Burnout in Healthcare Leadership
February 2020
You can’t open a business magazine or scroll through LinkedIn these days without running across an article about burnout. It’s a topic on a lot of people’s minds. A quick Google search of the word “burnout” brought up over 104 million results in 0.53 seconds. Wow! Narrowing that down to “burnout in healthcare leadership” dropped it to slightly less than 3 million.
In 2019, the World Health Organization classified burnout as an “occupational phenomenon.” Specifically, they said, “burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
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.”
There has been a lot of attention given to physician burnout in recent years and rightly so. The suicide rate among physicians is alarming and burnout is often pointed to as a contributing factor. Health systems are making efforts to address burnout by pursuing initiatives that focus on physician wellness and engagement, reducing “pajama” time, and addressing the bureaucratic challenges that electronic medical records have placed on physicians by doing such things as adding scribes. All of these are important to help combat the burnout that our physician partners are experiencing and they should continue.
However, burnout in the healthcare industry isn’t exclusively experienced by physicians. It’s happening in many positions – nursing and others. According to a 2017 white paper published by the Institute for Healthcare Improvement titled IHI Framework for Improving Joy in Work, “If burnout in health care were described in clinical or public health terms, it might well be called an epidemic.”
What most health systems are neglecting to address is the burnout that the rest of their employees are experiencing. I see it in the most extreme and with the least attention given in the area of leadership. Burned-out leaders responsible for units that are operational 24/7, such as nursing leaders, are being hit particularly hard, but even leadership over areas such as Information Systems and Human Resources are reporting burnout.
In a 2017 study by Witt Kieffer called The Impact of Burnout on Healthcare Executives, 79% of study participants indicated that burnout was negatively impacting their organization and 79% of participants didn’t feel that their organization was doing enough to reduce or prevent executive burnout. The report indicates that “respondents at all levels report experiencing feelings of burnout during the previous six months with directors, CIOs and CFOs reporting the highest rates.” 100% of directors participating in the study indicated experiencing some level of burnout. That is staggering.
The study also indicated, “An alarming 71% of survey respondents indicate they are concerned that burnout will affect their careers in healthcare management.” Most disturbingly, “three-quarters of healthcare executives know a colleague who left the industry altogether due to career burnout.”
This is a crisis in the healthcare industry that we must start talking about more openly and addressing. If we don't, the talent shortages that already exist in an industry that is already experiencing pressures is only going to get worse. Talent is leaving the industry at a time when we need their expertise.
What is it like to experience burnout?
It’s similar to the proverbial frog being boiled in a pot of water. I can speak from experience on this because it happened to me. I’ve spent most of my career in the healthcare industry and it’s always been demanding and rewarding. I’ve always been energized by the mission of the organizations I’ve worked for. Although I’ve never been in direct patient care roles, I’ve always felt a great privilege to lead a support department and knowing the important role that my team played. As I moved into an executive position, my responsibilities became broader and I took those responsibilities very seriously. For me, and I know for all of my colleagues, it was always about doing what was best for our patients and our community.
Burnout snuck up on me. I was a good team player, a hard worker, and willing to take on more responsibility when it was needed. I didn’t know burnout was happening to me until it was too late. For me, it happened throughout a couple of years. Unfortunately, it took finally leaving my corporate job altogether to recover. I just couldn’t see any other way out by that point. I had tried addressing the problem with extended time off, using a health coach, putting limits on my work time, and blocking my calendar, but none of those interventions were working.
For me, the long-term chronic stress and workload that exceeded my capacity had gone on too long and came from systemic issues that needed to be addressed to make an impact. The things I tried to address on my own were mere band-aids to a bigger organizational problem and I couldn't get traction on the primary contributing factors. I also needed to take some serious time to step back and reflect on how my approaches to work under stress might also be contributing to my problem.
Ironically just a few days after my decision to leave the organization was made public, we had a national speaker (Dr. Bryan Sexton from Duke University Health System) give a talk to our organizational leadership on burnout in healthcare workers. As I was sitting there listening to him speak, there were two things he said that really resonated with me:
Telling someone who is burned out to learn a new skill like meditation is like telling someone who is drowning to learn how to swim. I wanted to jump up and shout “Yes!” I had been working with a health coach for a year to learn how to meditate and it just wouldn’t stick. Nothing was working and now it made sense as to why. By the time I had already hit the burnout stage, it was too late. The key is learning new skills to help you combat burnout before burnout happens.
Telling someone who is burned out to stop and look at the sunset is like telling someone who is being chased by a tiger to stop and appreciate life. They just can’t do it. They feel like they are running for their life. After all, they are being chased by a tiger! This helped me understand why I felt defensive all of the time and why my attitude about everything seemed so negative. I didn’t want to be that way. I didn’t like the person I’d become. This helped me understand it. It was so enlightening, and, in a way, I felt such a sense of relief.
In the weeks leading up to my last day, I had the opportunity to have a lot of individual conversations with colleagues about my experience, and, in turn, several shared with me their sense of understanding, their support, and, their experiences. I learned that some of them were struggling too. I wished we’d been able to talk more openly about our mutual struggles instead of quietly charging forward like everything was fine. Burnout can feel very isolating and lonely because when you are struggling and you think everyone else is fine, you feel like it must be you that’s the problem.
When I quietly shared with a colleague that some days when I was on my commute home (the only part of my day that I truly had to myself), I was so exhausted that a fleeting thought went through my head that if I had a car accident maybe I’d end up in the hospital and at least I could get some real rest that way. I clarified with her that I was not thinking about hurting myself. She said she completely understood and shared with me that sometimes she had a fleeting thought of getting pregnant just so she could go on maternity leave.
We both recognized how warped and twisted our thinking had become. But it also demonstrates how desperate you can start to get when burnout makes you feel trapped and in need of a real break – something far beyond what a typical vacation can provide. You feel like you need to keep up the façade that everything is okay…and keep going at the same crazy pace that the healthcare industry demands of leaders. What is wrong with this picture? A lot. And it needs to change.
The Complex Health Care Environment
According to a white paper produced by Change Management Solutions, Inc. titled, Why Employees Burn Out: The Burnout During Organizational Change Model (B-DOC), “Burnout is NOT simply an individual’s maladaptive response to stress. Work environments strongly influence an employee’s attitudes, behaviors, levels of motivation, and feelings of stress. Many organizations unwittingly build cultures and work environments that create burnout.”
The high pressure, high demand, and complex culture of healthcare make it ripe for burnout. Add to it that the type of people often attracted to work in the healthcare industry are often those personality types that are service-oriented and highly empathetic people. Coincidentally, those are the same type of people who are more prone to compassion fatigue and burnout.
The healthcare industry is filled with hardworking, committed, and caring leaders. It’s also filled with extraordinary work demands, a constant sense of urgency to get things done, and limited capacity in which to achieve them. These things together can be problematic. The motivation to continuously go, go, go is always in the best interest of the patient, but often it’s at the risk of self-sacrifice. The culture of healthcare, with the increasing pressures to reduce costs due to declining reimbursements, new government regulations, and the need to become more efficient, all while continuing to provide exceptional quality and service to patients can be unrelenting for leaders.
And in case you missed it, we’re all getting older. People are living longer, patients that are accessing health care are sicker and there are more of them…which creates its own set of challenges. For some communities, as the population is aging and the demand for services and technology continues to grow, the facilities are aging as well. All of this comes at a cost. Hospitals must make a positive bottom line to reinvest in their aging infrastructure so they can care for the community in the future.
Leaders rarely get to put their worries away at the end of the day and go home. Their work often comes home with them and that contributes to their burnout. Rarely does it feel like there’s time for a break…or to even take a breath. And there’s certainly no time to stop and reflect. There’s always a mountain of work ahead to tackle and complex problems to solve. In the beginning, this is exciting and energizing, but over time the chronic stress that this creates can take its toll.
Eight Things That Will Help Prevent Leadership Burnout
So, what is the solution? There is a lot that needs to change about our complex health system. More than I can address with this article. But there are a handful of things that I think can help start to address the burnout problem that leaders are struggling with.
I see it as a problem that has to be tackled from two angles. Those who are experiencing it need to learn to do things differently and the environment that is placing unrelenting demands on leaders needs to change.
Leaders can help themselves by:
1. Developing Self Awareness – Burnout is more about our perception of our effectiveness than our actual effectiveness so accuracy in our perception is important. It’s important to have reliable, trusted colleagues to provide feedback, help develop self-awareness, and maintain perspective. Find a coach or mentor to help you.
For those of you who are introverted or highly sensitive, it’s particularly important to build space into your day to have time to process your thoughts and decompress. Learn to value this about yourself and do not allow others to intrude on this time. If you must, leave your office to take a walk so that you cannot be interrupted.
Recognize your limitations and know when to seek support and help from others. Learn when to let go – for your self-preservation. For some, it’s easy to fall into the trap of being constantly busy and in some cases, this can lead one down a path into victim mentality. Be aware of this trap and recognize when it is starting to occur. Competing with other leaders of who is the busiest is helping nobody. It can be harmful to an organization’s culture. Leaders need to become problem solvers to the solution and not victims of a busy culture.
2. Practicing Gratitude & Positivity – Practicing gratitude and positivity will help you see things in a more positive light and there are many ways to do this, personally and within an organization:
As a leader, you can role model this for staff by adding a section to every meeting agenda to spend time on staff recognition.
Practice positive rounding where the sole purpose is to look for things to celebrate.
Participate in random acts of kindness – and focus on other leaders who often get far too little recognition because those in leadership positions are often so focused on ensuring staff are recognized.
Not only will all of these things make the recipients feel good, but they make you feel good!
Dr. Bryan Sexton suggests the simple act of jotting down three good things that happened to you at the end of each day (https://bmjopen.bmj.com/content/7/5/e015826). This daily reinforcement of gratitude helps build an attitude of positivity that can help combat burnout.
These are seemingly little things, but they can help rewire the brain’s thinking to be more positive over time and create an important protective mechanism when one is feeling overwhelmed. They help create resiliency.
3. Practicing Self-Care – Those in the helping industries are at particularly high risk for burnout because of the amount of compassion that the job often requires. This makes the need for self-care particularly important. Create a self-care plan that is unique and meaningful to you and that supports positive mental health and boosts personal resiliency. Make sure it includes some or all of the following:
Spend time in nature.
Exercise.
Get sufficient sleep.
Practice meditation and mindfulness.
Eat foods that are nourishing to your body.
Spend time with people cultivating relationships that are deep and meaningful.
Invest time in a hobby that brings you joy.
Being a role model for others in practicing self-care and demonstrating a healthy work-life balance where caring for you is a necessity, not an afterthought.
Organizations can protect leaders from burnout by:
1. Openly talking about it. The feelings of burnout can be isolating. If it’s openly talked about in a way that’s not viewed as shameful or weak, but more as a check-in to make sure everyone is doing okay, and if any adjustments need to be made, the conversation can be viewed more positively. An organization must create a culture of psychological safety for meaningful dialogue to occur.
Creating a culture of high standards and expectations can be good for an organization (e.g. stretch goals), but it’s important for executive leadership to assess and openly talk about when the expectations may be too high and if they’re contributing toward burnout within a leadership team. You don’t want to establish a culture where leaders create such a high bar that people burn themselves out trying to achieve the goals. In the long run, turnover goes up and that is not good for the organization. It’s costly. Morale and productivity can then be negatively impacted, which has longer-term implications.
2. Ensuring reasonable workloads – Those who are the highest performers and the most highly engaged are often at the highest risk for burnout. Our most capable leaders are the ones we tend to turn to with new and bigger projects because they are so capable. And because they are so engaged, they willingly take on the challenge. Consequently, their workloads get bigger and bigger. But this also contributes to burnout.
CEOs and Boards of Trustees need to look at strategies and targets and determine if they are reasonable for the organization. They should also be assessing:
How far can leaders be reasonably stretched?
Is there enough organizational capacity to accomplish the work?
Do leaders have enough staff to support their work?
Nursing leaders notoriously have huge spans of control. What is the right ratio of leaders and direct reports to be effective?
Do leaders have the appropriate technology to support them and help make their work processes efficient?
Organizations need to ensure that they are distributing workload demands appropriately and providing leaders with the tools and resources they need to be successful.
A July 2019 Harvard Business Review Article titled 6 Causes of Burnout, and How to Avoid Them lists workload as the first of six causes. The article states, “When you have a workload that matches your capacity, you can effectively get your work done, have opportunities for rest and recovery, and find time for professional growth and development. When you chronically feel overloaded, these opportunities to restore balance don’t exist.” It’s the organization’s responsibility to help keep this in check.
3. Protecting calendar time – This is particularly challenging in hospital environments when leaders need to meet with physicians and they run 24/7 operational units. Supporting flexibility can help. If a leader needs to come in very early or stay late for a meeting, encourage them to adjust to the other end of their day to account for that.
Don’t allow people to be boastful about working all night and discourage leaders from sending late-night emails or working during vacations. You want leaders to be getting real respite when they aren’t at work. They are role modeling behavior for staff to help ensure they are setting the organizational standard. This starts at the top. Respect people’s home lives and keep interruptions to true emergencies.
Encourage calendar “white space.” An organizationally mandated calendar block time for “planning” or “well-being” and a guideline to avoid scheduling meetings over the lunch hour can help with this. The key is ensuring it’s adhered to.
4. Allowing space and celebration between high-demand projects – High-driving cultures tend to roll right into the next big thing without slowing down even to acknowledge the completion of the last project. While this might mean a lot gets accomplished, it can be a contributor toward burnout.
In an improvement culture, we are trained to look for the “reds” – those things that need our attention. But it’s important to balance that with celebrating the “greens”- those areas where we are meeting the goals. It’s necessary to allow time and space between big projects for those who carried the bulk of the workload to have some breathing space and for the team to celebrate the achievements.
One way to allow respite time for your leaders between high-demand projects is to ensure leadership is shared or alternated fairly among leadership team members so that there is not a disproportionate burden on certain team members to carry the workload. If the same team members are carrying more of the load than others over and over again, this can increase the chances of burnout.
5. Creating a culture that allows autonomy and empowerment – This requires trusting leaders to do what they believe is the right thing and having faith that they will. Put mechanisms in place to allow leaders to have input into the organizational strategies that will impact their daily work. They are the ones that are required to carry out the strategies so ask them what they think and incorporate what they have to say.
Allow leaders to lead and avoid micromanaging their work. If you have a leader with performance issues, address that head-on, ensuring you have accountability systems in place, but don’t address performance issues through micromanagement. Develop your high-performing leaders by giving them opportunities to learn and grow. Empowering them with stretch assignments as they are ready is another good way to combat burnout.
The Cost of Burnout
According to A 2020 Global Culture Report by OC Tanner, employees are more burned out than ever. “Employee burnout costs companies more than $190 billion in healthcare spending.” OC Tanner also indicates that there is an 87% decrease in the probability that an employee will stay with the organization if they are moderately to severely burned out. And turnover is very costly.
An article published by the Society for Human Resources Management called Blocking Burnout in Your Organization states the following: “Employees who say they very often or always experience burnout at work are:
63% more likely to take a sick day.
23% more likely to visit the emergency room.
Half as likely to discuss how to approach performance goals with their manager.
13% less confident in their performance.
2.6 times as likely to leave their current employer.
The cost of burnout to an organization is seen in increased turnover and lower productivity.” And when this is translated to leadership, it’s even more costly due to the impact that the loss of a highly engaged leader has on the progression of strategy within an organization.
My Hope for the Future
My great hope is that others don’t find themselves in the situation that I found myself in – that proverbial frog in a pot of boiling water. And that health systems start to address the issue of leadership burnout more openly by finding systematic ways to combat it from a prevention standpoint before more leaders choose the path that I did and leave altogether.
When you couple this with the large challenge that the healthcare industry already has in filling many leadership positions due to the hard-to-fill nature of the jobs, this is an issue that the industry must address. Failure to do so means the talent gap is going to get worse and fewer and fewer young talent will be willing to step into these leadership roles in the future. The industry has to act now.