Burnout Among Physiotherapists:

Addressing the Elephant in the Room

Justin Berry, PT, DPT, PhD
Leanne Loranger, PT, MHM
Anna Wong, PT, MScPT
Objectives:
After attending this session, participants will be able to:
1. Identify the impact that burnout has on patient safety, staff attrition
and absenteeism.
2. Recall the components of burnout and the relationship between
burnout and work engagement.
3. Understand the findings of research into burnout among
physiotherapists.
4. Understand the concepts of self-awareness, self-regulation, self-
care and resilience as relate to burnout.
5. Access resources to take action against burnout.
Session Plan:
• Part 1:
• Defining Burnout + Work
Engagement
• Physiotherapy Alberta Research
• Part 2:
• US Research + Implications
• Regulatory Considerations
• Part 3:
• Personal strategies to prevent
burnout: self-awareness & self-care
strategies
• Organizational strategies
What is burnout?

“A syndrome of emotional exhaustion,

depersonalization, and reduced personal
accomplishment that can occur among individuals
who work with people in some capacity.”
(Maslach & Jackson, 1996)
The Maslach Burnout Inventory:
• Quantifies the 3 Domains of burnout.
What is work engagement?

“Engagement is a positive, fulfilling, work-related

state of mind that is characterized by vigor,
dedication, and absorption.”

Schaufeli, Salanova, Gonzalez-Roma, & Bakker, 2002

Utrecht Work Engagement Scale (UWES-9):

• Quantifies 3 domains of engagement.

• scores high degree of engagement.

• Thought to be protective against burnout.

Autonomy
• Negative correlation to burnout
(Jonge & Schaufeli, 1998)

• Positive correlation to job

satisfaction
(Thompson & Prottas, 2005)
Work Autonomy Scale
• Common instrument for assessing autonomy

• Composed of 9 questions; 3 in each construct:

• 1. Work Method Autonomy
• 2. Work Scheduling Autonomy
• 3. Work Criteria Autonomy

• Good internal consistency: .85-.93 (Breaugh, 1999)

Does this sound familiar?
• I feel emotionally drained from my work.
• I feel tired when I get up in the morning and have to face another day
on the job.
• I feel I am making an effective contribution to what this organization
does.
• I feel exhilarated when I accomplish something at work.
• I have become more cynical about whether my work contributes
anything.
Burnout and
Quality?

• Factors into:
o Patient complaints
o Disruptive behaviour
o Absenteeism
o Presenteeism
o Attrition
Physiotherapy Alberta
Study-Why?
• Anecdotal evidence.
• Regulatory mandate.
• Interest to ensure quality of
practice & retain members.
• Goal: Instruct employers.
• Goal: Help individuals
recognize & manage burnout.
Physiotherapy Alberta
Study:

• Conducted in 2016.
• All members.
• Standardized measures
• MBI-HSS.
• UWES-9.
• Qualitative questions.
Quantitative Research Questions:

• The prevalence of burnout?

• The contributing factors (practice context, patient population, age,
education, experience)?
• Subgroups demonstrating higher levels of burnout than others?
Qualitative Questions:
• How does burnout manifest itself?
• What did you observe when colleagues demonstrated burnout?
• What do you believe causes burnout?
• What do you do to prevent burnout in yourself?
• Does your life outside work affect the potential for burnout?
• Does the patient population you treat affect the potential for
burnout?
Quantitative Findings:
Degree of Burnout

MBI-EE MBI-DP MBI-PA UWES

Mean 23.1194 5.2338 35.2686 4.1945
Standard 12.4605 4.9869 5.3336 0.9968
Deviation

Median 23.0000 4.0000 37.0000 4.3333

Quantitative Findings:
Proportion Estimate

Criteria Proportion
estimate (%)
Emotional 37.31
Exhaustion
Depersonalization 9.45
Personal 17.41
Achievement
2 in MBI 13.43
3 in MBI 7.46
UWES 14.42
Quantitative Findings:
Associations

• Associations between burnout & practice or demographic

characteristics:
o Age
o Experience
o Education
o Practice Setting
Qualitative Findings:
The experience of burnout
Global Theme #1:
Clusters of Workplace Factors

The work
context

Burnout
The
The
individual
patient
PT
Global Theme #2:
Continuum of Contributing Factors

Contributing Prevention
factors

Burnout
Discussion: (1/2)
• ‘Average’ degree of burnout exhibited.

• Consistent with published literature.

• EE Scores - The canary in the coal mine?

• Low DP and high UWES scores.

• Engagement is protective against burnout.
Discussion: (2/2)

• Manifestations related to fatigue

and exhaustion.
• Work, patient, and personal factors
impact burnout.

• Burnout results from an interaction

between factors that contribute to
and those preventive of burnout.
Acknowledgements-
Physiotherapy Alberta Study:
• Research Team:
• Lesley Bainbridge
• Kathy Davidson

• Funding:
• Government of Alberta, Department of Labour, Occupational Health & Safety
Innovation & Engagement Grant Program
References:
• Alameddine, M., Saleh, S., El-Jardali, F., Dimassi, H., & Mourad, Y. (2012). The retention of health human resources in primary healthcare centers in Lebanon: a national survey. BMC Health Services Research, 12, 1-11. doi:10.1186/1472-6963-12-419

• Balogun, J. A. Titiloye, V., Balogun, A., Oyeyemi, A., & Katz, J. (2002). Prevalence and determinants of burnout among physical and occupational therapists. Journal of Allied Health, 31(3),131-139.

• Canadian Medical Protective Association. (2018) Healthier Physicians: An investment in safe medical care. Canadian Medical Protective Association, Ottawa. Retrieved from https://www.cmpa-acpm.ca/static-assets/pdf/about/annual-
meeting/18_healthier_physicians_backgrounder-e.pdf

• Dewa, C.S., Jacobs P., Thanh, N.X., & Loong, D. (2014) An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Services Research, 14:254. doi 10.1186/1472-6963-14-254

• Fischer, M., Mitsche, M., Endler, P., Mesenholl-Strehler, E., Lothaller, H., & Roth, R. (2013). Burnout in physiotherapists: Use of clinical supervision and desire for emotional closeness or distance to clients. International Journal of Therapy & Rehabilitation, 20(11), 550-558.

• Health Quality Council of Alberta. (2013). Managing disruptive behaviour in the healthcare workplace: Provincial framework. Retrieved from https://d10k7k7mywg42z.cloudfront.net/assets/531e04a0d6af6803fd000864/HQCA_Disruptive_Behaviour_Framework_041113.pdf

• Maslach, C., & Jackson, S. E. (1996). Maslach Burnout Inventory-Human Services Survey (MBI-HSS). In C. Maslach, S. E. Jackson, & M. P. Leiter (Eds.), Maslach Burnout Inventory Manual (3-17). Palo Alto, CA: Consulting Psychologists Press.

• Maslach, C., Jackson, S. E., & Leitner, M. P. (1996). Maslach Burnout Inventory Manual. Retrieved from http://www.mindgarden.com/117-maslach-burnout-inventory#horizontalTab1

• Maslach, C., & Leitner, M. P. (2015). It’s time to take action on burnout. Burnout Research, 2(1), iv-v. http://dx.doi.org.ezproxy.library.ubc.ca/10.1016/j.burn.2015.05.002

• Maslach, C., Leitner, M. P., & Jackson, S. E. (2012). Making a significant difference with burnout interventions: researcher and practitioner collaboration. Journal of Organizational Behavior, 33, 296–300. doi 10.1002/job.784.

• Maslach, C., Schaufeli, W. B., & Leitner, M. P. (2001). Job Burnout. Annual Review of Psychology, 52, 397-422.

• McMullin, J.A., Cooke, M., & Downie, R. (2004). Labour force ageing and skill shortages in Canada and Ontario. Canadian Policy and Research Networks. Retrieved from http://www.cprn.org/documents/31517_en.pdf

• Pavlakis, A., Raftopoulos, V., & Theodorou, M. (2010). Burnout syndrome in Cypriot physiotherapists: a national survey. BMC Health Services Research, 10(63), 1-8.

• Schaufeli, W. B., & Bakker, A. (2006). The measurement of work engagement with a short questionnaire. Educational and Psychological Measurement, 66(4), 701-715.

• Schaufeli,W. B. & Bakker, A. (2003). Utrecht Work Engagement Scale, Preliminary Manual (Vol 1). Retrieved from http://www.beanmanaged.com/doc/pdf/arnoldbakker/articles/articles_arnold_bakker_87.pdf

• Schaufeli, W. B., & Bakker, A. (2010a). The conceptualization and measurement of work engagement: A review. In A. B. Bakker & M. P. Leiter (Eds.), Work engagement: A handbook of essential theory and research. New York: Psychology Press.

• Schaufeli, W. B., & Bakker, A. (2010b). Defining and measuring work engagement: bringing clarity to the concept. In A. B. Bakker & M. P. Leiter (Eds.), Work engagement: A handbook of essential theory and research. New York: Psychology Press.
230 Km South
Job-Person-Fit Model of Burnout Development
1. Demanding workload
2. Lack of autonomy
3. Perceived deficiency in rewards
4. Absence of workplace community
5. Perceived unfairness re: job conditions
6. Feeling compelled to act unethically
(Maslach & Leiter, 1997)
 Burnout in PT: The 90’s

Donahoe et al, 1993 Wandling & Smith, 1997

 PT’s in MA Rehab Hospitals (n =  APTA Orthopaedic PTS (n = 387)

129)
 46% scored high for emotional
exhaustion burnout  Burnout levels were low to
 20% scored high for depersonalization moderate

 Burnout not significantly associated  Years of practice, caseload, &

with years of practice, years in age showed no significant
current position, or caseload correlations with burnout
 Burnout in PT:
Balogun et al., 2002
 PTs & OTs employed in NYC (n = 307)

 High mean level of emotional exhaustion

 58% in the high category
 # of Children predicted levels of emotional exhaustion
 High mean level of depersonalization
 97% in the high category
 Low levels of personal accomplishment
 97% in the low category
 Burnout in PT:
Berry & Hosford, 2015
• 61.2% of surveyed rural health CEO’s reporting a facility PT
shortage
• MacDowell et al., 2010

• PTs in rural areas may be at increased burnout risk due to:

• Small/absent professional communities
• High workload
• Decreased professional development activities
• Recruitment and retention difficulties
Frontier Counties (US Census, 2010)
 Frontier Physical Therapist Burnout Results
 Emotional Exhaustion
 High: 22.3%; Moderate: 17%; Low: 60.7%

 Depersonalization
 High: 4.5%; Moderate: 8.9%, Low: 86.6%

 Personal Accomplishment
 Low: 79.5%; Moderate: 15.2%, High: 5.3%

 n = 135
 Burnout Among PTs in Wisconsin
Berry JW, to be presented at APTA CSM 2019

• n = 297 (Response rate of 11.7%)

• Subjects had:
• High levels of emotional exhaustion
• Moderate levels of depersonalization,
• High levels of personal accomplishment

• Subjects with 10+ years of experience had significantly higher levels of

depersonalization (p =.002).
 Burnout Among PTAs
Berry et al., presented at APTA CSM, 2017

 255 PTAs in WA, ND, and SD

 Moderate levels of emotional exhaustion
 Low levels of depersonalization
 High levels of personal accomplishment

 Subjects with over 10 years of experience had significantly higher

levels of depersonalization (p = .033)
 PTAs and Potential Work-Life Domain Issues
 Decreased salary compared to PT
 Often have higher productivity requirements
 Less student loan debt
 Potentially small professional community of PTAs within institutions
Additional Potential Contributors to PT Burnout
Productivity Unmet
Requirements Expectations

Electronic
Student Loan
Medical
Debt
Records
Burnout
 PT Student Loan Debt
 High levels of student loan debt can delay buying a home,
starting a family, or saving for retirement
(Jette, 2016)

 High student loan debt can influence decisions about where to

work
(APTA, 2011)

 Negative association between cumulative student loan amounts

and psychological well-being
(Walseman et al., 2015)
 USA PT Student Loan Debt
 From 2004-2005 to 2014-
2015, the mean cost of PT
programs increased:
 Nearly 100% at private
institutions
 $99,797
 Nearly 50% at public
institutions
 $55,997
(Jette, 2016)
 Productivity & PTs
• N = 297 PTs in Wisconsin

• Subjects with a productivity requirement had significantly:

• Higher levels of emotional exhaustion (p < .001)
• Higher levels of depersonalization (p = .030)
• Lower levels of personal accomplishment (p = .002)

• Berry JW, to be presented at APTA CSM 2019

 Productivity & PTAs
 n = 144 PTAs in WA
 70.1% had a productivity
requirement
 Mean requirement of 81.8%
 56.9% of subjects reported a
productivity requirement over
85%
 Berry et al., will be presented at
CSM 2019
• n = 255; PTAs in WA, SD, and
ND
• PTAs who had a productivity
requirement had
significantly higher levels of
emotional exhaustion (p <
.001)
• Berry et al. presented at APTA
CSM 2017
 Unmet Expectations of New Graduates
• Unmet expectations about one’s
profession, and organization can
contribute to burnout
(Cordes & Dougherty, 1993; Maslach &
Jackson, 1984)

• Can also lead to greater

employee turnover
 New Graduate Expectations
 New graduates may be
prone to burnout due to
unrealistic expectations
 They may envision a
workplace with high
autonomy; stimulating work,
and supportive coworkers
 Cherniss, 1980
 Electronic Medical Records
 6,375 actively practicing
physicians

 Physicians who used EMRs

had higher rates of burnout
and lower satisfaction with
the amount of time spent on
clerical tasks
 Shanafelt, et al. (2016)
 Job-Person-Fit Model &
Electronic Medical Records
 Increases Workload
 May decrease autonomy
 May results in insufficient
rewards
 Unpaid overtime
 May decrease professional
community
 May be perceived as unfair
 Mundane data entry
I believe occupational burnout is a problem within the
PT profession
Adequate resources are available within my state for PTs
and PTAs who have occupational burnout
 NC Medical Board Change
• Following a physician suicide due to burnout the state medical board
looked at their policies
• Specifically due the physician's fear of seeking assistance due to possible
negative repercussions

• At the time of the MD’s suicide, the license renewal application asked
the applicant if he/she “was aware of any medical condition that
impairs or limits your ability to practice medicine safely?”
• Medical conditions included “…psychological conditions or disorders”
 NC Medical Board:
Revised Language
• “Important: The Board recognizes that licensees encounter health
conditions, including those involving mental health and substance abuse
disorders, just like their patients and other health care providers do.

• The board expects its licensees to address their health concerns and
ensure patient safety. Options include seeking medical care, self-limiting
the licensee’s medical practice, and anonymously self-referring to the NC
Physicians Health Program, a physician advocacy organization dedicated
to improving the health and wellness of medical professionals in a
confidential manner”
Is there a role for state licensure boards to assess occupational
burnout in licensees?
• Recommendations from “Yes”
 “Recommend to participate in mental
health counseling with compliance
monitoring”
 “Screenings for characteristics of
burnout”
 “Questionnaire on the year
recertification”
 “Series of questions and then maybe
flag someone who marks high”
 Comments on board role regarding burnout
education
 Provide educational resources X 20
 Brochure, pamphlet, webinar, course, links
 Signs and symptoms checklist
 Recommend self assessment

 “I agree that boards could provide information…but we should not

require individuals to “out” themselves”

 Should be professional association, not board X 3

 Other Actions
 Tri-Regulatory Collaborative Position Statement
 Position Statement on Provider Wellness
 “Expresses its commitment to identifying and preventing practitioner burnout
 “More needs to be done to provide practitioners with the wellness strategies
and assistance they need to deal”
 September 2017

 Canadian Medical Association: Physician Health & Wellness

 Focuses on improving physical health, mental health & social health of
physicians
 Other Actions
 NH Professionals Health Professions Program
 Provides resources for health professionals in need of assistance with
substance abuse and addiction, psychiatric and mental health concerns,
stress, burnout, work-related conflict or other life/family issues

 AMA: In March 2017, AMA partnered with health industry CEO’s to declare
physician burnout to be a public health crisis
 Policy calls to involve state medical boards
 Focus on researching and identifying risk factors
The Solution?

• The $213.1M question.

(Dewa, Jacobs, Thanh& Loong, 2014)

• System Change?
• Individual Actions?
• Both?
Implications:
“Managerial interventions are necessary… but are insufficient unless
educational interventions convey the requisite individual skills and
attitudes. Neither changing the setting nor changing the individual is
enough.” Maslach et al. (2001)

The two pronged approach to:

• Address contributing factors to burnout, AND
• Act to achieve increased work engagement
Recommendations for Employers:
• Early recognition of burnout
• Improve communication and engagement
• Address flexibility in work hours
• Employee recognition
• Access to professional development
• Discuss burnout
• Empower employees to identify and act on signs of burnout
• Collaborate to find solutions
• Provide resources
• Assess organizational culture
• Provide team training
Recommendations for Individuals:
• Seek resources and training to recognize burnout
• Work towards attaining a healthy lifestyle and realistic work-life
balance
• Career and lifestyle choices
• Access help/employee support programs
• Seek referral to a mental health specialist if necessary
• Establish and re-establish personal boundaries
• Identify expectations with patients and families
 References
• Balogun JA, Titiloye V, Balogun A, Oyeyemi A, Katz J. Prevalence and determinants of
burnout among physical and occupational therapists. J Allied Health. 2002;31(3):131-139.
• Berry JW, Hosford, CC. A Regional Survey & Analysis of Burnout among Physical Therapists in
Frontier Counties. Physical Therapy Journal of Policy, Administration, & Leadership. 2015.
15(3). J1-J11.
• Donohoe E, Nawawi A, Wilker L, Schindler T, Jette DU (1993), Factors associated with
burnout of physical therapists in Massachusetts rehabilitation hospitals. Phys Ther.
1993;73:750-756.
• National Rural Health Association Policy Position. Definition of Frontier. October 2008.
• Felton, JS. Burnout as a clinical entity – its importance in health care workers. Occup Med.
1998;48(4): 237-250.
• Maslach C, Leiter MP. The Truth About Burnout: How Organizations Cause Personal Stress
and What To Do About It. San Francisco CA: Jossey-Bass; 1997.
• Maslach C, Jackson SE. Maslach Burnout Inventory: Manual. Research ed. Palo Alto, CA:
Consulting Psychologists Press; 1981.
• Maslach C, Schaufeli WB, Leiter M. Job burnout. Annu Rev Psychol, 2001;52:397-422.
My story
How do we prevent burnout….
and foster engagement & resilience?

• Burnout
• Cynicism • Loving their work
• Reduced quality of care & patient satisfaction • Highly engaged
• Affecting personal life • Resilient
• Work-life balance
Self-awareness is the first step
Self-awareness is the first step
Taking notice of changes from stress

Emotional Intolerant, lonely, disinterested, angry, sad, anxious

Cognitive Trouble connecting, indecisive, making more mistakes, memory problems

Physical Insomnia, increased HR, headaches, indigestion, restlessness

Behavioural Cravings, snapping at others, withdrawn, procrastination, inefficient

Relationship Nagging, reduced intimacy, irritable, cynical, argumentative

Self-awareness is a learned skill

• Metacognitive awareness
• Taking a look at your thinking as a third person
observer

• Interoceptive awareness
• Interoception = ability to sense your own
physiological condition

• Takes practice to strengthen your “awareness

muscle”
• e.g meditation, journaling, daily check-ins, etc
Checking in with yourself
Daily Check-in with Yourself

• How am I feeling today?

• On a scale from 0 to 10, how “good” do I feel?

• How stressed or anxious do I feel?

• Can I sense this stress in my body?

• Has my behaviour changed recently?

• How am I showing up in my relationships?

Daily Check-in with Yourself

“When the practitioner works in a highly stressful

environment, this means monitoring and
nourishing oneself, just as a person with diabetes
will monitor their insulin levels”

Skovholt & Trotter-Mathison, 2016

What charges your battery?
What depletes your battery?

Depleting Energy Charging Energy

What charges your battery?
What depletes your battery?

Depleting Energy Charging Energy

- Taking on too many work and personal - Taking a mindful lunch break: going for a
commitments walk outside
“It is not enough to recognize that stresses exist, that they are
unavoidable, and that they can result in cognitive errors,
strong feelings, and moral distress.

Clinicians also need to realize the degree to which they have

choices about how to address those stresses and self-regulate
their own cognitive, emotional, and somatic reactions.”

Epstein & Kraser, Acad Med. 2013

“It is not enough to recognize that stresses exist, that they are
unavoidable, and that they can result in cognitive errors,
strong feelings, and moral distress.

Clinicians also need to realize the degree to which they have

choices about how to address those stresses and self-regulate
their own cognitive, emotional, and somatic reactions.”

Epstein & Kraser, Acad Med. 2013

What are the effects of stress?
The relaxation response (RR)

Dusek, J., Benson, H. 2009

Mind-Body Interventions elicits the relaxation response (RR)

• Two necessary steps:

• Repetition of a word, sound, prayer, thought, phrase, or muscular activity

• Passive return to the repetition when other thoughts intrude

Dusek, J., Benson, H. 2009

What makes a good life?
Personal strategies for burnout prevention

• Self-awareness is the first step

• Knowing the early signs of burnout
• Identifying personal coping strategies
• Mind-body interventions to elicit the relaxation response
• Holistic view of health and wellness
Conclusion:
• Significant issue.
• Physiotherapists are not immune.
• Physiotherapists and employers need to take action to
address the problem.
Acknowledgements:
Resiliency & Burnout Prevention
Funding
• Olive Wallace Pester Fellowship In Physical Therapy, University of Toronto

Courses & Programs:

• Certificate of Applied Positive Psychology (CAPP), Flourishing Center
• Guiding Patients to Health & Happiness, Benson-Henry Institute for Mind-Body Medicine,
Harvard Medical School

My mentors & continuous supports:

• Euson Yeung, BScPT, MEd, FCAMPT, PhD, Lecturer, University of Toronto
• Sharon Switzer-McIntyre, BPE, BScPT, MEd, PhD, Assistant Professor, University of Toronto

www.annawong.ca
Anna’s References:
• Bainbridge, L., Davidson, K., Loranger, L. Burnout among Alberta physiotherapists. Physiotherapy Alberta – College and Association: 2017; 3.
• Chiesa, A., Calatai, R., Serretti, A. Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clin
Psychol Rev. 2011: 31(3): 449-64
• Dyrbye, L., et al. Burnout among healthcare professionals: a call to explore and address this underrecognized threat to safe, high-quality care. 2017.
National Academy of Medicine: 1-11.
• Epstein, R., Krasner, M. Physician resilinece: what it means, why it matters, how to promote it. 2013. Academic medicine: journal of the association of
american medical colleges: 88:3.
• Friedman, S.E., and Baum, N. (2016). The role of positive psychology in the modern medical practice. J Med Pract Manage. 2016: 5:287-91.
• Keng, SL, Smoski, MJ, Robins, CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev 2011:31(6):1041-56.
• Jones, J., Norman, K., Saunders, S. Trends and drivers of change in physiotherapy in Ontario in 2014. 2014; 1-45.
• Salyers, M.P., et al. The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. 2017. Journal of General
Internal Medicine; 32: 475-482.
• Sanchez-Reily, S., et al. Caring for oneself to care for others: physicians and their self-care. 2013. The Journal of Supportive Oncology; 11: 75-81.
• Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J
Stress Manage. 2005; 12(2): 164-176.
• Skovholt, T., Trotter-Mathison, M. The resilient practitioner: burnout and compassion fatigue prevention and self-care strategies for helping
professions. New York: Routledge, 2016.
 Justin Berry
Justin.Berry@northlandcollege.edu

Leanne Loranger
lloranger@physiotherapyalberta.ca

Anna Wong
annawong92@gmail.com