Healthy Practices, Burnout & Provider Characteristics
The work of the primary care provider involves a complicated blend of compassion with emotional distance, personal concern with detached objectivity. The pace of care is fast and getting faster, demands on providers and accountability to outside bodies are increasing, and the volatility of our healthcare system shows no signs of ending. The additional stresses and strains accompanying poverty further challenge the delivery of care and the resources of individuals and organizations who practice in medically underserved contexts.
The medical literature first identified the problem of physician burnout about 20 years ago and studies report burnout levels between 30% and 80% in specialists and general practitioners. Burnout was once thought to be a late-career phenomenon but evidence suggests that younger physicians may be at higher risk than their older colleagues and that burnout can occur as early as in residency training. Rafferty describes the process of physician burnout as “the tendency for committed physicians to lose enthusiasm for their work and to become less effective in managing the stress of emotional contact with patients”. Symptoms may include fatigue, cynicism, irritability, and physical manifestation of anxiety and depression and feelings of diminished enthusiasm and effectiveness at work. These debilitating effects can extend beyond the individual provider and result in suboptimal patient care .
The mission of CCHF is to educate, encourage and equip individuals to live out the gospel through healthcare among the poor. This mission can only be accomplished through faithful, long-term, resilient service of individuals and communities of people who work together. Knowing that the living out of this mission is both rewarding and stressful, we wondered how CCHF partners were faring. With the permission of the board and leadership of CCHF, a survey of attendees to the 2010 CCHF Conference was conducted to assess levels of burnout, as well as their involvement in the kinds of healthy practices that the literature suggests may help foster wellbeing and protect against burnout.
Burnout is thought to occur when emotional exhaustion and depersonalization are high but the person’s sense of personal accomplishment is low.
Participants in the Survey: Who Are We?
Providers and nurses who attended the 2010 CCHF Annual Conference were specifically asked to complete the questionnaire. Of the 382 registered conference attendees, 114 individuals (30%) completed the survey; 97 were healthcare providers and the rest were participants who reported not having direct patient contact such as administrators, health support workers, or students.
114 CONFERENCE ATTENDEES SURVEYED
HEALTH SUPPORT: 10%
Table 1 provides a complete listing of demographic characteristics of people completing the survey. Most of those who completed the survey were Caucasian between the ages of 20 and 49. Approximately two-thirds were female, married, and have served in their healthcare role for six to fifteen years. Approximately three-fifths of our respondents work in urban communities and community clinics, and almost half reported working more than 40 hours a week.
DEMOGRAPHIC CHARACTERISTICS OF CCHF 2010 CONFERENCE SURVEY RESPONDENTS
Key: Characteristic Participants (n, %)
Male 35, 36%
Female 61, 63%
Age (in years)
20-29 27, 29%
30-39 21, 22%
40-49 28, 30%
50-59 12, 13%
60-69 5, 5%
70-79 1, 1%
White/Caucasian 76, 78%
Black/African American 8, 8%
Asian/Asian American 7, 7%
Hispanic/Latina 5, 5%
Married 61, 63%
Single 32, 33%
Divorced 2, 2%
Widow 1, 1%
Support/Care for Children
No 50, 52%
Yes 46, 47%
Support Care for Parents
Yes 25, 25%
Support for Other Dependents
No 80, 83%
Yes 16, 17%
Support/Care for Two of the Caregiving Questions
No 96, 85%
Yes 17, 15%
Support/Care for Three of the Caregiving Questions
No 106, 94%
Yes 7, 6%
Percentage of patients that are from poor/underserved area
0-10% 3, 3%
11-20% 3, 3%
21-30% 4, 5%
31-40% 3, 3%
41-50% 4, 5%
51-60% 1, 1%
61-70% 3, 3%
71-80% 11, 12%
81-90% 12, 13%
91-100% 45, 51%
Role in Healthcare
Physician/other provider 54, 56%
Physician/Administrator 7, 7%
Nurse 16, 17%
Health Support 10, 10%
Student/other trainees 9, 9%
Years in Healthcare Role
1-5 11, 11%
6-10 24, 57%
11-15 16, 16%
16-20 5, 6%
21-25 3, 3%
26-30 2, 2%
31-35 1, 1%
36-40 2, 2%
41-45 2, 2%
Hours Worked per Week
0-10 7, 7%
11-20 7, 7%
21-30 6, 7%
31-40 29, 31%
41-50 30, 32%
51-60 7, 7%
61-70 5, 6%
71-80 1, 1%
81-90 1, 1%
Community I Work
Urban 59, 61%
Rural/Frontier 8, 8%
Suburban 9, 9%
Mix Urban/Suburban 8, 8%
Mix All 6, 6%
No Applicable 2, 2%
Medical Setting I
Community Clinic 54, 56%
Free Clinic 9, 9%
Hospital 9, 9%
Independent Practice 8, 8%
University/Medical Setting 12, 12%
Other 2, 2%
Not Applicable 2, 2%
Medical Setting 2
Community Clinic 4, 4%
Free Clinic 5, 5%
University/Medical Setting 2, 2%
Not Applicable 85, 88%
Medical Setting 3
Hospital 1, 1%
Not Applicable 95, 98%
Healthy Practices: What Are We Doing?
Conference attendees were asked to review a set of 28 healthy practices and record (a) how frequently they engaged in the practices, and (b) how important they thought each individual practice was for their own wellbeing. Healthy practices fell into four categories:
- Physical-Recreational (e.g.: adequate sleep, exercise, hobbies)
- Professional-Organizational (e.g.: supportive leadership, good job-person fit, focus on positive aspects of work)
- Psychological-Social (e.g.: acceptance of limitations, maintenance of professional values/identity, relationships with friends)
- Spiritual-Religious (e.g.: prayer/meditation, scripture/religious text reading or study, Sabbath-keeping)
The types of healthy practices conference attendees reported engaging in most frequently were Spiritual-Religious and Professional-Organizational. The categories of healthy practices with the greatest range in responses were Spiritual-Religious and Physical-Recreational Practices.
TABLE 2. FREQUENCY OF HEALTHY PRACTICES BY CATEGORY:
Key: Healthy Practice Category M(SD), (Range) Min, Max
Spiritual-Religious 4.47(.97), .20, 6
Professional-Organizational 4.23(.81), 2.14, 5.86
Psychological-Social 3.86(.78), 2.20, 5.90
Physical-Recreational 3.66(.86), 1.43, 5.71
Notes. N=114. Scores reflect responses on the Healthcare Provider Healthy Practices Scale (HPHPS, Canning & Koh, 2009). Category means can range from 0 to 6. HPHPS items belonging to the healthy practice categories include: Spiritual-Religious (17, 21, 22, 23, 24), Professional-Organizational (6, 7, 15, 25, 26, 27, 28), Psychological-Social (5, 8, 10, 13, 14, 16, 18, 19, 20) and Physical-Recreational (1, 2, 3, 4, 9, 11, 12).
People also recorded the practices they consider most important for their well-being, as well as the frequency in which they engaged in these practices. Prayer/meditation was listed as the most important practice for well-being and was followed by participation in religious group/community, scripture/religious text reading or study, relationships with family, and adequate sleep. However, the practices most frequently engaged in include: participation in religious group/community, relationships with family, good job-person fit, and maintenance of professional values/identity.
The degree to which a person’s perception of the importance of a healthy practice differed from the reported engagement in those practices was also examined. Healthy practices with the greatest discrepancies between perceived importance and reported engagement were “relationship with mentor/mentee”, “exercise”, “rest/relaxation”, “vacations”, “sports/physical activities”, “prayer/meditation” and “scripture/religious text reading or study”. Healthy practices with the smallest differences between perceived importance and reported frequency were “maintenance of professional values/identity”, “active problem solving”, “good job-person fit”, “sense of humor”, “relationships with family”, “self-awareness/monitoring”, and “focusing on the positive aspects of work”.
In general, healthy practices were overwhelmingly viewed as more important for wellbeing than the frequency with which they were engaged in by participants. This finding is understandable given the occupations and lifestyles of our participants and is not likely to be unique to our community. A close examination of the scores shows that healthy practices with the smallest discrepancies tended to be those that conference attendees reported engaging in frequently. Conversely, those with the largest discrepancies tended to be those with lower reported engagement. There were a few interesting exceptions, however. Two spiritual-religious practices (prayer/meditation and scripture/ religious text reading/study) generated some of the largest discrepancy scores, despite the finding that these practices were also some of the most frequently engaged in of those queried. This likely demonstrates the high degree importance that CCHF conference attendees place on spiritual/religious practices as well as their perception that very frequent engagement in these practices is desirable for wellbeing.
Four of the five practices generating the largest discrepancies between perceived importance and frequency of engagement were physical or recreational in nature, namely exercise, rest/relaxation, vacations, and sports/physical activities. While vacations are typically a low frequency activity, the others in this set can conceivably be engaged in with greater regularity. The large discrepancies in physical/recreational practices are especially notable given the well-established relationship between these kinds of activities and physical and emotional wellbeing. They are also interesting given that the respondents were themselves healthcare providers who no doubt prescribe physical practices such as these for their patients. The finding is not surprising, however, as the phenomenon of physicians, psychologists and other healthcare providers neglecting their own physical and psychological health has been well documented (Freeborn, 2000; Shanafelt, Sloan, & Habermann, 2003).
Burnout: How Are We Doing?
In the final section of the survey, conference attendees completed the Maslach Burnout Inventory in which they were asked to rate how often they experienced a sense of emotional exhaustion, depersonalization and personal accomplishment. Burnout is thought to occur when emotional exhaustion and depersonalization (or an excessively detached, negative calloused response toward patients or others) are high but the person’s sense of personal accomplishment is low.
In our survey, individual provider scores on each of the three components of burnout ranged from low to high. As a group, providers’ mean scores for both emotional exhaustion and depersonalization would be considered in the moderate range. On average, providers’ sense of personal accomplishment fell just into the low range. Approximately one fifth of respondents met Maslach’s full criteria for burnout. This finding needs to be interpreted with caution, however, as those who answered the survey may be more or less healthy than conference attendees or CCHF members or associates who did not or could not do so. Regardless, this result might be viewed as good news if seen as a small percentage of our respondents. Even so, concern over even a minority of individuals experiencing burnout seems consistent with the nature of our organization’s mission, values and concern for our members and associates. Finally, it should be emphasized that the overall scores for this group of almost 100 providers were not far away from meeting the criteria for burnout. Expending some efforts toward prevention is vastly preferable to the fallout from healthcare professionals’ burnout on patients, providers and their family members and friends, organizations and communities.
Relationships Among Healthy Practices, Burnout & Provider Characteristics: What's the Connection?
The relationships among healthy practices and the components of burnout was investigated by generating correlations among the variables. Frequency of healthy practices was significantly correlated with all three components of burnout in the expected directions. In other words, the higher the frequency of reported healthy practices, the lower the levels of emotional exhaustion and depersonalization, and the higher the sense of personal accomplishment. Discrepancies between perceived importance of various healthy practices, and reported engagement was significantly related to two of the three components of burnout. The greater the discrepancies, the greater the reported emotional exhaustion and the lower the sense of personal accomplishment. Depersonalization was not significantly associated with discrepancies between importance and engagement in healthy practices in this set of respondents.
A further examination of associations among demographic characteristics, healthy practices and components of burnout yielded some additional findings of interest. Years in healthcare yielded the most correlations of all the demographic variables. The number of years in healthcare was positively associated with frequency of engagement in healthy practices and sense of personal accomplishment, but also with emotional exhaustion. Age was similarly correlated with sense of personal accomplishment and frequency of engagement in healthy practices. While these findings are only preliminary, this interesting set of correlations suggests a picture of a more experienced/older healthcare professional who may prosper in the face of emotionally exhausting work when the sense of personal accomplishment is high and healthy practices are a regular part of his or her life. They also lend some credence to the notion that younger providers may benefit from peers and leadership support to successfully negotiate the early years in a healthcare context as well as stewardship of their own wellbeing.
Perceived social support was significantly correlated with the four study variables. It was positively correlated with sense of personal accomplishment and frequency of healthy practices, and negatively correlated with emotional exhaustion and discrepancies between importance and engagement in healthy practices. While the design of our study does not allow us to examine the direction of effects, the associations among social support and stress buffering has been well established. Whether social support may also help encourage engagement in healthy practices, we cannot tell from these results. It is also possible that those who engage in more healthy practices are more likely to access social support.
Number of hours worked was significantly correlated with only one of the burnout components, although perhaps the most pernicious: depersonalization. Additionally, hours worked varied by gender, with women reporting fewer work hours than men. It is notable that numbers of hours worked was not correlated with emotional exhaustion, nor with any of the healthy practice scores.
Besides number of hours worked, gender was associated only with age and years in healthcare. Both correlations were negative, such that women were younger and reported fewer years in healthcare. Interestingly, neither healthy practice variables nor burnout components varied by gender.
(The relationship between study variables was also investigated through regression analyses, complete results of which may be obtained from the first author. In sum, regression analyses supported the significant correlations between burnout and both the frequency of healthy practices, as well as the discrepancies between perceived importance and reported frequency. Social support was the sole demographic variable that contributed to the strength of the regression models in these analyses.)
Where Do We Go From Here?
We hope these preliminary findings can be a source of reflection for individuals in varied roles within Christian healthcare, and across stages of their professional and personal development. For example, individuals who complete the Healthcare Provider Healthy Practices Scale have the opportunity to identify practices with significant discrepancies between importance and engagement, setting the stage for potential behavior change. When healthy practices are seen as ‘one more thing to do’, they will likely add to a sense of burden. But when individuals and groups carve out time for honest assessment and reflection, motivation can be catalyzed and small changes may result.
We hope these results will also stimulate dialogue between individuals and the significant others in their lives about wellbeing, healthy practices, going the distance, and what it means to be faithful followers of Christ in challenging contexts. What would the important people in our lives say about our personal and professional health? What changes would significant others like to see? Who can we draw upon for support, and support in turn?
Finally, we hope leaders and influencers within CCHF and affiliated organizations will look for ways to identify and foster practices, policies and organizational climates that promote resilience and help prevent burnout such as increasing opportunities for appropriate input and autonomy, providing supportive leadership and designing systems in which individuals can continue to develop professionally, but also spiritually and personally.
Sally Schwer Canning, Ph.D., Helen DeVries, Ph.D., and J. Derek McNeil, Ph.D. are faculty members in the Clinical Psychology Doctoral Department at Wheaton College in Wheaton, Illinois. Sally Canning is also a behavioral health provider at Lawndale Christian Health Center in Chicago, Illinois. This article is based on a study conducted in partial completion of the doctoral program for John Koh, MA. For a complete listing of results, references and tables contact John Koh at johnkijookoh [at] gmail [dot] com. An unedited version of the complete study is available on the CCHS website.