The Dark Side of Burnout: Suicide Risk

Burnout is not just about exhaustion and disengagement; it can have fatal consequences. One of the darkest aspects of burnout is the increased risk of suicide among healthcare professionals. What leads to this tragic outcome, and how can we provide better support?

Increased Risk of Suicide:

Healthcare professionals, particularly physicians, have some of the highest suicide rates in the U.S. The constant stress, emotional exhaustion, and lack of support contribute to feelings of hopelessness and despair.

Contributing Factors:

• Emotional Exhaustion: Chronic fatigue and stress can lead to feelings of hopelessness.

• Depersonalization: Emotional numbness and detachment can increase the risk of suicide.

• Low Sense of Accomplishment: Feeling ineffective and unfulfilled can contribute to depression and suicidal thoughts.

Providing Support:

• Mental Health Resources: Ensure access to mental health support, including counseling and therapy.

• Supportive Work Environment: Create a culture where employees feel supported and valued.

• Open Conversations: Encourage open discussions about mental health and the challenges of the profession.

Conclusion:

The increased risk of suicide among healthcare professionals underscores the urgent need for comprehensive mental health support. By addressing the root causes of burnout, we can save lives and promote a healthier work environment.

The Deep Wounds of Moral Distress

Let’s delve into the concept of moral distress. Remember, moral distress occurs when we take an action or witness an action that violates our inner values. It’s important to acknowledge that our inner values differ from person to person. What bothers one person deeply might not affect another as much. These values are shaped by various factors such as upbringing, culture, religious background, personality, and past experiences. Moral distress arises when something goes against these deeply held values.

Sometimes moral distress is triggered by a single event, while other times it's a result of systemic issues, policies, or cultural norms—like water dripping on a rock until its strength is eroded. In this chapter, I (Patrick) will share two personal experiences of moral distress.

Zero-Visitor Policy

At the onset of the pandemic, many healthcare facilities, including nursing homes and hospitals, implemented a zero-visitor policy. At the time, I was a department director and the chairperson of the Ethics Committee for a large health system. I was responsible for advising on whether we should adopt this policy, which would close our doors to visitors, family included. Given the circumstances, I recommended that we follow suit, which unfortunately meant patients would die without their loved ones by their side, only accompanied by healthcare workers.

Despite my recommendation, our health system did not immediately implement the zero-visitor policy. Although the delay felt lengthy at the time, in hindsight, it probably wasn’t very long. Nonetheless, as chair of the Ethics Committee, I felt our recommendation should be promptly followed, as it was thoroughly considered and well-intentioned.

Three aspects of this situation caused me significant moral distress. First, the Ethics Committee's recommendation was briefly ignored, conflicting with my belief that such recommendations should be heeded. Second, I felt terrible about making the recommendation. As the leader of the chaplaincy department, it was a complete reversal of our usual values, which emphasized the presence of loved ones during critical moments. Third, about a year later, our state passed a law prohibiting zero-visitor policies in the future, making me feel morally distressed for having supported a now illegal policy.

The Full-Code Patient

Now, let’s shift to a more clinical example of moral distress experienced by nurses. Years ago, we had an elderly, frail patient with necrosis of the brain and metastasized cancer. She had multi-organ failure and was vent-dependent. She was in bad shape, to say the least. My heart went out to her. However, despite her dire condition, her family insisted on keeping her a full code, demanding that everything possible be done to preserve her life.

For the healthcare team, this was a source of moral distress. They knew that resuscitating her would not change the inevitable outcome due to her severe conditions. Even a non-clinical reader can easily understand that if this patient regained pulses following CPR, that would not remedy her cancer, dead brain tissue, and organs that had stopped working. Day after day, nurses, patient care techs, respiratory therapists, physicians, and others, dreaded the possibility of this frail patient’s heart stopping.

Late one night, the situation came to a head when she flatlined, and all the alarms sounded. Following protocol, the team performed CPR, including chest compressions and other resuscitative measures on this frail patient. This was deeply distressing for the staff, who felt they were violating their own values by providing aggressive care that seemed futile and inhumane. Not to mention that the only family member in the room was the patient’s granddaughter. Since she was not the designated decision maker for the patient, she could only watch her grandmother’s last moments on earth, characterized by the trauma of CPR.

It was awful.

While these examples may seem extreme, healthcare workers know that morally distressing situations are commonplace.

An office policy about the number of patients to be seen requires a physician to rush her visits and express less compassion that is natural for her. HIPAA laws keep front desk coworkers from being straightforward about the work happening around them, sometimes leading to interpersonal conflict. Financial pressures prevent a nurse from providing the medications or supplies he believes would be most appropriate for a certain patient. These sources of distress are woven into the daily lives of healthcare workers.

I used to feel as though there was an evil person behind every morally distressing situation. If we could just find him and remove him, the stress and obstacles would all dissolve. Of course, that was a child’s fantasy.

While there are plenty of misguided or inept leaders making things more difficult, the system itself provides moral distress and burnout opportunities even if every executive is kind and supportive.

Despite being normal and commonplace, moral distress inflicts a cost on us—particularly when it is sudden or profound. This can lead to moral injury, a deeper wound to our inner selves. Moral distress and injury can pave the way to burnout, making it challenging to reverse the damage done.

Soon, we will consider how burnout feels. But first, Erin explains the phenomena of vicarious trauma, moral injury, and compassion fatigue.

Qualitative Consequences of Burnout

While the quantitative impact of burnout is significant, the qualitative consequences are equally important. Burnout affects personal well-being, workplace culture, and overall job satisfaction. What are these human aspects, and how can we address them?

Decreased Employee Satisfaction:

Burnout leads to decreased job satisfaction, leaving employees feeling unfulfilled and disengaged. This can result in higher turnover rates and a negative workplace culture.

Reduced Empathy:

Burned-out professionals often experience reduced empathy, impacting their interactions with colleagues and patients. This emotional numbness can lead to errors and a decline in the quality of care.

Personal Well-being:

Burnout takes a toll on personal well-being, leading to stress, anxiety, and strained relationships. It can affect every aspect of life, from physical health to mental health.

Conclusion:

The qualitative consequences of burnout highlight the need for supportive work environments that prioritize employee well-being. By addressing these human aspects, we can improve job satisfaction, enhance empathy, and promote overall well-being.

Burnout for Beginners

Taken from “Let’s Talk About Healthcare Burnout: A Prevention and Recovery Guidebook,” by Rev. Patrick Riecke and Dr. Erin Alexander DNP.

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Let's begin by outlining where we’re headed. We'll define key terms like "moral distress" and "burnout." The term "burnout" is frequently used, but it has specific, technical definitions and distinct characteristics, especially in the workplace. We’ll delve into these definitions and characteristics, particularly how they manifest in our professional lives, and bleed over into our personal lives.

As we start to uncover the complex crisis of burnout, it's crucial to understand the emotional toll it takes on healthcare workers. Dr. Erin Alexander delves into this in chapter four, where she discusses vicarious trauma and compassion fatigue in detail.

We'll examine various studies and statistics. Unsurprisingly, burnout, moral distress, and work-related mental health issues have been extensively studied, particularly in the healthcare and education sectors. We’ll review some of these findings to provide a solid grounding.

Next, we’ll discuss examples of moral distress. While having a technical definition is helpful, it’s crucial to understand what moral distress looks and feels like in the workplace. I’ll also share my personal burnout story, detailing my experiences in healthcare during the pandemic and beyond.

We’ll explore the stakes involved. What happens if we don’t address burnout? What are the costs of failing to create supportive systems in our workplaces? We’ll also look at the organizational path: what can leaders do to prevent burnout and foster a supportive culture? This leads naturally into Dr. Alexander's exploration of psychological safety in the workplace in chapter nine.

Finally, we’ll discuss the personal path. If you’re currently experiencing burnout, know that you’re not alone. This conversation is largely for you. We’ll cover practical steps and innovative methods to recover from burnout and offer some encouragement along the way. We want to warn you that this topic is very personal to both of us, and our experiences will be woven throughout our discussion.

In most chapters, the voice will be Patrick's, but Erin's influence is ever-present.

The remainder of this chapter introduces historical voices in burnout study, technical definitions of moral distress and burnout, and studies and statistics around the crisis.

Pioneers in Burnout

Christina Maslach is a pioneering figure in the field of burnout research. Her work, particularly the Maslach Burnout Inventory (MBI), has provided a foundational framework for understanding burnout's core components: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.

Maslach's research emphasizes how chronic workplace stress leads to burnout. Her insights have shaped interventions designed to mitigate burnout and promote well-being, making her work essential for anyone seeking to understand and address this pervasive issue.

Johnathon Shay and Andrew Jameton have also made significant contributions to our understanding of burnout, particularly through the lenses of moral distress and moral injury.

Shay's work, especially with veterans, introduced the concept of moral injury, which occurs when individuals witness or partake in actions that violate their ethical beliefs, leading to profound psychological distress. Jameton expanded on this idea within the healthcare context, coining the term "moral distress" to describe the experience of knowing the right action to take but being constrained from taking it. Together, their work highlights the deep emotional and ethical impacts that can contribute to burnout, especially in high-stakes environments.

A Framework

To provide a framework, researcher Amanda Rosen and her team describe a continuum from moral awareness to moral distress to moral injury, often leading to burnout.

Moral awareness is having a sense of how things should be at work—an awareness of right and wrong. This can vary, but it often involves a moral sense of the quality of care, patient treatment, and standards that should be met.

Not everyone starts with moral awareness. Some coworkers are simply trying to avoid trouble or pay the bills and may not engage deeply with concepts like moral distress or burnout.

However, for those of us in helping professions, moral awareness is common and important. Most of us have some sense of “right and wrong” when it comes to our work. That’s good, but it sets us up for dissonance when things don’t go as they should, leading to moral distress—a violation of our internal ethics.

When moral distress is profound or sudden, it can escalate to moral injury, and potentially burnout. So, moral distress occurs when actions or situations violate your personal values. If this distress is severe or prolonged, it can result in moral injury, causing deeper internal harm.

Next, let's explore the characteristics of burnout.

The Three Characteristics

Emotional exhaustion, burnout's first characteristic, is not just tiredness after a long day. It is a deep-seated fatigue that persists even after rest. For self-reflection, recall the last time you returned to work after some time away (for vacation, a holiday, or medical leave). What feelings did you have? If the only feelings that come to mind are anxiety, dread, and fatigue, then you might be emotionally exhausted.

The second characteristic of burnout, depersonalization, involves a loss of connection to others, often manifesting as cynicism. Cynicism is something deeper than sarcasm. In fact, sarcasm can illuminate truth. But cynicism is a deeper level of hopelessness, a sense that nothing will ever improve. When we are in this state, even good news is received with a subtle sense of dread and defeat.

Lastly, a lowered sense of accomplishment occurs when you no longer feel your work makes a meaningful difference. Perhaps you took the job because you believed that you could make an impact. Now, things have changed, and you’re just trying to survive.

People who are burned out feel like their actions don’t matter much.

Statistics and Studies

Burnout is a common experience, particularly in healthcare. And while the COVID-19 pandemic did not introduce healthcare burnout, and its end did not resolve it, the impact from 2020-2022 is clear. Between 18% and 25% of coworkers left their jobs in the first year and a half of the pandemic.

Many nurses and physicians have left their fields entirely. A recent survey found that 2.7 million US nurses are currently experiencing burnout, representing 15% of the entire healthcare workforce.

Burnout symptoms are prevalent among nurses: at least 25% report symptoms like stress, anxiety, and depression. One study found that 95% of nurses felt burned out at some point in the past three years. Additionally, 27% of nurses who quit cited burnout as the primary reason. The annual turnover rate for nurses is over 25%, with nursing homes seeing even higher turnover rates, sometimes exceeding 50%.

An American Association of Critical-Care Nurses survey found that 92% of nurses believe their experiences during the pandemic will shorten their careers.

An article from The Atlantic highlighted that between 35% and 54% of nurses and physicians felt overwhelmed before the pandemic, a situation exacerbated by COVID-19.

Healthcare leaders face unique challenges. Often overlooked in burnout research, leaders experience hyper-responsibility and guilt when taking time for their own well-being. This hyper-responsibility and perceived lack of empowerment can lead to burnout.

For managers, several daily factors can also lead to burnout:

1. Increased workloads

2. Staffing shortages

3. Emotional strain

4. Insufficient resources

5. A lack of recognition

For coworkers under their leadership, who are hands-on with patients, there are similar contributors to burnout:

1. Physical demands

2. Emotional stressors

3. A perceived lack of support

4. High workloads

These challenges are compounded by the emotional toll of patient care and turnover in their work environment.

Conclusion

In conclusion, staffing shortages and employee burnout continue to plague healthcare. It’s unlikely that this comes as a surprise to you. If you are a healthcare worker, you know that morale is sagging, hours are long, and systems are convoluted. But what do we do about it? Can organizations change the experiences of coworkers? Even more importantly, what can stressed out coworkers do to care for themselves before it’s too late?

As we move forward, we’ll explore the concept of moral distress, a key component of burnout, and explore its profound impact on healthcare professionals.

Quantitative Impact of Burnout

Burnout is often discussed in qualitative terms, but its quantitative impact is equally alarming. The numbers reveal a stark reality of shortages and economic costs. What do these statistics tell us, and why is it crucial to address burnout now?

Shortages in Healthcare:

The U.S. is predicted to face a shortage of up to 94,000 physicians by 2025 due to burnout. Similarly, many nurses are considering leaving the profession, with 62% of acute care nurses believing the pandemic will shorten their careers. These shortages will significantly impact patient care and access to healthcare.

Economic Costs:

Burnout leads to increased turnover, reduced productivity, and higher healthcare costs. The loss of experienced professionals and the need for recruiting and training new staff can be costly. Organizations also face higher rates of absenteeism and decreased employee engagement.

Conclusion:

The quantitative impact of burnout is clear and alarming. By understanding the numbers, we can see the urgent need for action to address burnout, support healthcare professionals, and ensure the sustainability of our healthcare systems.