Burnout Response for Leaders
An exploration of how leaders can better understand, respond to, and improve factors influencing staff burnout
By Stephanie Weyrauch, DPT
At the height of the COVID-19 pandemic, I was pregnant, unsure if I would contract the virus, facing the possibility of being laid off, and unable to visit my family who lived across the country.
New information released daily about the pandemic added to my anxiety. I was becoming emotionally exhausted. Would my clinic survive the storm?
The support and transparency of Anthony, our clinic owner, was essential in alleviating my stress. Our entire team cut hours so none of us would have to be laid off. Our HR department guided applications for partial unemployment. “We’re a family,” said Anthony. “We are in this together.” Throughout the pandemic, Anthony remained completely transparent, inspiring us through teamwork and compassion. Each of us played a role in keeping our clinic afloat when revenue decreased.
2020 was a difficult year for many physical therapists, especially in private practice. With the global pandemic raging, practice owners saw emergency funds and revenue sources dry up. Employees felt these strains as many practice leaders had to make difficult decisions to save their businesses. Those who continued working faced risk of infection and possible transmission to their loved ones.
These stressors renewed conversations about burnout among health care workers. While it is well-studied in physician and nursing populations, data regarding burnout in physical therapists is surprisingly limited and outdated. Most studies published on burnout in physical therapy are close to 20 years old or older, leaving us to rely on anecdotal evidence and blog posts. It is likely that burnout has increased during the coronavirus pandemic. In order to decrease burnout in physical therapy and, as leaders, help employees navigate these challenging times, we must address its underlying causes. This article examines anecdotal and data-derived evidence on the causes of burnout, its effects on private practitioners and employees, and solutions for keeping it from destroying company culture and morale.
The first issue in discussing “burnout” is its definition. Anecdotal versus scientific definitions of burnout differ. Typically, anecdotal discussions surround feelings of stress or a single component of burnout. In research, burnout is defined as physical or emotional exhaustion due to prolonged stress or frustration. It is characterized in the literature by feelings of high emotional exhaustion, high depersonalization, and a low sense of personal accomplishment1-3 Burnout can be a major contributor to employee absenteeism, increased attrition, increased health care costs, and decreased quality of the health care provided.2 Research examining burnout in physical therapists is sparse, with studies mainly focusing on specific practice settings or geographic regions, all resulting in inconsistent findings.1
BURNOUT RATES AMONG PHYSICAL THERAPISTS
Dr. Ellen Zambo Anderson, PT, PhD, an associate professor at Rutgers University, is one of the most recent scientists to address burnout in the physical therapist population. She is interested in how burnout differs from job stress. “Burnout is very well-studied in medicine and nursing—in fact, burnout was first observed in healthcare providers back in 1975,” she said. Scientists who originally defined burnout understood health care providers worked with people in crisis, which placed significant demands on their personal psyches. “Physical therapists also fall into the category of people working with others in crisis most of the time,” said Dr. Anderson.
In her dissertation1 “Stress and burnout in physical therapists,” Dr. Anderson surveyed a national sample of 1366 APTA members (37% worked in private practice outpatient clinics) on levels of burnout and perceived stress. She utilized standardized outcome measures to quantify stress and the characteristics of burnout: emotional exhaustion (feeling that a clinician can no longer psychologically support their patients), depersonalization (feeling detachment and negative attitude toward patients), and personal accomplishment (satisfaction with work and personal goals). To be classified as burnout, all three domains must be present simultaneously. She found that 13% of respondents were experiencing burnout, with 34% experiencing high emotional exhaustion, 30% with high depersonalization, and 32% feeling low personal accomplishment. Additionally, physical therapists who reported high perceived stress were seven times more likely to experience burnout than those who did not have high perceived stress. Those experiencing high emotional exhaustion were at increased risk for developing burnout.
CAUSES OF BURNOUT
Research indicates there are six domains that may predict burnout: 1) a demanding workload, 2) lack of control over resources and authority required to perform job duties, 3) lack of rewards for workplace performance, 4) poor workplace community, 5) absence of perceived fairness, and 6) conflicting values between an employee and organization or leadership.1-4
Anecdotal evidence suggests the top reasons for burnout in physical therapy include the rising cost of education, unmet career expectations compared to the reality of daily clinical life, changing payment structures, unrealistic productivity demands, and lack of non-clinical career opportunities.5-8 High turnover rates within a company may indicate high burnout among employees, which can be exacerbated by a poisonous culture within a company or among leadership.
Further, burnout rates increase when healthcare providers feel they are unable to contribute to good patient care or effective, efficient workplaces.1 During the COVID-19 pandemic, many private practice owners were forced to lay off employees. Colleagues working in other settings were transferred from treating patients to working at a security desk, performing nursing care, or other jobs physical therapists typically don’t perform, just to keep their positions. Many had little input about their work environment, responsibilities, or time spent with patients. It is unknown how the pandemic will affect our student physical therapists and new graduates as they enter the profession.
For leaders to address burnout, they must understand its prevalence within their organization. Private practices are increasingly using standardized outcome measures and key performance indicators to collect and analyze patient data and employee performance. Utilizing standardized assessments to measure employee risk for burnout may help companies identify at-risk employees early, avoiding the high costs of employee turnover.
One standardized outcome measure is the Perceived Stress Scale.9 This resource measures the perceived stress of an employee, is free, and provides reliable and valid data useful in determining which employees may be at risk for burnout. It also allows for more personalized communication between employers and employees regarding stress. “When I have had physical therapists fill out this scale, many are surprised by their scores,” said Dr. Anderson. “Some think they will score high and then don’t. Others who thought they managed stress well were surprised when they scored high. It leads to a conversation about strategies to manage health and well-being. Companies who integrate this information into their culture increase awareness, and leaders can better support their colleagues and improve employee coping strategies.
Once the prevalence of burnout is established, leaders can begin to implement solutions. Researchers have suggested six mitigation strategies for health care organizations: 1) providing a nurturing and supportive environment for employees, 2) listening to employee feedback and empowering them to solve problems in the workplace, 3) protecting clinician autonomy, 4) promoting workplace fairness and justice, 5) prioritizing employee satisfaction, and 6) understanding the intrinsic motivations that cultivate employee success.
In her research, Dr. Anderson found that an effective way to manage burnout is by providing a nurturing and caring environment. “If leaders support employees when in crisis, the company will decrease the rate of burnout,” she said. Leaders should create a culture that allows employees to safely voice concerns and, more importantly, listen to those suggestions. “When people suggest changes within the environment, the response from administration should be ‘I will look into that.’ Administration then needs to come back with information that supports the idea or instead, say ‘At this time and in this situation that idea won’t work, and here are the reasons why,’” said Dr. Anderson. “It is very detrimental to have the first response be ‘We can’t’ or ‘No’ without any real honest investigation into the suggestion or recommendation.”
Another solution: protect clinician autonomy. Leaders should allow clinicians to schedule their patients based on the patient’s individual needs. Decreasing redundancy in the EMR and documentation policies gives clinicians more time to dedicate to patients. Acknowledgement of credentials and encouragement of continuing education opportunities and professional development will contribute to high personal accomplishment. For example, employees who are board certified clinical specialists need time to maintain their expertise and treat the appropriate caseload. Leaders who have empathy for the stress that comes with treating people who are in crisis creates a culture that optimizes physical therapist autonomy. It lowers the burden of unreasonable demands.
Fairness and justice are important aspects of mitigating burnout. Leaders can promote these via transparency. Both employers and employees must communicate their expectations, especially regarding caseload. Regular recognition by leadership of job and community outreach performance promotes a sense of pride and appreciation. It is essential leadership avoid punitive action on issues outside employee control, such as cancellation/no show rates or inability to reach unreasonable benchmarks. Many clinic owners are instituting novel systems which encourage employee participatory-type management strategies.
Employee satisfaction needs to be as high of a priority as customer satisfaction. Employees determine whether a customer returns for treatment. If employees are unhappy in their position or experiencing burnout, they will be unable to provide patients with an exceptional experience. Leaders may offer anonymous surveys measuring employee satisfaction, dedicate a portion of the practice budget for employee raises, create innovative incentives or bonus-based pay structures, ensure employees have proper equipment to optimize treatment experience, support employees wanting to perform community outreach, and discourage working when ill.
Many owners go into private practice because they themselves were experiencing low job satisfaction and high stress. Think about why you started your private practice. Was it because you lacked autonomy? Couldn’t meet unrealistic productivity requirements? Worked for an incompetent boss who never listened? These are reasons many of my colleagues cite for starting their own practices, leading to a common theme that emphasizes supporting employees over solely focusing on productivity. When leaders understand the motivations of their employees—their dreams, hobbies, passions, and families—it allows them to utilize these intrinsic motivators to optimize productivity effectively without forcing clinicians to reach unrealistic benchmarks.
Many factors may increase a person’s risk for burnout. I have been lucky to avoid burnout thus far in my career. Leadership in my workplace has been strong, and my employers have prioritized many of the factors research suggests may mitigate burnout. However, many of my friends and colleagues, especially those who are new professionals, have not been quite as fortunate. This global pandemic has further challenged many practice owners and their employees. Owners who implement the solutions listed will not only survive this time where burnout prevalence is likely increased, but thrive in the days, months and years that follow.
1Anderson EZ. Stress and burnout in physical therapists [dissertation]. https://rucore.libraries.rutgers.edu/rutgers-lib/47324/. Accessed January 1, 2021.
2Berry JW, Hosford, CC. A regional survey: analysis of burnout among physical therapists in frontier counties. PT-PAL. 2015;15(3):1-11.
3De Hert S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg Anesth. 2020;13:171-183. Published October 28, 2020. doi:10.2147/LRA.S240564
4Maslach C, Leiter MP. The Truth About Burnout: How Organizations Cause Personal Stress and What To Do About It. San Francisco CA: Jossey-Bass; 1997.
5Castin M. Physical therapy burnout is destroying our profession (blogpost). http://covalentcareers.com/blog/physical-therapy-burnout/. Accessed December 20, 2020.
6Elliot, T. Understanding and avoiding burnout. APTA Magazine. Nov 2020:20-31.
7Ambler SB, Jette DU, Nordstrom T. Return on investment in physical therapy: professional tension. Phys Ther. 2020;100(12):2227-2230.
8Reis E. Beating Burnout. APTA Magazine. https://www.apta.org/apta-magazine/2019/02/01/beating-burnout. Published February 2019. Accessed December 20, 2020.
9Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;(24):386-396. https://das.nh.gov/wellness/docs/percieved%20stress%20scale.pdf. Accessed January 1, 2021.
Acknowledgement: The author would like to thank Ellen Zambo Anderson, PT, PhD, for her input on this article.