Burnout: Coping with Stress

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By Persis Mary Hamilton, RN, CNS, MS, EdD

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Describe the effects of stress on the human body.
• Analyze the stages of burnout.
• Explain the causes of job burnout.
• Identify the symptoms of burnout.
• Discuss the management and prevention of burnout.

Carol is suffering from what Maslach and others call burnout, a maladaptive response to stress. The disorder is characterized by emotional exhaustion, detachment, and a reduced sense of personal accomplishment (2009). Caregivers like Carol are especially vulnerable to job burnout. They work in demanding situations, hold high expectations for themselves, and believe they should be able to handle anything no matter what the challenge. Fortunately, the condition is treatable and preventable. Caregivers like Carol can learn to cope with stress and burnout by gaining an understanding of stress and stressors, recognizing the signs and symptoms of job burnout, acquiring skills to manage its destructive effects, and preventing its occurrence in the future.

STRESS AND STRESSORS

The idea of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence. Han Selye carried on the work of Cannon, defining stress as the “rate of wear and tear on the body” and stressors as the “causative agents of stress” (1956). Selye found that stressors may be physical, such as infection, injury, and pain, or may be psychological, such as fear, anger, and sadness. He identified what he called a general adaptation syndrome (GAS), whereby the body seeks to maintain homeostasis, or balance, first by producing an alarm reaction, then by resisting the effects of stress, and finally by giving in to overwhelming stress.

Lazarus (1966) enlarged our understanding of stress and the ways people deal with it when he observed that, when individuals view a new or evolving situation, they first decide whether it is a threat. He called this primary appraisal. Then, as people further monitor a threat, they evaluate their ability to cope with it by what Lazarus called secondary appraisal. In this second step of appraisal, individuals judge themselves unable to handle the situation and withdraw. Others, especially caregivers, are apt to believe they “should” be able to handle anything and attempt to do so, no matter how great the cost. These individuals are at high risk of reaching the end stage of stress: exhaustion.

Instead of persisting until they reach the state of exhaustion, caregivers can learn more effective coping strategies, become self-aware, acknowledge their own limitations, and acquire emotion-focused and problem-solving skills. Managers can provide physical and emotional support for staff members because they value them and understand the stressful nature of their work. Caregivers can do much to prevent burnout in patients by supporting and nurturing them through what may be a long and stressful illness.

Carol, our caregiver, felt overworked and underappreciated. At some point she realized (primary appraisal) she was overpowered by an entrenched bureaucracy and out-numbered by an unsympathetic staff. She realized she was not performing at the level she expected of herself, and she felt guilty, insecure, inadequate, and fearful she might lose her job.

To cope, Carol began using a strategy she had seen others employ: detachment and dissociation. After a while she realized (secondary appraisal) her method of coping was not solving the problem; the situation was only getting worse and she was becoming emotionally and physically exhausted. She was experiencing the three cardinal symptoms of burnout: emotional exhaustion, detachment from others, and a reduced sense of efficiency and personal accomplishment.

THE STAGES OF BURNOUT

Burnout is a state of physical and emotional exhaustion caused by excessive and prolonged stress (Smith et al., 2011). It is gradual process by which people detach from meaningful relationships in response to protracted stress and physical, mental, and emotional strain. The result is a feeling of being drained, unproductive, and having nothing more to give. Gorkin (2008) says that when “results, rewards, recognition, and relief are not forthcoming, the groundwork for burnout is being laid.” He suggests that, although there are differences among individuals, burnout generally occurs in four stages:

1. Physical and emotional exhaustion
2. Shame and doubt
3. Cynicism and callousness
4. Failure, helplessness, and collapse

These four stages are evident in the following case.

Physical and Emotional Exhaustion

Physical and emotional exhaustion are caused by heavy, unrealistic workloads at home and on the job, stress-producing time limitations, inadequate rest and sleep, unfair work assignments, and lack of respect from managers. For instance, with stress, the pineal gland produces melatonin, which disrupts the sleep-wake cycle, further contributing to fatigue.

In the case study, Dan Caring assumed the duties of the absent attendants rather than assertively addressing the issue of inadequate staffing with his supervisor. Instead of gaining appreciation, his efforts merely increased his workload, magnified his stress, and led to physical and emotional exhaustion.

Shame and Doubt

As individuals become more and more overwhelmed, their sense of competence decreases and feelings of shame increase. They discount past accomplishments, even in the face of objective evidence. Gorkin (2008) suggests that although these folks project an image of competence to others, a voice inside them shouts, “Imposter! You may fool others, but you can’t fool yourself. You are a fraud!” Indeed, the process is not logical; it is emotional. At this stage of burnout, individuals may sigh heavily, breathe deeply, and experience a profound sense of loss, uncertainty, and vulnerability.

Normally, Dan took pride in doing high-quality work, but as his exhaustion progressed he began looking for shortcuts. That was when he made the medication error. This gave him pangs of guilt and further undermined his self-esteem. He could not admit to himself that he was near the end of his rope. Neither could he admit his utter exhaustion to his employer. It is no surprise that Dan was about to enter the third stage of burnout: cynicism and callousness.

Cynicism and Callousness

As a defense against feelings of vulnerability and inadequacy, many individuals decide there is only one thing to do:protect themselves. Like Carol in our first vignette, they develop an “attitude,” saying to their selves, “I can’t let them get to me. I’ve got to take care of myself!” At first, the strategy works because people tend to avoid unpleasant or brusque individuals. Predictably, the strategy does not work because caregivers are not comfortable being “bad guys.” They have always thought of themselves as gracious and accommodating and now they feel angry and rejected. As they seek to protect themselves, their hostility turns to suspicion and mistrust and they become cynical and callous.

For a while, Dan went along with the excuses the supervisor made for not employing more help. He was not comfortable with anger and wanted to avoid confrontation. He had always thought of himself as strong and capable. Even so, he began losing sleep, felt his blood pressure rise, his stomach churn, and his heart pound. Gorkin said it well: “Burnout does not just harden the attitude; it begins to harden the arteries” (2008).

Failure, Hopelessness, and Collapse

At the fourth stage of burnout, coping skills are at their lowest level. People are worn down, vulnerable, and exhausted. Their defenses have begun to fail. Old hurts and upsetting memories of past failures and poor choices begin to seep through their protective shield. Every area of life is affected. The smallest of slights and least important omission makes them respond intensely. When someone else is recognized instead of them, the smoldered coals of sibling rivalry reignite. Nothing is going well. Everything seems to be going wrong (Smith et al., 2011).

Dan welcomed the sick leave because it helped him escape the burnout he was experiencing. He had run out of energy and was at the bottom of a dark and lonely pit. He no longer trusted his abilities and became disillusioned with the nursing profession and the entire health care system. Dan’s story fits the description of Smith, Segal, & Segal: “Job burnout is a special type of job stress, a state of physical, emotional, or mental exhaustion combined with doubts about your competence and the value of your work” (2011).

RECOGNIZING BURNOUT

Burnout is the culmination of unrelenting pressure over an extended period of time, often from multiple stressors. Gorkin describes the “Four Rs” that can cause burnout:

• Lack of results or feelings of achievement
• Absence of rewards, both tangible and intangible
• Lack of recognition for accomplishments
• No relief or hope of relief from the stressor of his job (Gorkin, 2008)

Contributing Factors

Job burnout is caused by many interactive factors; some are due to the personality and lifestyle of workers and some are due to the work environment.

FACTORS CONTRIBUTING TO BURNOUT

Worker Personality and Lifestyle Factors	Work Environment Factors
Source: Mayo Clinic, 2011.
Assumption of too many responsibilities Inadequate down-time, sleep, relaxation Unrealistic achievement goals and expectations Lack of close, supportive relationships Type A personality, perfectionism Low self esteem, pessimistic worldview Need for control, reluctance to delegate duties Sensitivity to criticism	Unclear job descriptions Unreasonable job expectations Ambiguous chain of command Scant recognition and rewards Chaotic or high-pressured environment Destructive interpersonal dynamics Mismatch of employee strengths with work assignment Dubious ethical practices causing conflict as regards honesty, integrity, respect, confidentiality

Leiter & Maslach (2009) identified six work-related issues that cause conflict and stress in the workplace, namely: workload, control, rewards, social community, fairness, and values.

• Workload. The amount of work expected of workers, the environment in which they do it, and the time they have to accomplish it. Overload increases stress and leads to burnout.
• Control. Power relationships with others, lines of authority, and areas of responsibility. It is complicated by cultural norms and communication styles.
• Rewards. What individuals receive as compensation for their work. These include money, security, belonging, recognition, and self-actualization.
• Social community. The group of folk who must work together to fulfill the mission of the organization. The community contributes to the rewards people receive and the level of stress they experience.
• Fairness. Equal treatment of every member of the workforce in such things as assignment of rewards, tasks, scheduling, recognition, promotions, and decision making.
• Values. Core ethical principles of an organization: its integrity, priorities, mission, and the quality of its products and services.

Signs and Symptoms of Burnout

Burnout does not happen overnight. It can creep up on folks if they are not paying attention to the warning signals. For example, in the case of Dan, he was just doing what he thought he had to do under the circumstances. The signs and symptoms may be physical, emotional, and behavioral, as follows:

Physical signs and symptoms:

• Feeling tired and drained most of the time
• Lowered immunity, feeling sick a lot
• Frequent headaches, back pain, muscle aches
• Changes in appetite or sleep habits

Emotional signs and symptoms:

• Sense of failure and self-doubt
• Feeling helpless, trapped, and defeated
• Losing motivation
• Feeling alone in the world and detached from others
• Having a negative outlook on life, becoming increasingly cynical
• Decreased satisfaction and sense of accomplishment

Behavioral signs and symptoms:

• Withdrawing from responsibilities
• Isolating oneself from others
• Procrastinating, taking longer to get things done
• Using food, drugs, or alcohol to cope
• Taking out one’s frustrations on others
• Skipping work or coming in late and leaving early (Smith et al., 2011)

RECOVERING FROM BURNOUT

When individuals such as Carol and Dan reach the fourth stage of burnout—failure, hopelessness, and collapse—they cannot go on. They must stop. They need to:

• Take a break and get help
• Identify and grieve for losses
• Confront denial and cynicism
• Acknowledge their limitations
• Establish personal boundaries
• Nurture themselves
• Learn and use stress-reducing actions
• Employ problem-solving strategies to prevent future burnout

Taking a Break and Getting Help

Burned-out individuals have used up their emotional and physical reserves. When people acknowledge they are burned out, they need to take a break and get help. Preferably, they find a therapist who will give them the nonpossessive warmth, accurate empathy, and genuineness. During initial counseling sessions, they need to be heard, to pour out their story to someone who respects them and gives them unconditional positive regard. Often their story consists of a collection of mixed-up, disconnected, jigsaw puzzle–like fragment of frustration, loss, and fear. In counseling sessions, these folk, with the help of their counselor, sort through the pieces, examine each one, and gradually put the puzzle of their lives back together again.

Identifying and Grieving for Losses

As burned-out individuals scrutinize each part of their story, it is not unusual to find that one or more of the pieces is a jagged, unhealed, unresolved loss. That loss may be their reputation, cherished loved one, a prized possession, their health, an opportunity, or some other treasured thing. When unresolved bereavement is a factor in burnout, individuals need to engage in what is called grief work. This is an emotional process by which bereaved individuals re-experience their loss, loosen the ties to it, and gradually adjust to life without the cherished person, item, or situation.

To facilitate the grieving process, individuals set aside a time to grieve during which they allow themselves to re-experience the loss. At the end of the allotted time, they close the book, dry their tears, and return to activities of daily living. They do this repeatedly and over time. Such grief-work facilitates a separation from the lost possession.

Though there are many conceptual frameworks for grieving, the complementary schemes of Worden and Attig (see table below) offer a broad view of the tasks and the coping strategies to accomplish it.

TASKS AND COPING STRATEGIES OF THE GRIEVING PROCESS

Tasks*	Coping Strategies**
* Source: Worden, 2008.	** Source: Attig, 2010.
Acknowledge the reality of the loss. Work through the emotional turmoil. Adjust to an environment in which the deceased is absent. Loosen ties to the deceased.	Struggle to take in the reality of the loss. Acknowledge feelings and express them or otherwise process them. Adopt life pattern changes required by the loss. Find new ways to relate to the lost one and accommodate the loss in relationships with fellow survivors.

Confronting Denial and Cynicism

When individuals are in positions of high stress and overwhelming anxiety, they may not realize just how stressed they have become. They may insist they can “handle it,” whatever “it” may be. Over time, they become distraught, distrustful, and skeptical of the goodwill of others. They may attempt to protect themselves with a defense of cynicism and denial. This does not work because denial is a lie they tell themselves.

When people confront the truth and admit their exhaustion, cynicism, and vulnerability, they open the door to health and healing. In fact, truth does set people free. As soon as they accept themselves just as they are, honestly admitting their frailty, failures, and fatigue, they are relieved of the burden of being perfect and are able to replace denial, cynicism, and fear with acceptance, joy, and hope.

Acknowledging Limitations

Often, individuals who are burned-out have been trying to be super-beings. They have been strong and accommodating, worked diligently, and persevered no matter what was asked of them. Things are different now. When people reach the end-stage of burnout, they must admit that they are not super-beings; they are human beings and have limits. These limits may be different from other people, but they are real and they are theirs. As with denial, when individuals admit they are less than perfect, they are wonderfully liberated. In the future, they will be better equipped to heed the signs and symptoms of emotional and physical exhaustion.

Establishing Personal Boundaries

Setting personal boundaries means knowing who you are, where you begin and where you end, and when to say, “This is my responsibility and that is yours.” Typically, caregivers are empathetic, understanding, and nurturing. All too often, however, they have weak boundaries and easily merge their identities with others. Such mergers are not healthy. They burden caregivers, contribute to burnout, and deprive the people with whom they merge of autonomy and self-respect. When individuals fail to maintain personal boundaries, they may exercise inappropriate control over others and become unwitting codependents. For example, Dan could have established proper boundaries by addressing the issue of inadequate staffing with his supervisor and accepting only as many duties as he could reasonably attend to. By failing to do so, he was merging boundaries with his supervisor and not maintaining his own.

Nurturing Oneself

Self-nurturance means caring for oneself. When people who are burned out finally stop what they are doing and get help, they are beginning to nurture themselves. Good for them! Self-nurturance is not the immature selfishness of children. It is a conscious awareness of personal needs, a taking responsibility for oneself so that others do not have to do it for you.

Ultimately, self-nurturance is a measure of maturity. It means taking care of your own basic needs for survival, safety and security, belonging and affection, respect and self-respect, and self-actualization (Maslow, 1968). Practically speaking, self-nurturance means providing adequate sleep, a balanced diet, physical and mental exercise, human companionship, and self-actualizing activities for oneself.

Employing Stress-Reducing Strategies

People who are burned out may have experienced high levels of stress for such a long time that they no longer know how to relax. Their home and work environment may have been so demanding that they could not take time for themselves, or they may have felt guilty when they took a moment to relax. Now they must learn to reduce their stress. Domrose (2008) suggests the following stress-reducing tips:

• Get a good night’s sleep.
• Eat regular, well-balanced meals.
• Exercise regularly.
• Do something relaxing and pleasurable every day.
• Socialize with family members and like-minded friends.
• Do something for others.
• Avoid narcotics, cigarettes, alcohol, and stress-producing environments.

To recover from burnout or prevent burnout, many individuals find the regular practice of a relaxation exercise of great value.

Using Problem-Solving Strategies

Problem solving is especially difficult for individuals who are burned out because they are emotionally and physically exhausted. Nonetheless, when burned-out individuals take a break, get help, grieve for losses, confront denial and cynicism, acknowledge limitations, establish personal boundaries, nurture themselves, and use stress-reducing strategies, they are ready to begin solving problems and prevent burnout in the future. The four steps of problem solving are as follows:

1. Define the problem. Ask, “What work-related area is causing me stress?” If there are several problem areas, prioritize the list and address the one you consider most amenable to solution.
2. Set objectives. Once you have identified a problem, make sure it is a manageable issue; be specific, positive, and practical. Set attainable objectives, preferably ones that are shared by others in the community, such as reducing time-consuming busy-work.
3. Take action. Take the initiative and do what you can by yourself without the approval or participation of others—such as gaining a new skill or knowledge. Some actions will need the support of others; if so, use your influence to gain their cooperation. Exercise leverage with those who have power to make changes. Give ultimatums only when you have exhausted milder approaches and when you can afford to lose.
4. Track progress. When you achieve some change, even a small change, keep track of your progress. This will encourage you and others to continue the process. Expect resistance to change and make adjustments as you go along, keeping your objectives in mind.

If Carol Diligent from our first case study had used these four steps, she would have identified at least two problems that were causing her stress—an excessive workload and interpersonal conflict with coworkers. She would have prioritized addressing these issues, determining what could likely be changed. If she had decided it was the workload, she could have taken actions such as approaching the employee organization for their help in solving the problem. Though she might not have gotten an immediate reduction in her workload, she could have taken some vacation time and begun to work with the committee negotiating the terms of a new contract. By taking action to solve her problem, Carol could quite possibly have improved her situation and prevented burnout.

PREVENTING BURNOUT

The causes and prevention of burnout are interrelated, involving both workers who suffer burnout and the environment in which they work. To prevent burnout, individuals need to identify and resolve stress-producing issues, and employers need to identify and address workplace stressors that create burnout. When individual workers and organizations address these matters, both benefit. Individuals experience less burnout and organizations become magnets, attracting and keeping staff members of the highest quality.

What Organizations Can Do to Prevent Burnout

When employees suffer burnout and become cynical, detached, and exhausted, productivity is reduced, standards are compromised, and the reputation of the organization is diminished. This is particularly true in service industries such as those that provide healthcare.

To prevent burnout in employees, managers in organizations need to identify the specific issues that create stress and take measures to alleviate them, namely:

• Unclear job descriptions
• Unreasonable job expectations
• Ambiguous chain of command
• Scant recognition and rewards
• Chaotic or high-pressured environment
• Destructive interpersonal dynamics
• Mismatch of employee strengths with work assignment
• Dubious ethical practices regarding honesty, integrity, kindness, respect, and confidentiality

Management needs to ask questions about the six issues that contribute to burnout in employees:

• Work load. Are job expectations reasonable? If not, how can they be changed to match the need? Are job descriptions current, clear, and accurate? Is there a mismatch between employee strengths and work assignments? Is the work environment chaotic or high-pressured? If so, how can it be moderated to reduce worker stress?
• Control issues. Is the chain of command clear and understandable? Does it foster efficiency, collegiality, and fulfillment of the organization’s mission? Is it being followed? If not, why not?
• Rewards & recognition. Are performance standards clearly stated and known by employees? Are workers recognized and rewarded for meeting high performance standards? What else can the organization do to support and encourage employees?
• Social community. Is there a positive, collegial work environment? If not, what is hampering its development? What can the organization do to foster a cooperative, supportive environment?
• Fairness. Do workers feel they are treated with respect and fairness? Are work schedules flexible enough to get the job done yet meet the needs of staff members? Is there a fair wage for every category of worker? How do wages compare to other similar organizations?
• Values. Are there any dubious ethical practices, such as double-charging clients? Is the institution known for its integrity? Is honesty, respect for human dignity, benevolence, autonomy, and justice encouraged and rewarded?

What Individuals Can Do to Prevent Burnout

Individuals can prevent job burnout by addressing the same causal factors as employers, namely:

• Workload. Am I assuming too many responsibilities; getting enough sleep, rest, and relaxation? Am I taking care of myself? If so, what can I do to balance the demands of my work with my energy, rest, and relaxation? Do I have unrealistic achievement goals and aspirations?
• Control. Do I have to be “in charge” at all times and in all circumstances? Do I need to be perfect all times? Is the cost of perfection worth the reward it gives? If it is, what can I do to reduce the stress it creates?
• Rewards. Does my work give me emotional and monetary rewards? Are they adequate for my needs? Am I appreciated and recognized by my colleagues and employer? If not, what can I do to receive recognition and feel good about myself?
• Social community. Is the work environment chaotic and unstructured? Do I have a collegial working relationship with staff members? If not, what can I do to increase mutual respect and support and thus nurture myself and my co-workers?
• Fairness. Do I feel that I am being treated fairly in work assignments, wages, or recognition? If not, are any institutional measures available to challenge the status quo and make thing fair?
• Values. Is there a mismatch of ethical values between me and my work? If so, is the problem systemic or is it limited to one person or one circumstance? What institutional measures are available to address the issue?

THE EFFECTS OF STRESS AND BURNOUT

Stress and burnout significantly affect individual caregivers, the organizations for whom they work, and the people to whom they give care. These conditions are especially common in healthcare providers because of the demanding nature of the work, the personal characteristics of caregivers, and the expectations of the managers of healthcare organizations.

For example, in the case study about Carol, she suffered from “nervous headaches and felt exhausted, angry, trapped, and inadequate.” Her ability to concentrate on patient needs was severely compromised. In the case study about Dan, he could not sleep, self-medicated with alcohol, and made a medication error. His ability to deliver safe patient care was seriously affected. In both cases, stress and burnout directly affected the quality of patient care and indirectly affected the organizations which employed the two caregivers. These sorts of circumstances can be eliminated. Job burnout can be treated and prevented.