Burnout
The VA recently released the results of its annual All Employee Survey (AES). The survey is sent out to employees of VHA, VBA, and NCS and is put together by the National Center for Organizational Development (NCOD). A recurring theme throughout their surveys, this year and in the past, is an inquiry as to whether the employees of VA are feeling burned out. Not surprisingly, during a year of intense challenges, changes, and uncertainties, employees have felt even more disconnected, isolated, and estranged from the mission, and from VA. Messages from senior and executive leaders, at the local and national level, broadcast through many different platforms over this past year indicated that VA expected, and demanded, that employees think of the mission and the patients before they think of themselves or their own families. This is certainly not a way for VA to connect, engage, and empower its’ workforce.
The All Employee Survey uses words such as Burned Out. Apathetic. Disengaged. These are words related to unresolved occupational stress. Burnout does not apply to other areas of one’s life, and according to the World Health Organization (WHO), Burn-out is included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. It is not classified as a medical condition. In the ICD-11, Burnout is defined as “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.
In a study by Winona State University, burnout, which can affect anyone, in any occupation, can be further subdivided into 5 phases. The Winona State study, and Veninga and Spradley’s 1981 model of job burn out classify the five phases as follows:
Honeymoon Phase: this occurs when we start a new job or task and have high job satisfaction. The predicted stresses of the job are there, and we are driven to prove ourselves, to be highly productive and we are optimistic for the changes that are occurring.
Onset of Stress/Balancing Act: In this stage we are aware that some days are more difficult to get through than others. The enthusiasm we had for the job or task we are doing begins to fade and we begin to experience symptoms of stress such as fatigue, forgetfulness, avoiding decision making, bruxism (grinding your teeth), headaches, intermittent tachycardia, hypertension, irritability and inability to focus. We may have a sense of job dissatisfaction and these stressors can lead to inability to get a good night’s sleep or we wake up in the night worrying about our job.
Chronic Stress: There is an increase in stress occurring on a frequent or daily basis. The symptoms experienced in this stage are more intense than the previous stage. Chronic exhaustion, anger, aggression, cynical attitude and apathy and depression are seen in this stage. There seems to be no end to the fight or flight response and a person in chronic stress may also experience physical illness, procrastination, tardiness and may partake in escapist activities.
Burnout/Crisis: Stage 4 symptoms become more critical. There is an inability to cope, we have reached our limit of tolerance. There may be chronic headaches, behavior changes, chronic stomach or bowel problems, an empty feeling inside, neglect of personal needs, a desire to drop out of society, move away from family or friends, self-doubt, social isolation, persistent pessimism and escapist activities
Habitual Burnout/Enmeshment: This means that the symptoms of burnout are so embedded in your life that you are experiencing significant ongoing mental, emotional, physical problem related to stress. Chronic depression, chronic physical and mental fatigue are presenting symptoms.
Randstad USA, a national recruiting company, surveyed over 2,000 professionals in an annual employee engagement study. The data they gathered indicates the following points can lead to burnout at work:
Pressure to be “always on,” and therefore check work emails late at night or on weekends.
Expectations to get more done than is possible in the workday.
Not making progress in your career.
Your boss(es) not appreciating what you do.
A lack of staff to do the work.
Inadequate pay and benefits.
A lack of work-life balance.
The American Medical Association says almost 50% of physicians experience symptoms of burnout with emergency medicine physicians and family physicians most likely to experience burnout symptoms as compared to their colleagues in cardiology and oncology
A study by Singh and Mangat in 2016 and another study by Janulyte found that 84% of dentists have reported feeling burned out. While exact percentages vary depending on the study design, the evidence clearly indicates increased prevalence and risk of burnout in dental professionals.
A combination of job stressors, the individuals’ resources, the emotional response of the individual to anxiety and exhaustion and their changes in attitude and behavior all lead to the individuals’ susceptibility to burnout.
VHA and the NCOD feel that burnout is such a problem in VA that the All Employee Survey (AES) asks several questions directly and indirectly about burnout. Directly they ask, “do you feel burned out; or how often do you feel burned out”. Indirectly the survey asks about how engaged or connected you feel to your work, how connected you are to the mission, your coworker relationships; and is your job more than just a paycheck.
This past year has introduced a significant amount of stress to all of us. From initially dealing with the shutdown of services and possible furlough, to working from home and balancing home schooling, childcare and other family obligations with work obligations, to resumption of services in a manner inconsistent across states, medical centers or even VISN’s, to the introduction of new and previously unused or underused telehealth technologies to deliver healthcare, to inconsistencies in obtaining needed and necessary PPE, it would be foolish to think that feelings of chronic stress had not increased. The results from the AES will likely show a higher degree of job dissatisfaction over this past survey year.
Many different associations will advocate self-care to combat acute and chronic stress and burnout symptoms. Such self-care modalities include improving your physical and mental health through yoga, meditation, going for a walk out in nature, listening to music, and practicing mindfulness. As helpful as self-care is, other areas that have been shown to decrease burn out include:
Making the work environment empowering: Having a high level of mutual respect, allowing the team to feel safe in honestly communicating. Decreasing negative communication and gossip. Instead of having a “Top Down” attitude where those at the top dictate and decree, those “down in the weeds” need to feel safe communicating and having their ideas heard and implemented especially regarding how to improve the healthcare we deliver. Too frequently, those in the Ivory Tower have no grasp on the reality of the day to day situation, and frequently issue decrees that cannot be implemented. VA gives non-clinicians power to dictate orders, duties and tasks to the dentists and physicians who are expected to then comply. All too often there are frequent impediments to implementation of new ideas, and services that are supposed to support the delivery of healthcare create and defend bureaucratic roadblocks to successful and timely healthcare delivery.
Take control over your schedule: all too often, Dentists, Physicians, Podiatrists, Optometrists, and other Licensed Independent Practitioners, have their schedules dictated to them. Clinicians seem to have no power or say in how and when they are scheduled. To VA, if there is an open slot, plug it in with a patient regardless. Requests for time out of the clinic are denied because a LEAF request was not put in or was not entered within a set timeframe. Medical Administrative Services have been given power to deny the leave requested by dentists and physicians if they feel the request was not put in far enough in advance or if the physician or dentist did not, themselves, reschedule any affected patients. Dentists and Physicians are frequently given clerical work to do such as entering Community Care consults or having to call to scheduled or reschedule patients. This takes significant amount of time, without that time being allotted into the Dentist’s and Physician’s schedules. These clinicians will come in early, work late or through lunch to complete these clerical tasks, often without acknowledgement, reward, appreciation or compensation, because at our core, taking care of the patient comes ahead of everything else. If we did not put the patient ahead of everything else that might be going on, we would not have chosen healthcare as our honored profession. Support services that should be taking care of these non-patient care issues find ways to force the dentist and physician to do their job for them.
To be Fairly Compensated: every clinician in VA knows that working in VA has its’ rewards and challenges. One of the challenges is fair and competitive compensation. VA argues that the lower salaries are balanced by benefit packages, however, this is clearly not the case as VA hemorrhages clinicians, and can’t recruit or retain clinicians because of highly attractive salaries offered outside VA. NAVAPD has worked very hard in this area to get VA to fairly compensate its physicians and dentists but the pay tiers still have a long way to go to be competitive with the civilian sector.
While we may be able to go home and do yoga, meditate and become more mindful, VA has a long road ahead to empower its’ physicians and dentists. VA cannot make changes solely for the empowerment of the patient at the expense of the physicians and dentists. It needs to allow physicians and dentists to make clinical decisions including scheduling decisions, allowing them to manage themselves independently without resorting to Top Down management, or even worse, management by a non-patientcare professional. Above all else, it needs to compensate physicians and dentists more competitively. Until changes are made in those areas it does not matter how many All Employee Surveys are taken, physicians and dentists will continue to burn out, VA will continue to hemorrhage its’ quality providers; and ultimately the veterans will bear the fruit of VA’s poor managerial decisions.