in burnout were primarily conducted among medical students. Of the six studies conducted within populations of medical students, 4 found no evidence of statistically significant differences in the prevalence of burnout by race/ethnicity [ 49- 52]; however, one found that non-minority students were significantly more likely to be burned out, and have higher depersonalization and emotional exhaustion scores [ 50]. In that study, the authors also found that among minority medical students, experiencing discrimination, prejudice, and isolation was frequently reported and was associated with being more likely to meet the established cutoffs for burnout and having high emotional exhaustion and depersonalization scores [ 50]. Others found more nuanced associations by race/ethnicity [ 53- 55]. Dyrbye and collaborators found that non-white medical students had greater odds of recovering from burnout and greater odds of resiliency, compared to white medical students [ 54]. In a separate analysis of medical students from 5 US medical institutions, Dyrbye et al. found non-minority students to have significantly greater odds of burnout compared to minority students [ 55]. Fang et al. also examined burnout among pre-medical students to understand whether burnout in medical school may be preceded by burnout in pre-medical training [ 53]. The authors found that Hispanic, pre-medicine students scored higher on cynicism and overall burnout compared to non-pre-medicine Hispanic students; however, no differences were observed for emotional exhaustion or personal accomplishment.

Study Quality and Risk of Bias

Using the criteria from the quality assessment tool available through the NHLBI, we identified concerns for potential bias among included studies (Fig. ). While included studies did not provide power calculations, all but two reported either sample size justifications or variance and effect size estimates. The majority of studies were cross-sectional and as such their data collected and subsequent analysis represented a single point in time. Variations in the ability to control for confounding variables were observed-particularly among studies that examined bivariate associations ( n = 8) compared to those that conducted forms of multivariable regression ( n = 8), though several important variables were considered in most papers. The majority of studies had sufficient participation rates (≥50%) and also provided clearly defined and validated outcome measures for all study participants. Based upon these criteria, 15 of 16 studies were classified as having good quality, with one receiving the assessment of fair.

Discussion

Our review documents the variation in burnout among UiM in existing literature, a contribution to the present understanding of burnout. Included studies were systematically drawn from several databases, used varied instruments to operationalize burnout, and included analyses conducted among several populations (e.g., faculty, medical students).

We observed that studies which assessed the prevalence of burnout among UiM produced inconsistent findings across various populations. For instance, some studies found that UiM experience burnout at lower rates compared to non-UiM [ 43, 55], while others have found no difference [ 40, 42, 44- 47, 49, 52] or greater burnout rate among UiM [ 41, 53]. Differences in results may be attributed to the variation of populations assessed-particularly given that many studies were composed of large populations of non-UiM participants-or covariates considered in the regression (e.g., socioeconomic status, specialty, years of practice). Another potential cause of this inconsistency may lie with how burnout is currently measured-particularly in how it is operationalized, and its accuracy in identifying burnout among UiM. Although most studies utilized the MBI, variations in the number of items or subscales used may lead to differences in results. To our knowledge, the psychometric properties of the MBI have not been examined among UiM populations. However, efforts to understand and measure the experiences of UiM in academic medicine may have the potential to help identify the presentation of burnout and address the sequelae of burnout in these populations.

The review of quantitative literature has highlighted the complexities of examining burnout among UiM. The majority of studies (15 of 16) identified were cross-sectional in design, which are unable to establish temporal relationships between the exposure and outcome (i.e., burnout). Statistical methods of some articles were limited to correlational assessments, t tests, or minimally adjusted linear or logistic regression models which fail to account for additional covariates; however, half of the studies conducted multivariable regressions that adjusted for potential confounders. Some models controlled for factors such as specialty, debt, socioeconomic status, and hours worked per week; however, these variables may be correlated with UiM status and mask differences in burnout. Future research on burnout among these populations would benefit from longitudinal designs, to help identify key precursors to burnout symptoms, as well as better consider for possible confounders such as institutional factors or mediators, such as promotion, that may shape trainee or faculty experiences. Longitudinal analysis, beyond the cross-sectional approaches, might also lend further insight into what individual and institutional factors facilitate successful transitions from medical school matriculation into practice and/or faculty positions and the role of burnout in that process. Another limitation of the existing literature includes the lack of focus on intersectionality (e.g., LGBTQ+ status, class, gender). For example, examining how marginalized identities intersect and affect burnout across UiM status and gender may provide an understanding of factors shaping burnout development by considering the racialized gender discrimination that UiM women face [ 24, 56].

Moreover, the conceptualization of burnout among UiM is limited to the scope of existing measures-failing to contextualize the unique experiences and factors pertaining to burnout among minority faculty, students, and physicians, and potentially resulting in underreporting. A majority of studies examining burnout among UiM utilized the MBI to elucidate differences in burnout; however, the utility of the MBI as the gold standard has been questioned by researchers [ 29, 30]. Studies have highlighted the differential manifestation of burnout across groups and time, finding differences in the utility of the MBI, OLBI, and CBI depending upon which population the measure is utilized in [ 27, 30, 31, 33, 34]. Additionally, existing measures of burnout fail to account for critically relevant constructs that structure the lived experiences of UiM, specifically (but not limited to) racism, sexism and gender discrimination, tokenism, isolation or lack of inclusion, resilience, and social support [ 57- 60]. Experiencing discrimination, microaggressions and implicit bias from students, colleagues, or the institution can result in isolation and feelings of not belonging [ 61, 62]. Experiences of discrimination within academia can manifest as the devaluation of research interests and skill sets of underrepresented minority faculty [ 61]. Gendered and race-based assumptions of competency, a type of microaggression in the workplace, are documented [ 63- 66]. Specifically, "double doubt" was mentioned in reference to Black women faculty, where their competence was questioned as a result of being Black and a woman [ 63]. URM faculty also face the expectation to take on additional service responsibilities related to diversity, mentoring and advising for URM students-a practice referred to as the "minority tax" [ 61]. Interviews among Black faculty highlighted differences in the expectations regarding service responsibilities [ 63]. These additional institutional service responsibilities affect promotion, tenure, and time available to do research (an item heavily weighted in promotion and tenure consideration) [ 61, 63]. Additionally, while resilience, coping, and social support are useful for combating adversity and have been suggested as reasons for the lower prevalence of burnout among UiM [ 54], drawing on individual resources yet failing to provide institutional change does little to mitigate and improve burnout outcomes [ 67]. These experiences may be important to consider when evaluating burnout among UiM at each career stage.

This review was limited by the availability of literature on burnout among UiM ( n = 16), highlighting the need for more research that examines differences in burnout and its implications by race/ethnicity. Additionally, given that this review restricts inclusion to studies that were published in English, contributions of the literature in other languages were not examined.

To better understand and improve the measurement of burnout among UiM populations, we have identified several points for consideration. Future research should further examine burnout by race/ethnicity, including issues of intersectionality, and contextualize the findings within the structural and systemic barriers specific to UiM populations. The historical and present lived experiences of the racial/ethnic groups that comprise UiM categorizations vary greatly; examining differences in burnout through the lens of UiM as a monolith may mask heterogeneous differences and increase the risk of specific groups being underserved or overlooked. Additionally, in order to not only focus on burnout prevalence, identification, and mitigation-but to also encourage positive outcomes-investigators may benefit from considerations of burnout as existing on a spectrum spanning from thriving (or other forms of well-being) to burnout. Improved measurement of burnout among UiM would benefit from mixed-method approaches where focus groups and/or interviews contribute to the development of instruments to measure burnout-ensuring that experiences and feelings of burnout (and well-being) specific to UiM are included. These measures should also be validated among UiM populations.

Research should also examine multilevel systems (e.g., institution, department, and individual) and the development of interventions that consider the context (e.g., discipline, academic setting, clinical setting), cultural relevance to and heterogeneity of UiM populations in supporting positive psychological outcomes and mitigating burnout.

A growing body of research suggests that what has been described as burnout exists as a consequence of the institutional environment of the healthcare system, and that moral injury-first attributed to healthcare by physicians Talbott and Dean (2018) [ 68]-better describes the experience of mental distress than burnout. Originally observed among Vietnam War veterans, moral injury is distress caused by engagement in duties (often involuntarily) which were misaligned with personal moral values [ 69, 70]. For physicians, competing needs of the healthcare system, such as business imperatives, regulatory and reporting requirements, or policies and practices that may lead to disparate outcomes for certain populations of patients and communities, may lead to moral injury. As research continues to emerge on how best to describe, name, and address physician distress [ 71- 73], it is imperative that the potentially differential experiences among UiM are examined. This will likely be an ongoing topic due to the stress and sacrifices associated with the COVID-19 pandemic, particularly as people of color remain most at risk for exposure and death due to structural factors and racism [ 74].

There is also a need for research to consider the stability of measurements of burnout. Researchers should assess critical periods of heightened susceptibility to burnout, investigate whether burnout is a transient state or a lasting one, and explore the implications of burnout on faculty, student, and trainee thriving, career and learning outcomes, recruitment, retention, and ways to encourage positive outcomes.

This work underscores the persistent exclusion of UiM individuals from multiple dimensions of study-theoretical and conceptual framing, measurement, analysis, and forging an evidence-based action agenda. This has led to insufficient understanding of the burnout phenomena for UiM students, trainees, physicians, and faculty. It is incumbent that those who both generate and utilize knowledge intentionally address and more fully apply the insights gained through this review in moving toward a more inclusive response to burnout among all members of the academic community.

Conclusion

Literature has documented that academic faculty, physicians, and medical students experiencing high levels of occupational stress and burnout were more likely to report an intention to leave their current position (or medical school) or reduce hours to part-time work [ 2, 8, 75- 77]. Last, but most importantly, the present body of work speaks to the need for increased focus on burnout of UiM. By omitting the experiences of UiM, we may miss opportunities for efforts that increase the retention, recruitment, well-being, and personal and professional trajectories for UiM physicians, faculty, students, and residents.

Funding

This study was supported by the Aetna Foundation, an independent, charitable and philanthropic affiliate of CVS Health that supports projects to promote wellness, health, and access to high-quality healthcare for everyone. The views presented here are those of the authors and not necessarily those of the Aetna Foundation, its directors, officers, or staff. The authors are indebted to the Foundation for their generosity.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

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Racial/Ethnic Differences in Burnout: a Systematic Review

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Jourdyn A. Lawrence, 1, 2, 3 Brigette A. Davis, 2, 3 Thea Corbette, 1 Emorcia V. Hill, 1 David R. Williams, 2, 4 and Joan Y. Reede 1, 2, 5 Keywords: Burnout, Underrepresented minority, Emotional exhaustion, Measurement Medical staff and faculty in academic medicine experience an alarmingly high level of stress [ 1].

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If you're feeling burned out, exhausted or at your wit's end, you're not alone. Many people are experiencing work stress, overwhelm and a struggle to keep slogging through. But you can reignite and get your mojo back. It's about realizing where the pressure is coming from and relieving it.

Burnout receives plenty of attention in key fields like tech, healthcare, retail work and social work-and this is certainly justified. But any job can be stressful. In fact one study by Microsoft of 30,000 people in 31 countries found 54% of people felt overworked and 39% felt exhausted.

Burnout also tends to overlap with symptoms of depression, according to research by City College of New York. And a study by Nominet found 88% of tech workers were stressed, and they were experiencing negative effects on physical health, mental health, work-life satisfaction and relationships.

What's Causing Burnout

It's no wonder people are struggling since overload is real. Digital communication is a root cause since there is so much communication and cognitive traffic. The Microsoft study found meeting time has risen 148%, chats have risen 45% and the number of documents people are working on has risen 66%.

But it's not just demanding work which is burnout-inducing. It's a lack of control. A study by Indiana University found when people had high-pressure jobs with control, they were less stressed, but the combination of high-pressure work paired with a lack of control was associated with a 15% increase in likelihood of death.

Burnout is most typical in situations people face high levels of demand and have little control over their work. It is also common when people feel they've been treated unfairly or when they feel disconnected from others.

But What Is Burnout, Really?

Beyond the buzzword, what is the experience of burnout? It's characterized by feelings of physical, mental and emotional exhaustion. Burnout is also characterized by doubt and shame-and people questioning their own capabilities and competencies. Burnout typically progresses to cynicism as well. Overall, it is a sense of hitting bottom, feeling helpless and experiencing negativity.

Importantly, burnout isn't just an individual experience either. According to a study by Michigan State University, it can actually be something you catch from others, or spread to others. Why? When people are struggling, they have a tough time providing support to those around them, and the whole network is affected.

Reducing the Pressure

A big part of burnout is pressure, and you can relieve it in three ways-finding ways to re-ignite your work, your life and your motivation.

Pressure To Perform

Chances are, you feel a great amount of pressure to perform. Over time, headcounts have been reduced by companies and people have left of their own accord. But the work hasn't gone away. As a result, many people experience increasing demands to address a myriad of responsibilities within the same envelope of time. It's important to recognize people also put pressure on themselves to perform. You feel the need to succeed and achieve-and to do more all the time. This is a hallmark of burnout-overwhelm and a view of your demands as greater than your capability or capacity.

You can mitigate this pressure by giving yourself space to make mistakes and admit them. You can contribute to a culture where others can do the same. Be open when you're personally struggling, ask for help and also strive to be more accepting of others. You have more influence than you may realize, and by making constructive personal choices, you're empowering others as well-and potentially starting a virtuous loop of positive actions.

Do your best, because your performance impacts on others, but also be realistic about what you can accomplish and push back on expectations when they are unreasonable. This is easier said than done, admittedly-but if you plan your work and understand what tasks take in terms of time, you can set boundaries based on the evidence of the work's requirements compared with the time you have available.

Pressure To Progress

Another aspect of pressure which people tend to put on themselves is the pressure to advance in their careers. The next promotion beckons or you believe the pay raise is the surest way to know you're valued. Career inflation suggests you must always be advancing in order to be successful, or you must always be happy in your work.

Burnout looms when you feel stalled or as if you're not moving fast enough. By putting pressure on yourself or judging yourself negatively, you're adding to the emotional labor you're doing. For some people, even feeling burned out adds to their stress-their burnout exacerbates their burnout. You may be feeling overworked with tasks, but this pressure contributes to overwork in terms of the emotional effort you're putting in.

Take a breath. In reality, you won't always love what you do, and career progress takes time. It may happen in fits and starts rather than a steady, undisrupted path. You tend to hear stories of those who move quickly up the ranks, but the majority of people take their time, do their time and even veer off course sometimes. You can achieve career growth in multiple ways-by expanding your network, by learning new skills or by shifting to a role which gives you new experiences in a lateral move. All of these are cause for celebration for the positive momentum you're continually building.

Redefine your success and reset your clock for advancement so you don't feel so hurried to progress. Be patient and enjoy the stage of your career you're at now, and revel in the learning you're getting every step of the way.

Pressure To Be Perfect

Another element of pressure which can exacerbate burnout is the desire for perfection. This has been amplified in the last handful of years through social media. As the saying goes, "Comparison is the thief of joy." You've heard it before, but it's important to remember in the burnout discussion-the best yardstick for your success is your own.

When you compare with others on social media, you're comparing to a curated version of people's achievement which is typically void of the true challenges they've faced. You're seeing them plant the flag at the top of the mountain, but you can't see their falls or their skinned knees from all their false starts and backslides during their climb.

Burnout is also characterized by feeling isolated or disconnected from those around you. If you're always in a state of comparison and competition with others, it will get in the way of building strong relationships. It's hard to feel close to the colleague you're trying to beat out, and it's tough to share learning and commiserate when you're protecting your image.

Better to remind yourself there is enough to go around and excellence doesn't have to be a zero-sum game. In fact, when you help others get ahead, you contribute to a culture that is generous and supportive-the kind of organization you want to be part of. In addition, when you strengthen relationships, you help yourself. Not that you're keeping count, but contributing to others' success will pay you back when they support to you, in turn.

In Sum

Burnout is certainly the result of the conditions you face, and work is legitimately tough. But you can take control, reignite and reimagine your future with a level of hope.

Relieve the pressure you place on yourself and others. Take small steps and embrace the progress of each increment. You have the power to reduce your burnout through your own choices, and you have influence on the conditions around you-through your actions and support of others.

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Getting Beyond Burnout: 3 Ways To Reignite

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If you're feeling burned out, exhausted or at your wit's end, you're not alone. Many people are experiencing work stress, overwhelm and a struggle to keep slogging through. But you can reignite and get your mojo back. It's about realizing where the pressure is coming from and relieving it.

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Many of us are hitting a new stage of pandemic slog in February.

Twenty-four percent of Americans reported they were "not too happy" in life in 2021, up from 13% in 2018, according to the General Social Survey, a sociological survey conducted by research organization NORC at the University of Chicago. The share of those who said they were "very happy" declined to 19% from 31% over the same period.

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Still Feeling Pandemic Miserable? There Are Ways to Dig Out

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Many of us are hitting a new stage of pandemic slog in February. Twenty-four percent of Americans reported they were "not too happy" in life in 2021, up from 13% in 2018, according to the General Social Survey, a sociological survey conducted by research organization NORC at the University of Chicago.

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Teachers are picking up slack for absent colleagues. They're covering for unfilled positions. And 55% of them say they will leave teaching sooner than they had originally planned, according to a poll of its members by the nation's largest teachers union.

The National Education Association poll, conducted in January, helps quantify the stress being placed on educators right now. It found that the number who say they'll leave the profession sooner has risen significantly since August. Among the NEA poll's other findings:

90% of its members say that feeling burned out is a serious problem.

86% say they have seen more educators leaving the profession or retiring early since the start of the pandemic.

80% report that unfilled job openings have led to more work obligations for those left.

"Last summer, I started traveling across the country," says Becky Pringle, president of the NEA, which has nearly 3 million members, talking about the impetus for the survey. "Without exception, every stop I made, from Kentucky to Oakland, I heard those similar stories of educators who were exhausted, overwhelmed, feeling unloved, disrespected."

The poll found a racial gap in discontent: 62% of Black teachers and 59% of Hispanic teachers say they will leave earlier than planned, compared with 55% overall. But the desire to leave the profession was at similar levels for rookies, midcareer educators and those closer to retirement.

"Our morning emails every day start with the vacancies that have been unfilled," says Amber McCoy, an NEA member who teaches fourth grade in Huntington, W.Va. "[It] will tell us where we have staffing shortages in the building and [ask] us to step in in any way or any time that we can."

She says it's less the 20-year veterans like herself and more the young teachers that are leaving, or considering leaving.

"This is just not what they bargained for," McCoy says. "I also mentor new teachers in my county and one of the girls that had done some clinical work in my classroom, she called me and she just said, 'Is it normal for me to cry every single day after school?' And I said, 'Honey, it's not normal. But this year it's not uncommon.' "

Of course, saying that you're thinking about leaving, or reporting the perception that others are leaving, is not the same as actually putting in your notice. Still, the Bureau of Labor Statistics says there are 567,000 fewer educators in America's public schools today than there were before the pandemic. And the NEA's analysis of BLS data indicates that 43% of jobs posted are going unfilled.

When it comes to solutions, the NEA says money is uppermost in its members' minds. They support raising salaries and hiring more people. Pringle says the union has been amplifying the Biden administration's message that American Rescue Plan money - $122 billion in federal aid to K-12 schools - can and should be used to improve pay and create new positions.

"We were asked to assist [U.S. Education Secretary Miguel Cardona] to really push on this part of the use of those funds," Pringle says, "because some school districts were a little leery about using them to hire staff."

One big reason for that, she explained, is that the extra money is set to sunset within three years, whereas hiring someone or giving them a raise is an indefinite financial commitment.

Yet even if the funding is temporary, Pringle argues, it's needed right now.

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More than half of teachers are looking for the exits, a poll says

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Teachers are picking up slack for absent colleagues. They're covering for unfilled positions. And 55% of them say they will leave teaching sooner than they had originally planned, according to a poll of its members by the nation's largest teachers union. The National Education Association poll, conducted in January, helps quantify the stress being placed on educators right now.

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Many hospitals are seeing a surge of new COVID-19 patients, which means longer hours, increased anxiety and burnout among health care workers. Comic artist and physician Dr. Grace Farris asked fellow doctors, nurses and others in medicine how they are coping with the prolonged stress. Many say their creative outlets provide solace and community to help them through.
Dr. Grace Farris is an associate professor of medicine at the University of Texas at Austin's Dell Medical School. Her book, Mom Milestones, comes out in the spring. You can find her on Instagram @coupdegracefarris.

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Why your doctor may be quilting and your nurse may have a podcast

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Many hospitals are seeing a surge of new COVID-19 patients, which means longer hours, increased anxiety and burnout among health care workers. Comic artist and physician Dr. Grace Farris asked fellow doctors, nurses and others in medicine how they are coping with the prolonged stress.

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For many Americans, the onset of the pandemic has led to increased burnout - that draining, exhausting feeling. Here & Now listeners share how burnout has affected them. And the Stress and Resilience Institute's Paula Davis weighs in.

And, a year ago, a powerful derecho in Iowa downed tens of thousands of trees in a matter of minutes. Kate Payne of Iowa Public Radio reports on how residents are trying to reforest their communities.
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Americans Face Burnout During The Pandemic; Reforesting In Iowa : Here & Now

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For many Americans, the onset of the pandemic has led to increased burnout - that draining, exhausting feeling. Here & Now listeners share how burnout has affected them. And the Stress and Resilience Institute's Paula Davis weighs in. And, a year ago, a powerful derecho in Iowa downed tens of thousands of trees in a matter of minutes.

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Whether working from home or not, many people are feeling burned out during the coronavirus pandemic.

A new survey found that nearly 90% of respondents in more than 40 countries felt that their work lives were getting worse during the pandemic. And more than 60% felt that they were experiencing burnout often or very often.

Workplace burnout was a growing problem in many professions even before the pandemic. For example, burnout has been common among physicians and health care workers for years.

In 2019, the World Health Organization brought some attention to the issue by defining burnout as a syndrome associated with chronic stress at work that goes unmanaged.

It's important to address burnout because it has serious consequences for individuals' mental health - it's a risk factor for depression, substance abuse and even suicide. Burnout can also be contagious and often affects entire workplaces.

We asked some of the top experts on the topic for tips to recognize and address burnout in oneself and in the workplace. Here's what they told us.

Burnout is more than you think.

Psychologist Christina Maslach of the University of California, Berkeley has been studying job-related burnout since the 1970s. She says burnout is more than the exhaustion that people think defines the experience. In fact, burnout has three components. One is the exhaustion - physical and emotional - you feel when you've been too stressed at work for too long. But burnout also comes with a feeling of cynicism about work. "You know, it's ... 'take this job and shove it' sort of thing," says Maslach. "And you begin to switch from trying to do your very best all the time to do the bare minimum."

The third component, she says, is when you start to blame yourself for it. "Thinking, 'What has gone wrong with me?' 'Why am I not good at this?' 'Why can't I handle it?' "

Spot the signs of burnout and regain some control.

One way to catch the early signs is to make a daily practice of asking yourself multiple times during your workday how you are feeling, says Dr. Jessi Gold, a psychiatristat the Washington University in St. Louis.

"It can even be helpful to sort of note your mood throughout the day," says Gold. "Like, 'Every time I have a meeting with so-and-so, I feel horrible, and then every time I'm with this person or doing this thing, that's where I find most meaning.' "

Lack of control is one factor in causing burnout, so knowing those things can help you find ways to reduce the more stressful parts of your job or find ways to buffer the stressful bits with things you enjoy.

For people working from home during the pandemic, Gold suggests creating a workday routine like you had when you worked from an office. "Get up at the same time, get dressed," she says. "Sometimes even pretend-commute. So get up, go for a walk, like you would go for a commute."

This helps put boundaries between work and life and helps you have some control over your day.

Know when you're working too much.

A heavy workload is another big risk factor for burnout, says Maslach. "You have way too much to do. You don't have enough resources to actually do the job well. You don't have enough time." As a result, your brain and body are perpetually stressed and after a while are unable to perform as well.

So it's important to take breaks, says Dr. Gaurava Agarwal, a psychiatrist and well-being coach with Northwestern University's Feinberg School of Medicine and the director of physician well-being.

We need to make sure "we are resting and calming our brain down because brains aren't designed to work this hard, this long, chronically," he says. "And so taking that five minutes in an hour or one day a week to your ability to recuperate is going to be a big part of dealing with that exhaustion."

Employers and managers need to address burnout.

Workplace culture has a huge impact on burnout, says Maslach.The absence of reward or recognition in the workplace, lack of social support or a sense of community, and the presence of unfairness, bullying and discrimination increase risk of burnout. That's why Maslach and other researchers say that burnout is a systemic issue and that organizations need to take a systemwide approach to addressing it.

For example, a 2019 National Academy of Medicine report on burnout in the health care industry recommended that organizations address the root causes of burnout, say by making workloads more manageable, by providing incentives for more collaboration and teamwork, and by creating an organization-wide culture where employees feel safe.

Agarwal also encourages leaders in workplaces to talk openly and compassionately about burnout, especially now, during the pandemic. "By being transparent, by being compassionate, by showing grief, leadership, what you're doing is you're building the sense that we are in this together and we are going to get through this together," he says. "And we have frankly gotten through difficult times before. So what happens is people start leveraging those experiences. And in some ways, that's the heart of resilience."
The podcast portion of this episode was produced by We'd love to hear from you. Leave us a voicemail at 202-216-9823, or email us at LifeKit@npr.org.Andee Tagle.

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Burnout Isn't Just Exhaustion. Here's How To Deal With It : Life Kit

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subscribe to Life Kit podcast subscribe to Life Kit podcast Whether working from home or not, many people are feeling burned out during the coronavirus pandemic. A new survey found that nearly 90% of respondents in more than 40 countries felt that their work lives were getting worse during the pandemic.

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NPR's Michel Martin talks with Jonathan Malesic, author of The End Of Burnout, about the changing nature of work since the start of the pandemic.

MICHEL MARTIN, HOST:

The numbers tell the story. According to a Labor Department report released last week, 4.5 million Americans quit or changed jobs in November, and that's higher than at any other time on record. And while a lot of attention has been given to so-called knowledge workers - people leaving in search of more fulfillment or something more in line with their true desires - it turns out the biggest churn happened among restaurant and bar workers, retail workers, hospitality workers and other jobs which typically offer lower wages.

Across the country, wages are getting higher. A wave of states and cities are raising their minimum wage this year, and 44 cities will be increasing it to above $15 an hour. So that got us thinking about whether these numbers could signal changes in the way Americans at all income levels are thinking about work, about the meaning of work in our lives and about the conditions necessary for people to thrive at work.

Writer Jonathan Malesic has one idea - burnout. He is the author of a book called "The End Of Burnout: Why Work Drains Us And How To Build Better Lives." He's had a number of jobs, from parking lot attendant to sushi chef to university professor, and has thought a lot about why people leave work. I spoke with him about how these recent economic indicators could also point to a larger shift in how Americans are thinking about the meaning of their work beyond the paycheck.

JONATHAN MALESIC: Wages and benefits are, obviously, a huge part of the rewards that we get from our work. But those aren't the only rewards. A reward is not just monetary, but it's social. It's emotional. It can even be spiritual. And, you know, simply being appreciated by your co-workers, your bosses but also your customers, patients, clients, your listeners is another reward that we can derive from work. So I think that job satisfaction, in terms of rewards, needs to encompass all of those different elements.

MARTIN: Your bio says you've worked as a parking lot attendant, a sushi chef, a college professor, which you loved until you didn't. Can you just talk a little bit about what were some of the factors at play when you thought about your satisfaction with each of those roles?

MALESIC: Yeah. Well, I'll start by talking about being a parking lot attendant. So I earned my Ph.D. and did not have any luck on the academic job market, and I ended up taking a job at a parking lot directly across the street from the university where I had just earned a Ph.D. And on the face of it, that sounds like a big mismatch, someone with all this education doing a job that doesn't require a whole lot of education. I mean, a high school student could do the job with no problem, generally. But I loved it.

And the reasons I loved this job that, you know, is ordinarily - has pretty low status is that, first of all, I had this great sense of camaraderie with the other parking lot attendants. The other attendants would swing by the lot and hang out for a bit. They would cover the booth if you needed to take a break or go get a cup of coffee or something like that. And some of those people are still, you know, some of my best friends. And so like, that sense of community that - those good feelings that you get by working with people you really like is a big part of the reward of work.

I would also say that being a parking lot attendant kind of stayed out of the way of my life. It didn't dominate my life. I would clock in for my shift, do the work, clock out at the end and I wasn't exhausted. I could do all the other things that mattered to me because my job didn't dominate every aspect of my being.

MARTIN: And what about, again, the other side of it, being a professor, which you loved until you didn't? So why do you think that happened?

MALESIC: I see burnout as the result of being stretched across this gap between your ideals for work and the reality of your job. And so my ideals for being a college professor were sky-high. I imagined it as the life of the mind - you know, the tweed-wearing professor asking questions about the meaning of life. And I literally did that. I truly asked students those kinds of questions. But - and at times, the reality lived up to those ideals, but oftentimes, it didn't. You know, it's still just a job, and the students were often not as excited about these questions as I was. But in addition, you know, there are still boring meetings. There's still paperwork. And it did seem like I wasn't really doing the work that I imagined I would be doing all those years ago. And so it was a real combination of factors, both internal and external, that I think caused my burnout there.

MARTIN: We haven't talked about gender. What role do you think gender has played in all this? And is this something that we could be talking more about?

MALESIC: There's evidence that women are more likely than men to experience burnout as exhaustion, and so burnout can manifest itself a little differently in women and men. And when you look at specifically parental burnout, women experience parental burnout more often than men do. They score higher on the burnout scale. But men react to parental stress much worse. There's greater risk of men being neglectful towards their children or having sort of escape fantasies. So those things show that, you know, we need to think about burnout between men and women a little differently.

MARTIN: So before we let you go, obviously, this is a big topic, which is why you wrote a whole book about it. But how can we start talking about this? Or is this just something that people have to tackle in their workplace?

MALESIC: Well, I think that one of the reasons that burnout remains so prevalent and such a stubborn problem is that we think of it as just an individual problem, but burnout is the result of conditions in workplaces, workplace culture. And it's a result of society and the view that we have of how work plays a role in being a good citizen, being a good person and so on. And so the way to beat what I call burnout culture is precisely to have these conversations, to talk with coworkers about the problems that you're having the - at work, the ideals that you brought to work to begin with and the way those ideals are not being fulfilled. And my hope is that we can start talking about how we might think about work differently on a cultural and societal scale.

MARTIN: Jonathan Malesic is a teacher and a writer. He's the author of the book "The End Of Burnout: Why Work Drains Us And How To Build Better Lives," and we reached him in Dallas. Jonathan Malesic, thanks so much for talking with me.

MALESIC: Thanks for having me.

Copyright © 2022 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR's programming is the audio record.

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'The End Of Burnout' and the changing nature of how we work

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NPR's Michel Martin talks with Jonathan Malesic, author of The End Of Burnout, about the changing nature of work since the start of the pandemic. MICHEL MARTIN, HOST: The numbers tell the story. According to a Labor Department report released last week, 4.5 million Americans quit or changed jobs in November, and that's higher than at any other time on record.

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This episode originally ran in
Exhaustion. Anxiety. Stress. Depression. Forgetfulness. Irritability. Screaming at large bodies of water. These are some symptoms of burnout.

Hospitals, tech companies, schools and law firms all struggle with burnout. Companies try to fix it. But burnout is really tough to solve. Even the psychologist who coined the term "burnout" had trouble preventing it. After working around the clock, he ended up burnt out.

Today on the show, why burnout is such a menace, and how a 26-year-old call center manager tried to beat it.

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All types of companies are struggling with burnout. Many try to fix it. Most of them fail. One exception: A 26-year-old call center manager, with stress balls and costumes in her arsenal. | Subscribe to our weekly newsletter here.

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Amid the pandemic, more people say they're feeling burnt out often. Researchers say it's important to address burnout before it takes a serious toll on one's mental health.

STEVE INSKEEP, HOST:

People feeling burned out at work are not alone. A recent survey of workers in more than 40 countries found that more than 60% of them reported they felt burnt out often or very often during the pandemic. Research shows that workplace burnout poses a serious risk to mental health. So our Life Kit team asked how you can know when you're burned out and what to do when you are. In this encore presentation, NPR's Rhitu Chatterjee has some tips.

(SOUNDBITE OF ARCHIVED NPR BROADCAST)

RHITU CHATTERJEE: Work was relentless in 2020 for Diane Ravago. She's an EMT in California.

DIANE RAVAGO: I work 24-hour shifts. Just the way that it falls, I'll work anywhere between two to three 24-hour shifts in a seven-day period.

CHATTERJEE: After an especially busy summer, Ravago hit a wall.

RAVAGO: It was an overwhelming set of feelings where I wasn't making the right decisions. I was beyond exhausted physically, mentally, emotionally.

CHATTERJEE: Then she began to doubt herself.

RAVAGO: I started to question myself. Like, man, like, can I do this? Can I do this for the rest of my life? Can I do this every day?

CHATTERJEE: That kind of self-doubt is part of the burnout experience, says psychologist Christina Maslach.

CHRISTINA MASLACH: Thinking, what has gone wrong with me? Why am I not good at this? Why can't I handle it?

CHATTERJEE: Maslach is at the University of California, Berkeley, and has studied burnout for decades. She says exhaustion is also a symptom.

MASLACH: You're tired. You can't focus. It's hard to get up the next morning and go back to work.

CHATTERJEE: Then, she says, people also start to feel cynical about work.

MASLACH: It's kind of take this job and shove it, you know, sort of thing.

CHATTERJEE: But it can be hard to recognize you're burnt out when you're in the middle of it. Dr. Jessi Gold is a psychiatrist at Washington University in St. Louis.

JESSI GOLD: One of the things that I tell people is trying to pause and take almost like an inventory of how you're doing.

CHATTERJEE: If you find yourself feeling exhausted, angry, irritable or stressed often, chances are you're burnt out. Gold says it can help to check in with your mood multiple times each day.

GOLD: Well, every time I have a meeting with so-and-so, I feel horrible. And then every time I'm with this person or doing this thing, that's where I find most meaning.

CHATTERJEE: She says find ways to make little changes to your workday to make it less stressful. Maybe skip those meetings you hate. If you can't do that, Gold says, maybe do something you really enjoy right after the meetings.

GOLD: We can rearrange our day to have some positives with some negatives, so it's not a horrible day of just negative.

CHATTERJEE: This is important, she says, because a lack of control at work is a factor for burnout, as is working too much. So even short bursts of rest can help.

GAURAVA AGARWAL: And so taking that five minutes in an hour or one day a week to your ability to recuperate is going to be a big part of dealing with that exhaustion.

CHATTERJEE: Dr. Gaurava Agarwal is a psychiatrist and a wellbeing coach at Northwestern Medicine.

AGARWAL: Once we have our tanks refilled a little bit more, we have the ability to face the ongoing stressors moving forward.

CHATTERJEE: And for people working from home right now, Jessi Gold says, have clear boundaries between work and personal life. Wake up at the same time, shower, get dressed, have a clear beginning and end to your workday.

GOLD: This really allows your brain to think, like, this is work. This is life. I can have both and distinguish between the two. And that can allow me to have, like, enjoyment in my day-to-day life as well.

CHATTERJEE: Rhitu Chatterjee, NPR News.

Copyright © 2021 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR's programming is the audio record.

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Amid the pandemic, more people say they're feeling burnt out often. Researchers say it's important to address burnout before it takes a serious toll on one's mental health. STEVE INSKEEP, HOST: People feeling burned out at work are not alone.

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Updated 7:55 p.m. ET
The World Health Organization is bringing attention to the problem of work-related stress. The group announced this week that it is updating its definition of burnout in the new version of its handbook of diseases, the International Classification of Diseases - ICD-11 - which will go into effect in January 2022

The new definition calls it a "syndrome" and specifically ties burnout to "chronic workplace stress that has not been successfully managed."

Despite earlier reports to the contrary, WHO does not classify the problem as a medical condition. It calls burnout an "occupational phenomenon" and includes it in a chapter on "factors influencing health status or contact with health services."

According to WHO, burnout is characterized by "feelings of energy depletion or exhaustion; increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy."

Burnout was also included in the previous version of WHO's disease handbook, the ICD-10, in the same category as it now appears. But it was defined simply as a "state of vital exhaustion," Tarik Jasarevic, a spokesperson for WHO, wrote in an email.

The earlier definition "was kind of this weird in-between 'you're not really sick, but you're not fully capable of doing your work,' " says Torsten Voigt, a sociologist at RWTH Aachen University in Germany, who published a review of existing studies on burnout in 2017.

The new definition is now more detailed, he says, and while it's not a major change, it gives people who suffer burnout more legitimacy.

"People who feel burnout are finally fully recognized as having a severe issue," he says. The new definition may be a step toward making it easier for people to get help, at least in some European countries, where health professionals rely on the ICD, he says.

Bringing more clarity to the definition of burnout is important, says Elaine Cheung, a professor of medical social sciences at Northwestern University Feinberg School of Medicine. "There needs to be greater critical discussion on how we can more precisely measure and define this condition," she said in a statement.

She also told NPR that she welcomes the WHO's new definition because it might raise awareness of the problem of burnout not only among health care workers but also individuals and employers.

"I think a lot of people have a lay definition of what burnout may be," she says. "But I think by highlighting the specific facets of burnout ... my hope is that it might create greater awareness."

Cheung says many studies show that certain aspects of workplace culture can increase risk of burnout.

She says employers have a big role in addressing burnout by paying attention to whether employees have a sense of community at work, strong social relationships, a collegial environment, a workload that's not too burdensome, a sense of agency at work, and a healthy work-life balance.

The new WHO definition also requires that to diagnose burnout, mental health professionals have to rule out anxiety, mood disorders and other stress-related disorders.

Cheung thinks that's important. "Burnout is different from depression in that it is tied specifically to our work and our relationship with our work," she says.

Cheung says that understanding this distinction could lead to more targeted research into how to prevent and treat the problem.

WHO also announced it plans to begin developing evidence-based guidelines on mental well-being in the workplace.

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WHO Redefines Burnout As A 'Syndrome' Linked To Chronic Stress At Work

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Updated 7:55 p.m. ET The World Health Organization is bringing attention to the problem of work-related stress. The group announced this week that it is updating its definition of burnout in the new version of its handbook of diseases, the International Classification of Diseases - ICD-11 - which will go into effect in January 2022 The new definition calls it a "syndrome" and specifically ties burnout to "chronic workplace stress that has not been successfully managed."