burnout Archives - Judith Johnson PhD

Dr Judith Johnson November 30, 2022

Is burnout really increasing in healthcare professionals?

Burnout is a hot topic right now. From magazine articles to academic conferences, podcasts to policy papers, the concept of ‘burnout’ is attracting attention like never before. Burnout isn’t a new idea, though. It first originated in the 1970s with Herbert Freudenberger, a US-based researcher. It then gathered more popularity in the 1980s when Christina Maslach introduced the ‘Maslach Burnout Inventory’, a questionnaire for measuring burnout. Since the turn of the century, the number of research studies into burnout has increased exponentially. In fact, more studies were published on burnout in 2020 alone than were published in the ten years between 2000 and 2010 combined (Figure 1). With so much popular interest, it can be easy to lose sight of the facts.

A graph depicting the exponential increase in burnout studies since the year 2000

Figure 1. Source: Vercio et al., 2021. https://doi.org/10.1080/10401334.2021.1879651

What is really happening with burnout?

To answer our opening question, yes: burnout is really increasing in healthcare professionals. The more surprising news is that burnout wasn’t increasing until the onset of the Covid-19 pandemic. Up until 2020, rates of burnout were stable. In the US, rates of burnout remained stable even after the onset of the pandemic, but that has since changed.

How do we know this?

There are only a small number of studies which have tracked burnout in a group of healthcare professionals over time. The first of these began in 2011 and measured burnout in US physicians. It has since gone back out to US physicians at four subsequent time points (2014, 2017, 2020 and 2021). As you can see from Figure 2, burnout fluctuated in the decade running up to the pandemic and even dipped a little at the start of the pandemic, but has since shot up to the highest rate recorded yet.

The best ongoing burnout survey is conducted by the UK General Medical Council (GMC). This survey has the largest number of respondents of any burnout survey in the world and also reports the best response rate. This means that the GMC survey results are more likely to reflect actual rates of burnout. The GMC first measured burnout in 2018, and they have since measured it annually. According to this survey, around 1 in 4 trainee doctors were reporting burnout when the survey was launched, and this remained stable until the onset of the pandemic. Increases were observed in the 2021 survey, and the 2022 survey results now suggest that 2 in 5 trainee doctors are experiencing burnout (Figure 3).

Should we be cautious?

There are two key problems with the datasets I have shared with you. The first is that they measure burnout differently. The GMC survey is particularly disappointing, as it uses a short questionnaire which only measures one aspect of burnout, emotional exhaustion. It entirely ignores depersonalisation, which is where clinicians began to detach and disengage from their patients. Depersonalisation is arguably the most concerning aspect of burnout, as our research has found that it is closely linked with poor patient care and bad career outcomes.

The second limitation is that these surveys are both in physicians. In fact, all the large and ongoing surveys of burnout I know of have been in physicians. This looks set to change now that the NHS Staff Survey has begun to include an item on burnout, but that survey will also suffer from the problem of using a poor measurement tool.

Where does this leave us?

Frankly, concerned. In many nations, austerity plans following the 2007/8 economic crash led to higher workloads and more challenging working conditions for healthcare professionals. This is the first time on recorded history, however, that we see burnout really increasing in a sustained manner. If there has ever been a time to actively invest in supporting staff, that time is now.

Dr Judith Johnson April 25, 2022

Free webinar! Four truths about burnout

Please note: this webinar took place on 26 April 2022 and registration has closed.

Tomorrow evening at 5pm I am presenting a 45m webinar: “Four truths about burnout: a talk on burnout trends, causes and outcomes“. The talk will be interactive, using quiz questions and opening up for Q&A discussions to ensure audience interaction.

The talk is being arranged and hosted by University College London Medical School, but all are welcome to join! Many of the talks I give are paywalled by the hosting organisations, or restricted to specific groups of professionals. This one is free to join and you can register your interest here:

Click to register!

Webinar information:

Date: 26 April 2022

Time: 17:00-18:00 BST

Overview: In the wake of the Covid-19 pandemic, burnout has become a hot topic. Rising rates of stress and burnout have become an increasing cause of concern for both health professionals and the organisations who employ them. With significant workforce shortages alongside increasing service demands and waiting list backlogs, health services are facing ‘a perfect storm’ which could result in unprecedented rates of health professional stress and burnout. This talk will address this issue, looking behind the headlines to present data on burnout trends, causes and outcomes. It will use an interactive voting approach to engage participants in polls and discussion.

Hope to see you there!

Dr Judith Johnson August 1, 2019

Healthcare workforce crisis: Why are so many staff leaving the NHS?

The NHS has a healthcare workforce crisis. It is estimated that 40,000 nursing and midwifery posts currently stand vacant – enough to fill Hong Kong Stadium. Furthermore, 68% of junior doctors report that staffing gaps occur often, which they suggest sometimes put patients’ safety at risk. To try and plug these gaps, there has been a focus on upping recruitment, with strategies aimed at funding training places in the UK and attracting more staff from overseas. However, it has been suggested that rather than being a problem of poor recruitment, the crisis is primarily driven by too many staff leaving. A quick look at the data supports this view: around 200,000 staff have left their NHS jobs every year since 2011, adding up to a combined total of 1.6 million over 8 years. Why is this? Here I explore the NHS dataset on ‘why staff leave’ to try and understand this problem.

The dataset

The data on ‘why staff leave’ has been recorded in a consistent manner since 2011/2012 and is available to download in a single excel file. There are 38 categories, ranging from ‘Death in Service’ to ‘Voluntary Resignation – Promotion’ (to download the original dataset, click here).

Concerning trends

Overall, the number of staff leaving jobs every year has been fairly stable with around 200,000 leavers per year. However, given the workforce crisis, there is a need to increase staff retention, and there is no sign that this is happening. There is also evidence that staff are increasingly leaving for specific negative reasons:

More staff are leaving due to poor work-life balance. In fact, more than twice as many cited this as their main reason for leaving in 2018-19 than 2011-12. This fits with broader data indicating increasing rates of burnout (see my previous blog post on burnout in mental healthcare staff for more on this).
More staff are leaving due to a lack of opportunities. Over 4800 cited this as their main reason in 2018-19 – more than twice as many who cited this as their reason in 2011-12.
More staff are resigning for health reasons. Similar to patterns seen with work-life balance and lack of opportunities, over twice as many staff cited this as their main reason for leaving in 2018-19 compared with 2011-12 – 4479 compared with 2126.

Positive trends

Sometimes staff leave their jobs for positive reasons, and the dataset reveals trends in some of these areas.

More staff are resigning due to gaining promotions. Over 15000 cited this as their main reason for leaving in 2018-19 – double the number who did in 2011-12.
More staff are leaving to take up education and training opportunities. Remarkably, the pattern is similar to that seen with promotions. Nearly 5000 left for this reason in 2018-19 – twice as many who said this was their reason in 2011-12.

The need for caution

These results highlight some concerning trends which suggest that dissatisfaction with work is one factor contributing to the current healthcare workforce crisis. However, they also reveal some positives – more staff than ever are leaving for education, training or a more senior post. When considering this data, there are two key issues to bear in mind. First, just because a staff member has left their job, it doesn’t mean they’ve left the NHS or even their organisation – they may simply have switched to another role. Second, if a person has had a few job changes over this 8-year period, they will be represented multiple times within the dataset. Both these issues could inflate the overall impression of the problem provided by this analysis.

Dr Judith Johnson September 12, 2018

Tackling burnout in UK trainee doctors is vital for a sustainable, safe, high quality NHS: Our letter to the BMJ

In 2018, for the first time, the General Medical Council (GMC) included items on burnout in its National Training Survey. The survey was completed by 51,956 trainee doctors and 19,193 trainers, making it the largest burnout survey in UK doctors to date. The response rate was also extremely high – 96% of all doctors in training who were contacted completed it, as did 41% of all contacted trainers. As such, these results provide a reliable picture of the current situation in the medical workforce. The survey found that 24% of trainees and 21% of trainers feel burnt-out to a high degree or a very high degree (for the full report, see here).

When I read these results in the BMJ, I wasn’t surprised. Rates of stress and burnout are high in healthcare staff internationally; in the 2018 Medscape report on physician burnout and depression, out of 15,000 US doctors, 42% were burnt-out and 12% were categorised as ‘colloquially depressed’. I was also concerned: a growing body of research shows a strong and consistent link between higher staff burnout and poorer patient care. Papers I have authored and co-authored show:

• 70% of studies which have investigated burnout and patient safety in healthcare staff have found a significant link between the two (Hall et al., 2016).
• In nurses, higher burnout is linked with poorer perceptions of patient safety both at the level of the individual practitioner and the ward level (Johnson et al., 2017).
• GPs think that burnout affects the quality of patient care by reducing their abilities to emphathise, to show positive attitudes to patients and by increasing the number of inappropriate referrals made (Hall et al., 2017).

Together with Dr Maria Panagioti and Dr Christopher Bu, I decided to respond to the BMJ article on the survey findings to highlight the evidence that burnout in doctors affects patient care. In particular, our letter focused on a recently published systematic review and meta-analysis led by Dr Panagioti. The findings of the review are described in more detail in a previous blog post (see here), but in brief, the review reported that burnt-out doctors are at twice the risk of being involved in a patient safety incident and at twice the risk of having dissatisfied patients.

This research reinforces the importance of measuring burnout in the medical workforce and the need to reduce this. The best way to intervene is currently unclear; while evidence suggests that interventions which target organisations (for example, redesigning jobs) are more effective than those which target individuals (for example, delivering mindfulness courses; Panagioti et al., 2017), there are many interventions which blur this boundary. These include training interventions, which are delivered to individual practitioners but aim to support them in their work, rather than improve their personal coping skills. Evidence suggests these are effective for tackling burnout (Dreison et al., 2018). Clearly, more research is needed. However, while we wait for this, I would suggest that organisations respond to the expressed needs of their workforce, providing the interventions that are both requested and well utilised.

To read our letter to the BMJ, please see here.

To read my previous blog on tackling burnout, please see here.

Dr Judith Johnson September 5, 2018

Burnout in doctors and the quality of patient care: Our systematic review

There is increasing evidence that healthcare staff burnout is linked to a range of negative outcomes, including increased staff absences, higher rate of staff turnover, and poorer quality of patient care (see my previous blog on this here). In a systematic review I co-authored, we found that that 21 out of 30 (70%) studies looking at the link between higher staff burnout and poorer patient safety reported a significant association between the two (Hall et al., 2016). The review found hard evidence for what many clinicians could see happening in their wards and surgeries: when staff are hard pressed, patient care suffers. It was well received on social media and has since been cited dozens of times.

However, while this previous review found clear evidence for a link between staff burnout and patient safety, it seemed to me that two questions remained unanswered. The first was whether there is also a link between burnout and other aspects of patient care, such as patient satisfaction. The second was what the strength of this relationship is: that is, just how much do increases in burnout impact patient care?

So, when I was invited to contribute to a systematic review on the links between burnout and patient care in doctors by Dr Maria Panagioti, I jumped at the chance. The review led by Dr Panagioti aimed to answer both these questions. It gathered studies which investigated burnout in doctors in relation to a broader range of outcomes, including:

Patient safety incidents, (e.g., adverse events, medication errors, diagnostic incidents)
Low professionalism (e.g., adherence to treatment guidelines, quality of communication, malpractice claims, empathy)
Low patient satisfaction

It also quantified the strength of these relationships using meta-analysis, which was not employed in the previous review.

Is burnout linked with patient safety incidents?

The review identified 21 studies which reported on the association between burnout and patient safety incidents. The results of the meta-analyses suggested that burnt-out doctors were twice as likely to be involved in a patient safety incident as those not suffering from burnout. All aspects of burnout (exhaustion, disengagement and low accomplishment) were associated with a significantly higher risk of being involved in a patient safety incident.

Is burnout linked with low professionalism?

28 studies were found which reported on the link between burnout and low professionalism (e.g., showing low empathy, having received a malpractice claim). The results of the meta-analyses suggested that burnt-out doctors were twice as likely to show low professionalism. When the different aspects of burnout were examined separately, disengagement was the aspect most linked with low professionalism. Doctors who were disengaged from their patients were 3-times as likely to exhibit low professionalism. Doctors high in emotional exhaustion or low in personal accomplishment were over 2.5-times as likely to exhibit low professionalism.

Importantly, the review found that the link between burnout and low professionalism was twice as high in trainee and early career doctors compared with more experienced doctors. This is particularly concerning when the recent GMC survey results showing that a quarter of trainee doctors are burnt-out are considered.

Is burnout linked with low patient satisfaction?

7 studies reported measures of patient satisfaction. It was found that burnt-out doctors were at twice the risk of having dissatisfied patients. Again, disengagement was the aspect of burnout most closely linked with low patient satisfaction, with disengaged doctors showing a 4.5-fold increased risk. Low personal accomplishment was also linked with twice the risk of low patient satisfaction. No link was found with emotional exhaustion.

Where now?

This review finds strong evidence that burnt-out doctors are at significantly higher risk of being involved in patient safety incidents, showing low professionalism and having dissatisfied patients. Having clarified the presence and size of the problem of burnout for patient care, the next step for us as researchers is to identify evidence-based solutions to this problem. While a number of interventions to reduce burnout have been proposed (see Panagioti et al., 2017), there is a need to identify 1) which interventions are most feasible and most effective, and 2) whether reducing burnout can improve patient care.

For my previous blog on tackling burnout, please see here.

The review described in this article was published in JAMA: Internal Medicine. To read it, please see here.