Burnout is driven largely by external factors outside the control of an individual clinician. These include the culture and policies of the organizations that employ clinicians, as well as the number of health care responsibilities assigned to individuals. Many of these factors are determined by leadership.
Leadership and Culture
As the U.S. health care industry evolves, clinicians are increasingly employed by large organizations like hospitals and health maintenance organizations – introducing a bureaucratic load that can impact clinicians’ sense of autonomy, control, and satisfaction. Amid this transition, it is more important than ever that organizational leaders partner with clinicians to shape culture, multi-component strategies, and policies that support their well-being.
Although burnout is widely recognized as a significant problem that impacts the quality of health care, including number of medical errors, and clinicians’ well-being, organizations must recognize it as a system issue, rather than placing the onus on clinicians to build personal resilience. Individual strategies to reduce burnout, such as stress management workshops and mindfulness trainings can result in well-meaning but inadequate solutions focused solely on the individual clinician. These activities do not address the upstream drivers that contribute to burnout, and may allow harmful system trends to continue. Furthermore, simply raising concern about burnout and its prevention without dedicated investment and follow-up by organizational leadership may alienate clinicians and contribute further to cynicism and reduction of work effort.
Evidence shows that the vision, mission, and values of an organization shape its culture and affect clinicians’ satisfaction, sense of belonging, and clarity of purpose. Specifically, an emphasis on productivity as a core value is associated with decreased professional satisfaction, whereas an emphasis on quality of care and work-life integration increases satisfaction and reduces stress. Leaders should be aware of the many factors that influence organizational culture and take steps to realign policies with values as needed.
The effectiveness of direct supervisors may also negatively or positively influence burnout. In one study, positive leadership skills in supervisors were associated with increased physician satisfaction and decreased burnout risk. Organizations that lack skilled supervisors, therefore, may be missing a crucial protective factor. The problem can be perpetuated when organizations fail to establish leadership standards, hold leaders accountable, and remove those who are ineffective.
Diversity and Inclusion
Despite widespread efforts to increase diversity, racial and ethnic minorities are still significantly underrepresented in health care professions. For example, African Americans make up about 13 percent of the U.S. population but only 7.5 percent of students entering medical school, a disparity that may have its roots in early education. According to the Association of American Medical Colleges, pervasive unconscious bias results in physicians from underrepresented groups being paid less, receiving fewer opportunities for advancement, and feeling marginalized within their teams. Organizations may send unintentional signals that reinforce this marginalization through “lack of diversity among top leadership positions; institutional grant and funding awardees; success stories featured in school magazines; names of centers, departments, and buildings; and even the portraits adorning the walls.” Health care professionals from underrepresented groups are often asked to serve on diversity taskforces, a request that, while well-intentioned, further pigeonholes these individuals and adds to their workload.
Women physicians may also experience exclusion and marginalization at work due to the perception that women are not well-suited for certain specialties or the assumption that women prioritize family life over career advancement. As a result, female physicians may feel unable to acknowledge their stress for fear of confirming biases. Women also endure sexual harassment, hold fewer leadership positions, are paid less, are less likely to be promoted from entry-level to senior-level administrative positions, and receive less recognition than male colleagues.
Finally, although more research is needed to understand the experiences of LGBTQ clinicians, one study shows that a significant percentage of LGBTQ physicians report being harassed and ostracized by colleagues or have witnessed disrespectful or discriminatory treatment of LGBTQ patients. In addition, some organizations do not offer partner benefits for LGBTQ employees, making them feel unwelcome or unable to accept a position that might otherwise advance their career.
Overall, discrimination and exclusion in the workplace may contribute to the erosion of important factors that protect against burnout – including effective teamwork, supportive professional relationships, fairness and opportunity, and a culture that values work-life integration.
Resources on Organizational Factors
A Journey to Construct an All-Encompassing Conceptual Model of Factors Affecting Clinician Well-Being and Resilience
Why are so many clinicians experiencing burnout? The answer is complex but this discussion paper from the National Academy of Medicine aims to shed light on the issues contributing to of clinician burnout and...
We can help prevent #burnout by looking at the culture and policies of the organizations that employ clinicians.
Workload and Compensation
Burnout risk rises with increased workload and hours worked. Physicians work about 10 more hours per week than other professionals, with nearly 40 percent working more than 60 hours—a schedule that many report doesn’t leave enough time for family or personal interests. Among surgeons, long work weeks and many nights on call are strongly correlated with burnout, depression, medical errors, and intent to leave the profession. Nurses, too, experience unrealistic workloads with unmanageably high patient-to-nurse ratios, a trend associated with burnout and turnover. Outside of actual hours worked, feeling pressured for time to deliver high-quality care also contributes to stress and dissatisfaction. More flexible organizational policies – such as allowing clinicians to work less than full time or to flex hours within the work week – may improve satisfaction with work-life integration, although stigma may prevent clinicians from utilizing them.
Consistent with the finding that productivity as an organizational value increases stress, physicians may be at greater risk for burnout when their income is based on individual productivity. This compensation structure may encourage physicians to spend less time per patient, order more tests, and work longer hours—effects that are harmful to quality of care as well as clinician well-being. Significant levels of educational debt among physicians and pharmacists, as well as cultural normalization of excessive work hours, may compound the tendency toward overwork within the individual productivity model of compensation. Risk may be mitigated by a salaried compensation structure or by innovative models that reward quality and patient satisfaction over volume, incorporate self-care requirements, or offer sabbatical-like opportunities.
Health Care Responsibilities
Health care responsibilities include clinical, administrative, training, teaching, and research duties. Complementary institutional and organizational supports that reduce the strain of health care responsibilities and prioritize clinician self-care routines would be helpful in alleviating the burden of these external factors.
Clinicians are tasked with a number of responsibilities, the foremost being clinical. These clinical responsibilities can be challenging and simultaneously rewarding as providing care is the reason many clinicians initially chose the healing professions. In addition to providing direct care, patient populations are becoming more complex and clinicians are increasingly addressing the social determinants of health—income, education, and transportation, to name a few—to ensure better health outcomes for their patients. Outside of direct care, clinicians are tasked with recruiting staff and ensuring sufficient coverage within the unit; and measuring and reporting the care provided to ensure the delivery of effective, safe, patient-centered, equitable, and timely care. Within clinical responsibilities are important principles of caring and integrity.
Caring, as defined by the National League for Nursing, is promoting health, healing and hope in response to the human condition. This commitment is usually only discussed in response to the patient’s condition but is also related to the human condition of the clinician. Health care professionals must have an opportunity, beginning at their educational institutions, to develop an awareness of their own human condition: energy level; emotional preparedness; mental status; and general overall health and well-being. Clinicians can then extend this assessment to their colleagues with a willingness to discuss their own well-being and preparedness as they work together in the healing process. With this formula, the patient is positioned to receive quality care and the clinicians carry their own responsibility to be aware of their need for personal healing.
Integrity means respecting the dignity and moral wholeness of every person without conditions or limitations. Integrity creates a culture in which organizational principles of shared communication and ethical decision-making are encouraged, expected and consistently demonstrated.
In addition to clinical responsibilities, clinicians have a number of administrative responsibilities that require a level of preparedness to lead. Tasks include leading committees, and clinical and faculty teams; and demonstrating fiduciary accountability through budget development and management. Clinicians are also expected to complete essential paperwork ensuring patient access to resources; establish chain of command maps; and design and implement disciplinary processes. Often times, clinicians spend a substantial amount of time on these administrative duties.
Trainee and Teaching/Research Responsibilities
Practice and training are essential dimensions of transforming a health professional student to an independent practitioner, and trainees have a unique set of responsibilities in the clinical learning environment. In addition to following all guidelines outlined by the accrediting bodies, trainees must meet duty hour requirements and achieve core competency requirements for their residencies, complete longitudinal projects and/or graduate coursework, actively participate in developing a culture of respect, and provide patient care to the maximum level of licensure.
Additional challenges in transitioning from student learner to practicing novice and beyond include, but are not limited to, loss of structure and definitive endpoints, decreased frequency of feedback, new liabilities and responsibilities, shifts in learning style, and work-life integration. Clinicians can rapidly experience threats to confidence in their knowledge, skills and abilities as early careerists that can persist throughout their careers. Depending on the level of resources provided, mentorship, and culture into which clinicians are placed, advancing through these phases of professional growth may be daunting.
As professional advancement occurs, teaching and research are part of an organization’s financial well-being, but clinicians in all professions may find it difficult to acquire adequate time for these responsibilities due to institutional over-emphasis on clinical productivity. Such teaching and research responsibilities may include overseeing research that meets all private and federal grant regulations, publishing research findings, and attending professional development activities.
Overall, a lack of alignment between health care responsibilities, authority, preparation, institutional support, effective communication and protected time can lead to job dissatisfaction. In both early and later stages of the clinician’s career, the volume of workload associated with the responsibility of the patients’ well-being can frequently outweigh the need for self-care and introspection. Self-care is an individual responsibility; however, it is a responsibility of the health care environment to create opportunities to develop positive self-care practices and promote their use as well as provide other institutional supports to reduce the burden of the health care responsibilities assigned to individual clinicians.
Many other elements relating to organizational culture and policies affect clinician well-being. Visit our Conceptual Model to see all the factors that shape burnout risk, or click here for information about documentation requirements, teamwork, and workplace safety.
Organizations that employ clinicians have a responsibility to design policies and foster workplace culture that promotes well-being. The leaders responsible for shaping these elements—from CEOs to frontline supervisors—are among most critical campions in the movement to prevent and reduce burnout.
Over 150 organizations are taking the lead and have committed to promoting well-being within their institutions. Read their commitment statements.