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Module 3 outline: Why burnout needs attention in the public health worker population

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  1. This module is part of our training series for helping public health supervisors and managers address burnout. You can expect to learn more about why it is important for you to care about burnout among your workers. Naturally, this will also allow you to consider how burnout may impact you personally in your work.
  2. This module focuses in on why burnout matters for public health workers in particular.
  3. After reviewing this module, you should be able to…
    1. Describe the scale and scope of burnout within the public health worker population.
    2. Explain multiple ways in which burnout negatively affects public health worker performance and impact.
    3. Describe the business case for addressing burnout among public health workers.
  4. Quick roadmap for the content that follow:
    1. The context around burnout in public health
    2. Prevalence of burnout
    3. Effects of burnout on workers, organizations, and communities
  1. Public health workers are tasked with carrying out the 10 essential public health services.
  2. With that overarching mission, the various jobs in public health come with many different demands that can be incredibly taxing over time.
    1. For some workers, these demands come from the work tasks or work environment. For example:
      1. Safety engineers or environmental technicians who may be required to carry out evaluations in high-risk settings. They may be exposed to hazardous materials, excess heat, or loud noises.
      2. An epidemiologist or health informatics specialist may have to exercise intense concentration working with data. They may also feel pressure to publish public data sets more quickly. This may be especially true since on-demand data became more common during the pandemic.
      3. For many (and probably most) public health workers, it is the pace, ambiguity, and unpredictability of work demands that can put you and your team into hyperdrive.
    2. Other demands that public health workers face are more psychological or social in nature. For instance:
      1. A nutritionist or health education specialist may spend much of their time working with individuals. This often requires emotional energy to motivate and express compassion for patients or clients.
      2. Other public health workers who do community outreach or case management may experience stress from uncooperative, critical, or judgmental community members.
      3. Sadly, studies surveying local health department workers and reviewing media events during the COVID-19 pandemic found that public health workers were faced with harassment, intimidation, and public disapproval (Ward et al., 2022). This was very real for some public health workers we spoke to as we developed this training. For many public health leaders, these experiences are extremely difficult to manage. Being villainized or undervalued for expertise and efforts runs directly counter to the image of public health workers as public servants who support their communities.
    3. Demands experienced by public health workers do not end with their workdays. Many workers also have caregiving, household, or community service responsibilities. If we do not consider workers as “whole persons” who exist beyond work, we can really miss the opportunity to improve all aspects of their well-being.
  3. Attention to the demands that public health workers face increased during the pandemic.
  4. However, a high workload, responding to ambiguous and unpredictable events, and burnout certainly are not new to public health.
  5. Also not new is the need to “make do” and complete work despite major resource constraints.
    1. Public health workers often must be prepared for emergency responses. They are used to “doing more with less” in their line of work. This is another critical element to the formula that leads to burnout.
    2. The “doing more with less” mode of working illustrates that it is not just the high demands that drive burnout. The lack of resources can be equally problematic.
      1. In many ways, the absence of resources can be the biggest demand that many public health workers face. Research shows that not having enough resources can be extremely stressful.
      2. Even anticipating not having enough resources in the future or the possibility of losing resources can be stressful.
      3. Some common examples of insufficient resources that we have heard about from public health workers are: not having enough staff; having to pause work that is what you trained for and what you find meaningful to jump to another role; or, lacking funds to reward or motivate employees with coffee or lunch during a stressful time.
    3. Many public health workers have the passion and drive to creatively solve problems and do what needs to get done, even in the absence of resources. However, we should not expect that they can or should do this long-term.
  6. Despite this “make do” reality that can be stress-inducing, burnout and other serious strains are not regularly discussed or addressed within public health.
  7. Thankfully, and as this training shows, attention to burnout is growing.
  8. This is in part because many public health workers experienced elevated workloads and significant resource limitations during much of the COVID pandemic.
    1. Before the pandemic, reviews of public health workforce research revealed that:
      1. there is really not enough research on this population of workers to begin with, and
      2. there is not much research yet to understand and improve the satisfaction and well-being of public health workers (Beck & Boulton, 2012; Hilliard & Boulton, 2012).
    2. The Association of State and Territorial Health Officials (ASTHO) acknowledged burnout as one of the seven trends that is going to affect the future of public health (Pearsol, 2022).
      1. In a blog post, Joanne Pearsol, director of workforce development for the ASTHO, wrote, “Working in public health agencies during a pandemic has placed stressors on the workforce, causing many to leave the field. Public health will need to provide mental health support, time off, and supportive workplace cultures for staff so they can stay healthy and in the field for the long-term.”
    3. Prior to the COVID-19 pandemic, self-care or burnout prevention was not a part of major competencies designed for public health workers or public health organizations. While the importance of serving the community and developing a strong workforce was clear, there was no focus on creating a resilient workforce.
      1. As one public health worker we talked with put it: Public health workers are good at “walking the walk” and leading by example when it comes to physical health, but sometimes there seems to be blinders on when it comes to mental health. So many public health workers are so dedicated to what they do, that they will do what needs to get done and keep doing it, even when they hit exhaustion.
    4. The lack of formal focus and attention on burnout and self-care within this profession differs notably from other health-related fields.
      1. For example, among physicians or psychologists, self-care is directly acknowledged as an essential and even ethical obligation.
      2. The basic argument in these professions is that if you are not taking care of yourself, you cannot possibly provide the best care for others.
      3. Even more seriously, is the risk that if you are not taking good care of yourself mentally, physically, and emotionally, you could end up harming the people you have committed to serve.
    5. The growing recognition of burnout as a problem during the pandemic has led to organizations like ASTHO and The National Association of County and City Health Officials (NACCHO) to develop more resources. We referenced these earlier, in the recommended resources for Module 2.
  1. As we learned in the opening modules of this training, when demands chronically exceed resources, workers are at a greater risk for burnout. This is a common experience for public health workers, especially during the COVID pandemic. As a result, current burnout statistics paint a rather disturbing picture:
    1. One study of more than 200 public health workers in Fall 2020 found that 66% of their sample reported symptoms of burnout (Stone et al., 2021).
    2. The 2021 Public Health Workforce Interests and Needs Survey (PH WINS) surveyed over 40,000 staff members in state and local government public health departments. They found that 53% of their sample reported symptoms of some form of mental health concern, such as anxiety, depression, or Post-Traumatic Stress Disorder (Bryant-Genevier et al., 2021). A follow-up survey in 2022 indicated that 48% of public health workers surveyed were still experiencing at least one mental health symptom.
    3. Public health workers were already at high risk for burnout. Now, after more than two years of operating with the added demands from the COVID-19 pandemic, these professionals are continuing to report high levels of burnout and mental health concerns more broadly.
  1. As a leader in public health, why should you care about burnout?
    1. We know that some (probably most) leaders participating in this training already have a natural drive to help others. That is true of many people that enter public health.
    2. Some of you may also be thinking, “burnout is a really personal thing; is it really important or necessary for me to get involved? Why is this my responsibility as a leader or supervisor?”
    3. Many organizations are embracing a Total Worker Health® perspective, and you could too.
      1. Total Worker Health is a program from the Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH). The goal is to encourage organizations to think beyond just protecting workers from hazard, but also promote worker well-being. This perspective also emphasizes using organizational strategies to protect worker health rather than focusing too much on individual strategies that place the burden on workers.
    4. We understand that you may be coming at this issue of burnout with your own personal challenges and needs.
      1. You may be a leader who already cares deeply about your staff. You want to do something to reduce burnout, but you feel like your options are so limited.
      2. Regardless of where you are starting from, addressing burnout can help your organization function better.
      3. We are going to explore several points that can help to support a personal and business case for working to minimize the impacts and occurrence of burnout.
        1. Importantly, this will not happen without help from leaders like you.
    5. Burnout involves symptoms that affect worker’s energy and attitudes. It is easy to see several ways in which burnout can significantly and negatively affect workers and organizations.
    6. These are areas that are important for leaders and the organization as a whole:
      1. Productivity and performance – burnout negatively affects a person’s ability to work.
        1. Higher levels of burnout are associated with low productivity and generally poor performance.
        2. Burnout is associated with more presenteeism (being at work when not feeling well) and absenteeism (missing work; Demerouti et al., 2009; Swider & Zimmerman, 2010).
        3. Burnout can be related to more errors or accidents at work (Nahrgang et al., 2011; Prins et al., 2009).
        4. This can be a part of self-undermining cycles where errors at work can cause more stress and make our situation worse.
      2. Financial impacts – low productivity, accidents, errors, and general reductions in engagement translate into financial losses for any organization. This can be through lost time and slower workflow, or more serious costs from workers compensation or litigation.
        1. Sometimes there are also indirect costs. For example, when a burned-out worker is underperforming, others may have to pick up the slack. This could increase the risk of your more engaged workers becoming overburdened too.
          1. This was brought up by some public health workers we talked with – they simply cannot “let the ball drop” when a coworker is not pulling their weight. Because they care about the work they are doing, they will find ways to get the work done, even if they end up exhausted.
        2. Burnout can also be a driver of turnover. In the recent Public Health WINS survey we mentioned earlier:
          1. 1 in 3 public health workers reported considering leaving their jobs.
          2. 41% cited the workload/burnout as a reason to leave (Bork et al., 2022).
          3. Talking with some public health leaders, the same sentiment was apparent. Some of their workers who really loved what they did decided “it’s just not worth it – I have a life”.
        3. When workers leave there are both direct and indirect financial impacts:
          1. Direct – costs to recruit and train a new worker. This is not cheap and can take time away from other workers who have to help with hiring and training.
          2. Indirect – loss of experience and potential impacts on morale of those who stay. It is hard to put a specific dollar amount on the informal knowledge and experience of a worker, but we know it can be so crucial.
      3. Professional reputation and worker attitudes – Workers’ rights and their experiences are getting more and more attention. There is also a growing desire to take care of yourself and not sacrifice your own well-being for a job.
        1. In what was labeled “the Great Resignation” in 2022, many people have left jobs that they found degrading, unfulfilling, or otherwise “just not worth it anymore”.
        2. Similar sentiments are at the heart of other popularized phenomena such as “quiet quitting”, when workers decide to only meet minimum requirements at work.
        3. Without getting lost in popular catchphrases, organizations in all industries are coming to grips with shifts in workers’ perspectives about how and what work needs to be to merit their time and commitment.
        4. Organizations that adopt a Total Worker Health® perspective, as we mentioned earlier, are likely to become those that are most competitive for attracting talented workers that value their personal well-being.
      4. Ethical and moral imperative – Protecting workers’ health, safety, and well-being from harm due to work-related risk factors is an ethical and moral requirement for any employer. It is simply the right thing to do.
        1. As a leader in public health, you have an opportunity to improve the lives of the people who work with and for you.
        2. With burnout in particular, it is also important to remember that the effects do not end with the individual worker. Instead, burnout has ripple effects:
          1. When a public health worker is burned out, it affects their coworkers, the community members they serve, their spouse, their children, etc.
        3. If you are serious about contributing to the greater good and protecting public health, it is critical that you start by purposefully acting to promote the health of the workers you supervise (i.e., start at home).
      5. We hope these points will help in convincing you (if you were not already convinced) and maybe other stakeholders with whom you work, that burnout is a problem for public health workers that needs to be addressed.
  2. In summary, there are many effects of burnout at various levels in organizations and society (the individual, the organization, the community).
    1. This is important to truly understand the forces and factors that affect burnout, as well as the ways we can work to prevent burnout.
  3. In later units of this training, we will look more closely at what is called the “IGLOO” model as a framework to think about the context around burnout.
    1. IGLOO stands for: Individual, group, leader, organization, and overarching context.
    2. Using this framework, we will see how burnout affects and is affected by individual characteristics and behaviors (at work and outside of work), by team norms and dynamics, by leader behaviors and attributes, by organizations (policies, procedures, culture), and by broader community relations.
References

Beck, A. J., & Boulton, M. L. (2012). Building an effective workforce: a systematic review of public health workforce literature. Am J Prev Med, 42(5 Suppl 1), S6-16. https://doi.org/10.1016/j.amepre.2012.01.020

Bork, R. H., Robins, M., Schaffer, K., Leider, J., & Castrucci, B. C. (2022). Workplace Perceptions and Experiences Related to COVID-19 Response Efforts Among Public Health Workers — Public Health Workforce Interests and Needs Survey, United States, September 2021–January 2022. Morbidity and Mortality Weekly Report, 71(29), 920-924.

Bryant-Genevier, J., Rao, C. Y., Lopes-Cardozo, B., Kone, A., Rose, C., Thomas, I., . . . Byrkit, R. (2021). Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic — United States, March–April 2021. Morbidity and Mortality Weekly Report, 7(48), 1680-1685.

Demerouti, E., Le Blanc, P. M., Bakker, A. B., Schaufeli, W. B., & Hox, J. (2009). Present but sick: a three-wave study on job demands, presenteeism and burnout. Career Development International, 14(1), 50-68. https://psycnet.apa.org/doi/10.1108/13620430910933574

Hilliard, T. M., & Boulton, M. L. (2012). Public health workforce research in review: a 25-year retrospective. Am J Prev Med, 42(5 Suppl 1), S17-28. https://doi.org/10.1016/j.amepre.2012.01.031

Imai, H., Nakao, H., Tsuchiya, M., Kuroda, Y., & Katoh, T. (2004). Burnout and work environments of public health nurses involved in mental health care. Occup Environ Med, 61(9), 764-768. https://doi.org/10.1136/oem.2003.009134

Nahrgang, J. D., Morgeson, F. P., & Hofmann, D. A. (2011). Safety at work: a meta-analytic investigation of the link between job demands, job resources, burnout, engagement, and safety outcomes. Journal of Applied Psychology, 96(1), 71-94. https://doi.org/10.1037/a0021484

Pearsol, J. (2022, October 8). Seven Trends Will Shape the Future Public Health Workforce. Association of State and Territorial Health Officials Blog. https://www.astho.org/communications/blog/seven-trends-will-shape-the-future-public-health-workforce/

Peters, S. E., Dennerlein, J. T., Wagner, G. R., & Sorensen, G. (2022). Work and worker health in the post-pandemic world: a public health perspective. The Lancet Public Health, 7(2), e188-e194. https://doi.org/10.1016/s2468-2667(21)00259-0

Prins, J. T., van der Heijden, F. M., Hoekstra-Weebers, J. E., Bakker, A. B., van de Wiel, H. B., Jacobs, B., & Gazendam-Donofrio, S. M. (2009). Burnout, engagement and resident physicians’ self-reported errors. Psychol Health Med, 14(6), 654-666. https://doi.org/10.1080/13548500903311554

Stone, K. W., Kintziger, K. W., Jagger, M. A., & Horney, J. A. (2021). Public Health Workforce Burnout in the COVID-19 Response in the U.S. Int J Environ Res Public Health, 18(8). https://doi.org/10.3390/ijerph18084369

Swider, B. W., & Zimmerman, R. D. (2010). Born to burnout: A meta-analytic path model of personality, job burnout, and work outcomes. Journal of Vocational Behavior, 76(3), 487-506. https://doi.org/10.1016/j.jvb.2010.01.003

Ward, J. A., Stone, E. M., Mui, P., & Resnick, B. (2022). Pandemic-Related Workplace Violence and Its Impact on Public Health Officials, March 2020January 2021. Am J Public Health, 112(5), 736-746. https://doi.org/10.2105/AJPH.2021.306649

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