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Module 1 Outline: Series Overview – Burnout and Public Health Workers

  1. Module one presents a high-level overview of the full training that is designed to educate and empower supervisors working in public health to better control burnout risks and consequences, for themselves and the workers they supervise.
  2. After reviewing this module, you should be able to…
    1. Define the concept and term of “burnout”.
    2. Explain why public health workers are at risk of experiencing burnout
    3. Explain the potential consequences of burnout for public health workers and their organizations.
    4. Identify examples of situational, environmental, psychological, and social demands and resources and explain how each relates to burnout for public health workers.
    5. Describe the IGLOO (individual, group, leader, organization, overarching context) framework and how each level is relevant to the experience of burnout among public health workers.
    6. Describe examples of intervention strategies to address demands-resources imbalances that apply at each level of the IGLOO model within a public health worker context.
  3. Module roadmap
    1. Understand the occupational population and health-related focus for this training
    2. Providing a high-level overview of what is covered in more depth in the rest of this training.
      • Highlight and encourage participants to dig deeper into this content by viewing all the subsequent modules that build on and add to the high-level overview this module provides.
      • Provide a summary of what those modules will cover (some sort of visual outline of the contents of the modules on one slide perhaps)
  1. As we developed this training, our focus was on supporting supervisors in governmental public health settings. We acknowledge that public health workers work in many different organizations and in many different roles. This includes:
    • health educators
    •  nutritionists
    •  researchers
    •  epidemiologists
    • occupational safety specialists
    • public health preparedness directors and first responders
    •  sanitarians
    • finance specialists
    • grant and program managers

    All public health workers take part in the larger goal of making sure all people in all communities are able to live healthier and safer lives (this definition adapted from American Public Health Association website).

  2. This training is designed with the recognition that the specific challenges faced by public health workers may vary across these different areas of specialization.
  3. This training should be especially applicable for those involved in governmental public health roles. However, the goal of this training is to share widely applicable information and principles that can be used in any public health setting to improve the quality of work-life for public health workers.
  4. This training was also designed with a multi-level perspective on burnout.
    1. In this context, we mean that there are many levels of factors influencing and contributing to burnout. For example,
      • workers’ own personalities and coping mechanisms can influence burnout risk.
      • group norms, leadership practices, and organizational policies and practices can too.
    2. So, as we begin this training, we hope that you will keep this framework in mind. Burnout is not just an individual problem to fix. Rather, leaders and organizations have an opportunity and responsibility to proactively be a part of reducing and responding to burnout.
  1. We know many public health workers have experienced feelings of exhaustion and disengagement at work, and may be wondering “am I experiencing burnout?” It is important to know that burnout, as originally described, can be a clinically serious and debilitating condition. And while many may use the word in everyday speech in a variety of ways, it is critical that we take the issue seriously.
  2. Sometimes this term is used when we are simply tired or feeling overwhelmed after a couple of difficult workdays.
    1. Just to be clear – it is important for supervisors to be involved in improving those everyday states too!
  3. Our recommendations through this training series, while targeted at the specific condition of burnout, can improve the work-life of workers ranging from fully contented and thriving to struggling through short-term fatigue to experiencing full-blown burnout.
    1. So, while one goal of this training is to explain what burnout is, we are not at all trying to argue that only workers who pass the burnout “threshold” need support and assistance.
  4. When we study burnout and try to intervene to reduce its effects, the focus is on a very serious psychological and physiological condition where someone is experiencing chronic (or long-lasting) exhaustion and disengagement related to their work and often nonwork experiences.
  5. This exhaustion can be felt and experienced mentally, emotionally, behaviorally, and physically, and often comes with some sense of mental disconnection from work, whether that’s a more cynical disposition or just an inability to really connect well with the work.
  6. Module 2 of this training explains more about how burnout is a condition that develops over more than just a few difficult days at work. It comes from prolonged and high levels of work demands that are not addressed. Burnout is a long-lasting state that can seriously impact workers’ abilities to respond to normal life activities adaptively and effectively, in and outside of work.
  7. Burnout among healthcare workers is not a new topic. However, widespread attention to burnout within this population and among public health workers skyrocketed over the course of the COVID-19 pandemic.
  8. How common is burnout, really?
    1. In one study from Fall 2020, 66% of a sample of approximately 200 Public Health Workers reported feeling “burned out” (Stone et al., 2021).
    2. Using a similarly broad indicator of burnout, other research completed before the onset of the COVID pandemic had previously shown burnout in approximately 39% of primary public health care workers in a Veterans Health Administration facility (Dolan et al., 2015).
    3. Another interesting source of data along these lines comes from the Public Health Workforce Interests and Needs survey (PH WINS). Although the survey did not include questions directly about burnout symptoms, the 2021 PH WINS revealed that 22% of more than 40,000 state and local public health department workers rated their mental health as bad or fair (as opposed to good, very good, or excellent). In this same study, workers reported high rates of mental health concerns, with 53% of those surveyed reporting symptoms 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.
    4. Implication: These and other studies suggests that burnout, or at least the perception of burnout has increased in recent years.
    5. The 2021 PH WINS just noted also showed that 1 in 3 public health workers were considering leaving their jobs, with 41% stating workload and burnout as a reason to leave.
      • Implication: This recent survey indicates that the state of mental health among public health workers is not good. This is also not good for the field as a whole. The combination of high rates of mental health concerns and strong intentions to turnover or quit may lead to insufficient numbers of public health workers to adequately meet public health needs.
    6. These experiences of poor health are not unique to workers in the United States.
      • Effects of the COVID-19 pandemic were felt globally. For example, 45% of public health workers surveyed in Malaysia were experiencing burnout (Ibrahim et al., 2022).
      • Similarly, public health nurses surveyed in Ireland reported burnout rates over 50%, with differences based on years of experience and work arrangements (Hanafin et al., 2020).
      • Implication: Burnout is not only experienced by public health workers in the U.S. It is prevalent in many settings. This suggests that universal experiences of increasing demands over the past couple of years may be contributing to these relatively high rates.
  9. We know that burnout is undesirable, but why is burnout a serious problem for public health workers as individuals? And for public health organizations?
    1. Workers can be both burned out and engaged at the same time (Timms et al., 2012). This is important for two reasons:
      • It means that burnout is not always easy to observe – sometimes the most engaged workers are most at risk.
      • The increase in efforts to raise worker engagement may have the unintended consequence of increasing the likelihood of worker burnout. There is a need for balance and caution, especially among workers who really care about the work they do and the people they are helping – you know, people like public health workers.
    2. When workers do experience burnout, there are negative outcomes for them personally and professionally. Some of these effects are complex and difficult to separate from other health conditions such as:
      • Mental health concerns, such as depression and anxiety (Schonfeld et al., 2019)
      • Physical health problems, like sleep impairments or musculoskeletal pain (Peterson et al., 2008)
      • Problematic lifestyle behaviors like alcohol use or smoking (Ahola et al., 2006; Petrelli et al., 2018) and a lack of exercise (Peterson et al., 2008).
      • Implications: Although the research has not fully clarified the causal ordering of these relationships, the breadth and depth of these observed connections highlights just how impactful burnout can be on a person’s well-being and work ability.
    3. Because burnout affects energy and attitudes toward work, it is not surprising that burnout affects organizational performance. This has implications for individual employees as well as entire organizations and industries.
      • Studies have found that burnout is related to
        • Higher absence and presenteeism levels (Demerouti et al., 2009; Swider & Zimmerman, 2010)
        • More workplace safety concerns (Nahrgang et al., 2011)
        • More medical errors and decreased patient safety in healthcare settings (Halbesleben, 2010; Tawfik et al., 2018)
        • Reduced performance (Swider & Zimmerman, 2010; Taris, 2006)
        • Increased turnover (Swider & Zimmerman, 2010; Van der Heijden et al., 2019). As previously mentioned, the recent Public Health WINS survey of specifically cited burnout as a commonly reported reason that workers considered leaving their job (Bork et al., 2022)
      • Implications: These issues can collectively be seen as counterproductive behaviors and forces within organizational settings, as they function against the goals of the organization. All of these outcomes are also associated with major costs or lost revenue, making burnout not just an individual concern but an organizational one as well.
  1. As discussed more fully in later modules of this training, burnout and other serious strain conditions (e.g., fatigue, emotional reactivity, lack of attentional focus) result from an imbalance between demands and resources (Demerouti et al., 2001).
    1. Demands are events, circumstances, or pressures to which we need to respond. Resources are what we need to respond to demands.
  2. Demands can take many forms and come from different domains, including our actual physical work environment or situations (e.g., standing or walking on hard floors all day, working too many hours without a break).
    1. They can also be more psychological or social in nature, where the challenges are from our expectations of ourselves or our interactions with others.
  3. In the same way, resources can come from the organization or our broader environment (e.g., a flexible schedule, benefits, a comfortable work environment) or can be personal or social in nature (e.g., a resilient personality, good time management skills, a supportive network).
  4. A key to understanding burnout and what can be done about it, is that we do not necessarily need to operate in the absence of demands. This would be impossible for any job. However, appropriate and sufficient resources are needed to meet the demands of work and nonwork environments.
  5. Sometimes the right resources to meet a demand are obvious, like when an extremely full work schedule could be offset by some flexibility in where and how work is done.
    1. Unfortunately, resources are not always that simple. They do not have to (and sometimes cannot) always be perfect one-to-one matches for specific demands.
    2. Some broadband resources help to address a variety of demands.
    3. Sometimes we truly need a set of resources to adequately respond to a demand.
      • For example, support from a mentor or family member could help someone face a variety of work-related challenges and help them to be best situated to make good use of other resources. A supportive supervisor may make an employee feel more comfortable taking advantage of opportunities for flexibility when they have a full day of difficult tasks.
  6. A related and important area of study and practice pertains to how people recover resources that have been expended while responding to demands.
    1. There is a whole module dedicated to this topic later in this training, but for now, understand that burnout is more likely to develop and be serious when people exist in a chronic state of unmet recovery, operating with a chronic resource deficit.
    2. For example, if we think about our personal energy as a fuel tank, this makes sense that we do need to refill our personal resources. If we don’t and try to keep running on empty (as would be the case with our cars), we’re bound to break down in some form.
  7. Extending from this scientifically supported perspective, public health workers are especially at risk for burnout because of the characteristically under-resourced, high-demand situations in which they tend to work.
  8. There are times when demands are high, based on uncontrollable environmental situations.
    1. In these instances, work hours are bound to increase and tensions can be raised.
    2. For many public health workers, this was especially true during the COVID pandemic, with chronic understaffing and high workloads (Bork et al., 2022).
      • These factors are also common reasons noted by public health workers who may be thinking of leaving their jobs.
  9. Somewhat paradoxically, chronically high demands can also erode the very resources we need to meet those demands.
    1. A high workload and other forms of job stress can relate to less cordial relationships among co-workers (e.g., Glomb et al., 2002), reducing support that is so highly needed when demands are high.
    2. More generally, workers who are most in need of recovery are often the least likely to pursue it, often because they lack the necessary personal resources to do so after finishing their work (Sonnentag et al., 2017).
  10. Burnout can also be a problem among many public health workers because these workers often enter these types of careers with a drive or calling to help others.
    1. This is great and can provide for a lot of personal meaning in public health work.
    2. However, this mindset and perspective can also mean that those with a really strong attachment to their work give of themselves to the point of near-total depletion, not taking time to regularly and completely recover or refuel.
  1. First, the “bad news”: Preventing burnout, or recovering from burnout for those already impacted, is not easy. There is not one magical one-size-fits-all solution.
  2. Now, the “good news”: There are a variety of promising and evidence-based strategies that can help public health workers.
    1. Some of these strategies are focused on preventing burnout from developing in the first place.
    2. Other strategies are focused on promoting more resource-rich work and nonwork existences for individuals (essentially promoting resilience).
    3. Some strategies target the individual, while other strategies target the work or organizational environment.
  3. In this module, we provide only a high-level overview of intervention strategies. We encourage you to keep working through this training to go more in-depth with us in the later modules. Later modules of this training will look at how a multi-level and multi-faceted intervention strategy is needed to control burnout risk within any occupational population.
    1. We will talk about these levels as the IGLOO model (Nielsen et al., 2017; Nielsen et al., 2018), which looks at influences at the individual, group, leader, organization, and overarching context levels.
      • Individual focused strategies are designed to help workers themselves respond to demand-resources imbalances. Examples may be individualized stress-management trainings, promoting recovery outside of work, or connecting workers to EAP resources.
      • Group based strategies leverage the social peer network in and outside of work environments to control demand-resource imbalances. This could include interventions to provide better social support among co-workers, such as intentional workgroup huddles or employee resource groups, or interventions to work on getting rid of unhelpful norms or practices.
      • Leadership level strategies equip operational and strategic leaders to make work design/assignment and resource allocation decisions that facilitate better demand-resource balance. Leaders also tend to have at least some authority to reduce some major demands through things like scheduling, work delegation, and the provision of key resources needed to meet demands like actual equipment, software systems, or training programs.
      • Organizational strategies impact burnout risk through changes to the broader work environment. This might include changes to policies and practices pertaining to scheduling, workload, and benefits to workers. In addition, interventions might target the organizational culture and formalized values which shape what is normal and expected (is burnout just a fact of life? Or is it something that is actively avoided?).
      • Overarching context strategies try to go beyond a specific work or organizational environment and might extend into a broader industry, community, and/or society domain. This type of strategy may be particularly important for public health workers, who commonly face demands that are not controlled by their direct employing agencies, but rather are driven by society and community level concerns and risks (e.g., a common demand in the pandemic was difficult interactions with the general public; Bork et al., 2022). An overarching context strategy might be to try to build better relationships and understanding in communities so that people work with PHWs rather than being skeptical or resistant.
  1. Here is an overview of the rest of this training course:
    1. The training includes strategies for leaders and individuals – because leaders need to protect themselves from burnout and they are in a position where they can help the workers they supervise through role modeling, changing the work environment, or providing supportive individual resources.
    2. The training will cover the following to learn more about what burnout is and what can be done about it:
      • Further define what burnout is and is not
      • Review different types of demands and resources that are relevant for public health workers
      • Provide practical recommendations for addressing burnout through strategies at the levels of individuals, groups, leaders, organizations, and the overall context around the work that public health workers do.

Ahola, K., Honkonen, T., Pirkola, S., Isometsa, E., Kalimo, R., Nykyri, E., . . . Lonnqvist, J. (2006). Alcohol dependence in relation to burnout among the Finnish working population. Addiction, 101(10), 1438-1443.

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., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499-512.

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.

Dolan, E. D., Mohr, D., Lempa, M., Joos, S., Fihn, S. D., Nelson, K. M., & Helfrich, C. D. (2015). Using a single item to measure burnout in primary care staff: a psychometric evaluation. Journal of General Internal Medicine, 30(5), 582-587.

Glomb, T. M., Steel, P. D. G., & Arvey, R. D. (2002). Office sneers, snipes, and stab wounds: Antecedents, consequences, and implications of workplace violence and aggression. In R. G. Lord (Ed.), Emotions in the workplace: Understanding the structure and role of emotions in organizational behavior (pp. 227-259). Jossey-Bass.

Halbesleben, J. R. (2010). The role of exhaustion and workarounds in predicting occupational injuries: a cross-lagged panel study of health care professionals. Journal of Occupational Health Psychology, 15(1), 1-16.

Hanafin, S., Cosgrove, J., Hanafin, P., Brady, A. M., & Lynch, C. (2020). Burnout and its prevalence among public health nurses in Ireland. British Journal of Community Nursing25(8), 370-375.

Ibrahim, F., Samsudin, E. Z., Chen, X. W., & Toha, H. R. (2022). The Prevalence and Work-Related Factors of Burnout Among Public Health Workforce During the COVID-19 Pandemic. Journal of Occupational and Environmental Medicine, 64(1), e20-e27.

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.

Nielsen, K., Nielsen, M. B., Ogbonnaya, C., Känsälä, M., Saari, E., & Isaksson, K. (2017). Workplace resources to improve both employee well-being and performance: A systematic review and meta-analysis. Work & Stress, 31(2), 101-120.

Nielsen, K., Yarker, J., Munir, F., & Bültmann, U. (2018). IGLOO: An integrated framework for sustainable return to work in workers with common mental disorders. Work & Stress, 32(4), 400-417.

Peterson, U., Demerouti, E., Bergstrom, G., Samuelsson, M., Asberg, M., & Nygren, A. (2008). Burnout and physical and mental health among Swedish healthcare workers. Journal of Advanced Nursing, 62(1), 84-95.

Petrelli, F., Scuri, S., Tanzi, E., Nguyen, C., & Grappasonni, I. (2018). Public health and burnout: a survey on lifestyle changes among workers in the healthcare sector. Acta Biomed, 90(1), 24-30.

Schonfeld, I. S., Verkuilen, J., & Bianchi, R. (2019). Inquiry into the correlation between burnout and depression. Journal of Occupational Health Psychology.

Sonnentag, S., Venz, L., & Casper, A. (2017). Advances in recovery research: What have we learned? What should be done next? Journal of Occupational Health Psychology, 22(3), 365-380.

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. International Journal of Environental Research and Public Health, 18(8).

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.

Taris, T. W. (2006). Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work & Stress, 20(4), 316-334.

Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., . . . Shanafelt, T. D. (2018). Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin Proc, 93(11), 1571-1580.

Timms, C., Brough, P., & Graham, D. (2012). Burnt‐out but engaged: the co‐existence of psychological burnout and engagement. Journal of Educational Administration, 50(3), 327-345.

Van der Heijden, B., Brown Mahoney, C., & Xu, Y. (2019). Impact of Job Demands and Resources on Nurses’ Burnout and Occupational Turnover Intention Towards an Age-Moderated Mediation Model for the Nursing Profession. International Journal of Environental Research and Public Health, 16(11).