Module 2 Outline: What burnout is and is not

1. This module is part of a training series for supervisors and managers of public health workers. The goal is to help supervisors and managers understand and prevent burnout in themselves and the workers they supervise.
2. Before we can take action against burnout, we need to understand what burnout is and what it is not
   1. With this in mind, after reviewing this module, you should be able to…
      1. Explain what burnout is as a chronic personal psychological phenomenon with physical and physiological elements.
      2. Recognize the differences between burnout and other distinct psychological states and health conditions.
      3. Explain the processes through which psychological and social resources are gained (and lost).
3. As a reminder, the multiple modules in this training series will help you more fully understand:
   1. the factors that contribute to burnout
   2. the consequences of burnout
   3. evidence-based strategies for preventing or at least minimizing burnout in work settings.

We hope you will continue on to these other modules once you have learned about what burnout is and is not.

4. Burnout is an “occupational phenomenon”, rather than a medical condition or actual disease (according to the International Classification of Diseases, 11^th revision or ICD-11).
5. Although burnout is not an official medical condition, it is an important and increasingly common phenomenon that needs to be intentionally addressed.
6. To understand current research and practice involving burnout, it is helpful to understand a bit of this phenomenon’s history:
   1. From early conceptualizations, burnout was a work-related condition believed to affect workers in helping and/or service professions.
   2. Interestingly, the earliest known examination of burnout was with public health workers staffing free medical clinics in the 1960s.
   3. In the years since, research has shown that burnout can happen in a wide variety of work and work-related settings (Bianchi et al., 2014).
      1. The boundaries between work and other parts of our lives are not always clear cut. But we do have to start somewhere – so thinking about burnout as a condition caused by work can be a meaningful starting point.
7. In practice, what does burnout look like, feel like, etc.?
   1. Some public health workers we interviewed described burnout as, “fatigue, fatigue, and more fatigue” or, when I’ve just “had it up to here.” Others shared feeling the sense that they just could not do it and could not care about their work or do it as well as they would like.
   2. Some leaders recognized burnout in employees who are, “in my office crying” or workers that are simply tired and on edge where “just one more little request” could be met with a breakdown. Leaders can see the impact of burnout when the workers who are typically kind, compassionate, and committed just lose their passion and are perhaps just going through the motions.
   3. It can look different for different public health workers – but most people know that feeling when they just feel worn out and aren’t psychologically experiencing work as they’d like to.
8. There is not just one model, framework, or perspective that fully explains burnout.
   1. From the mid-1970s to the present day (Freudenberger, 1974; 1989) burnout has received increasing attention. Many models and perspectives about burnout exist, generally known by names linked to the developing researchers or institutions
      1. g., Maslach & Jackson, 1981; Shirom & Melamed, 2006; the Cophenhagen Burnout Inventory (Tage et al., 2005)
   2. These models are more alike than they are different. When we talk about burnout, we are talking about a very serious strain state or condition that involves:
      1. Serious exhaustion that goes beyond typical daily fatigue or low energy levels. With burnout, such exhaustion is also generally classified as chronic (i.e., recurring and/or always present). It is also particularly linked to one’s emotional experiences and ability to adaptively manage oneself.
      2. Strong and persistent negative attitude (e.g., cynicism, reduced sense of accomplishment), particularly about the demands the individual must address.
9. Implication: It is easy to see how these two elements together can seriously impair a worker’s ability to perform job duties. In the public health arena, working in a state of burnout can affect not only our own job performance, but the communities we serve. Burnout can ultimately be life-threatening. Burnout may impair your decision-making abilities, putting those you serve at risk. It could also put workers themselves at risk – for instance getting in a wreck driving home from work because of high levels of fatigue or making a serious error when treating a patient or client, due to inability to think clearly. Understanding and working to reduce burnout is important for achieving the mission of public health and keeping public health workers safe and healthy.

10. You might be wondering how people end up experiencing burnout – in other words, where does burnout come from?
11. In a general sense, burnout develops in workers who repeatedly experience mismatched demand-resource scenarios paired with poor personal coping and emotion management (e.g., Bakker & de Vries, 2020).
12. Serious strains (and potentially burnout) can develop when we have too many demands that require effort from us and not enough of the resources we need to meet those demands.
    1. Multiple theories and frameworks guide research and intervention efforts that target burnout prevention. Two particular theories with clear explanatory value and utility in most work settings are the Job-Demands Resources Model (Demerouti et al., 2001; Bakker & Demerouti, 2017) and the Conservation of Resources Model (Hobfoll, 1989).
13. Unfortunately, this general scenario seems to be common among public health workers. It is linked not only to limited financial resources in some situations, but also to lack of actionable information, lack of community engagement and trust, lack of time, lack of personnel, etc. all while the number and intensity of demands stays nearly continuously high.
14. Within the theories of burnout we mentioned, the role of resources is really important.
    1. Resources take many forms (as discussed in later modules of this training), including: psychological, social, physical, and environmental.
    2. Resources can be tangible or physical objects, like a comfortable office or high-quality work equipment.
    3. Resources can also be intangible, such as support from others, feeling a sense of self-efficacy, feeling energized, or being in a good mood.
    4. We all experience resource loss or the threat of resource loss with feelings of stress.
       1. Stress is especially likely to happen when our resources are chronically depleted.
          1. We lose our energy and may experience negative emotions. This may lead us to withdraw from our support networks. We may not be able to connect to resources that could help us.
    5. It is important to be able to spot and stop chronic demand and resource mismatches and associated “drain cycles.” This is true for each of us individually, but also for the people and teams we supervise.
       1. When we lose resources, it becomes easier to lose more resources (a sort of “quicksand” or downward spiraling experience).
          1. Take the example of working with a clunky software system (a tangible resource). This could slow a public health worker down and trigger feelings of frustration over trying to complete basic tasks. Feeling frustrated could further harm the public health worker’s performance. Over time, they are less likely to be considered for a desired promotion and pay raise. All of this could undermine the worker’s sense of self-worth and efficacy in their job. Although this may sound dramatic, this type of process can unfold faster than we might realize when workers lack the resources they need to meet their job demands.
       2. An opposite scenario can also unfold – It is easier to gain resources, when you have more resources.
          1. Consider the previous scenario, but imagine the worker now has great software that minimizes frustrations that might otherwise be experienced when completing paperwork. This helps the worker spend more time and energy on more meaningful tasks, which increases the worker’s satisfaction with their work. The worker has a more positive attitude about work, which makes it easier for others to work with them. This mix of good performance, positive attitude, and healthy relationships builds up over time. It supports this worker’s chances of sustaining an impactful career and pursuing promotion opportunities if interested. This also supports the worker’s personal and professional sense of self-worth, self-confidence, and general well-being.
       3. When we get into demand-drain cycles, the imbalance in our demands and resources can lead us to do things that make our situation worse at work and at home. This can further increase demands or reduce resources and our ability to recover spent resources.
          1. For example, we might snap at a coworker during an extremely busy day. This might reduce the support we could have received from them.
          2. Alternatively, when we are tired, we might make a mistake in our notes that leads to further mistakes by other team members. When we later have to fix the situation, this creates additional demands that could have been avoided.

15. When we want to understand an abstract condition like burnout, it can be helpful to understand not only what it is, but also what it is not.
16. Here are some other, similar yet different strain conditions to distinguish from burnout:
    1. Fatigue – feelings of tiredness, low energy, and general attention/cognitive impairment. The big distinguishing feature here vs. burnout is that feelings and effects of fatigue tend to last only a few hours or weeks at a time.
    2. Boredom – may also be experienced and observed as low energy or low engagement, but it is linked to under-stimulation. Chronic over-stimulation and overload leads to burnout.
    3. Loneliness – more than a feeling and a serious risk to our health. This condition is linked to unmet affiliation needs in and outside of work.
    4. Engagement – typically seen in terms of workers’ energy and dedication to one’s work. At one point, engagement was seen as the opposing end of a continuum that ranged from burnout to engagement. More recent research and theoretical development clearly shows that this was an oversimplification: Plenty of workers who are heavily engaged also end up being at high risk for or even experiencing burnout.
    5. Moral distress – within healthcare settings especially, moral distress is experienced when a person, “is prevented from acting in ways they would have considered right based on personal values” (Riedel et al., 2022, p. 3).
    6. Moral injury – A moral injury can develop as a strain state similar to burnout after chronic exposure to moral distress. Moral injury is a loss of trust in self (a betrayal of what is right), due to or by an authority figure in a high stakes situation or system (e.g., Shay, 2014). Moral Injury was developed to more fully explain the complexity and severity of challenges experienced by military veterans than Post-Traumatic Stress Disorder (PTSD) can. Burnout is more focused on the individual and their own feelings about themselves, while moral injury also involves perceptions of the organization or environment in which one works.
    7. Compassion fatigue – to really confuse matters, compassion fatigue has been defined as, “the extreme stress and burnout from helping others (Paiva-Salisbury & Schwanz, 2022). Compassion fatigue is often linked with burnout and compassion satisfaction within nursing and healthcare research. For our purposes, compassion fatigue is perhaps best understood as one component of more generalized burnout.
    8. There is also some developing evidence that suggests a possible link between burnout and a variety of mental health conditions, including depression and anxiety (e.g., Schonfeld et al., 2019a/b).
       1. Researchers are still trying to narrow down if these types of relationships are truly meaningful or just the result of using similar research methods and measurement scales.
          1. Take for instance the idea that both depression and burnout can leave someone too tired to do their work. These are similar symptoms that could come up in both measures, even if they have some differences.
       2. It is not always clear how burnout differs from depression, anxiety, and other mental health conditions. Burnout is typically caused by chronic demand overload at work, while mental health conditions can have a variety of underlying causes.
17. We do not want to dismiss symptoms of serious mental health conditions by assuming someone is just a little “burned out”.
    1. Be alert to when you think or feel that experiences at work (and in general) are becoming burdensome for you or others with whom you work.
    2. People experiencing burnout or one of these mental health conditions may all benefit from professional counseling or other mental health services.
    3. You can connect to help by dialing 988 to access the U.S. National Suicide & Crisis Lifeline. You can also find licensed/credentialed mental health professionals through national resources like the American Psychological Association or other regional resources.
    4. Check out the supplemental resources included with this module if you are interested in learning a bit more about these topics and your own burnout risks.