Burnout in physiotherapy is an increasingly prevalent issue, affecting physical and mental health, career satisfaction, and contributing to a high attrition rate in the profession. I have personally suffered from burnout on two occasions, adding my personal experience to an evidence-based coverage of a complex topic. While it is beyond the ability of one article to ‘solve’ this problem, this blog aims to shed light on burnout, the factors contributing towards its onset, and strategies to address it. Additionally, the blog will pose the questions of what changes need to be implemented to combat this problem in physiotherapy.
What is burnout:
Many people have been ‘burnt out’ in their life, or have had colleagues and friends that have referenced burnout.. but do we actually know what burnout means and why it occurs? Burnout is an occupational experience or syndrome (1, 2), thought to occur when an individual’s relationship to their work has gone wrong (3). The World Health Organization (WHO) defines burnout as the following, “Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” (4). This definition is generally well matched to the literature, with a breadth of evidence available on burnout (1, 5-13).
Burnout is a syndrome characterized by three domains, emotional exhaustion (EE), depersonalization (DP) and low professional accomplishment (LPA).
Emotional exhaustion refers to an inability to cope at a psychological level. This occurs when a worker has emotional stress, exhaustion, along with the perception of being overextended and physical/energy depletion related to one’s job.
Depersonalization or feelings of cynicism and negative attitudes related to one’s job. Also includes detached concern, irritability, loss of idealism, and withdrawal.
Feelings or perception of low professional accomplishment can also be described as reduced productivity or capability, low morale, and an inability to cope. (1, 3-6, 8-15).
It is conceptualized that burnout can be viewed as a continuum, where risk factor and work demands exceed an individual’s capacity, leading to emotional exhaustion. This is considered a key early burnout sign, leading to reduced emotional resources. Workers may no longer have a desire or ability to invest energy and time into normal workday situations, with work engagement reduced. As emotional exhaustion continues, individuals often experience depersonalization and feelings of cynicism, leading to negative attitudes towards work. Reduced personal accomplishment is likely the combination of emotional exhaustion and cynicism, reducing an individual’s sense of achievement and effectiveness (1, 6, 10-13). Burnout is assessed formally using the Maslach Burnout Inventory (MBI), which has 22 items in three subscales analysing all domains of the syndrome (see resources at the end for a link to the tool) (1, 2, 6, 9, 13).
There are numerous evidence-based risk factors and contributors to burnout, with many referenced in the figure below. These can be separated into factors relating to work role, workplace, and non-work factors. Overall, the evidence-based considers high workload, lack of adequate rewards for performance, along with poor workplace support and environment, as key factors influencing burnout risk. Physiotherapy specific contributing factors are discussed in a further section below.
Anyone who has experience burnout will attest to the profound role that this syndrome can have on an individual’s health and work performance. Some of the impacts of burnout are detailed in the figure below, including poorer physical and mental health, reduced sleep, reduced work performance and higher staff turnover (1, 3, 13).
A personal experience of burnout:
One of the key reasons for putting this evidence-based article together stems from my own personal experience of burnout in my physiotherapy career. Those that have followed my social media, listened to some of my lectures, or read this previous blog (see here) will have heard me discuss my experiences. I can pinpoint two discrete time points in my career where I have been ‘burnt out’. I have illustrated this timeline in the figure below, with my initial burnout experience occurring at the end of my first year working as a physiotherapist.
I experienced extreme fatigue, low motivation, reduced work drive and satisfaction. When looking at the factors that contributed to this burnout, they were well matched to the evidence-base. I was early in my career, tick! I had a high workload, tick! I had two work roles, one with high pressure (elite sporting environment), and the workplace support didn’t match the demands of the role. Additionally, I had a lack of financial reward compared to the hours I was putting in, tick. When I stepped back and analysed the factors it made a lot of sense to me why this occurred. The second occurrence of burnout is a little more ‘complicated’. I believe this has a lot more to do with a broader problem in physiotherapy rather than me being exposed to a specific risk factors (more on this later). Although it built over my 5th-6th years as a physio, I became acutely aware of my burnout around the end of my 6th year of clinical work. I was emotionally exhausted, showing signs of depersonalization, and considering a career change out of the profession. How did I get here? Was it a lack of resilience? Is it my intrinsic risk factors? Or is it the industry and profession of physiotherapy as a whole?
I will discuss these broader issues, including how I have managed my own burnout experiences, and compare this to the evidence base, in later sections of this article. The following sections of this article look to tackle to the issue of ‘Burnout in Physiotherapy’ more specifically.
Burnout in Physiotherapy
Many physiotherapists leave the profession early in their careers (8, 16- 23), a concern that was raised by the Australian Physiotherapy Association (APA) in a 2022 media release (16). The figure below details statistics on the attrition rate in physiotherapy, painting a sobering picture. Studies show high job turnover, and physios exiting the profession within the first 5-10 years. Should we be worried? And how does burnout fit into this picture?
While studies report numerous factors contributing to this physiotherapist exodus, burnout is considered one of the factors influencing the attrition rate (18-20, 24, 25). Burnout is commonly reported in physiotherapists in the literature (6, 8-10, 13, 19, 25-35), where practitioners can report high levels of stress and burnout within as little as 1-5 years into their careers (8, 19, 25, 34). Along with turning physiotherapists away from the profession, burnout affects problem solving ability, reduced empathy for patients, increases medical errors, and overall decreases the satisfaction patients have with their care (13, 25, 26, 29). Do we have a problem in the physiotherapy profession? Statistics say we should take this threat seriously. While burnout rates vary, studies have shown prevalence typically ranges between 15-22.5% (6, 13, 27, 33), however some studies show rates close to 60% in some physiotherapy populations (26, 31). Burnout in physio appears to be an issue irrespective of country of work, with moderate-high rates reported in Australia (8, 17, 19, 25, 34), along with Europe, Asia and Northern America. Additionally, rates appear consistent despite type of work setting (e.g. public and private) or gender (36). The figure below details some of the key factors influencing the risk in physiotherapists. In particular, the type of roles, including regular contact with unwell patients and high responsibility that many therapists have increases the risk of emotional exhaustion. Furthermore, the nature of many physiotherapy roles having a high workload, and relatively capped financial progression compared to other industries, are key factors influencing physiotherapy burnout. Workplace structures and support (or lack of), lack of recognition, poor mentoring, and low time allocated to administration tasks all affect the risk. Like in many professions, age and inexperience affect physiotherapy burnout rates.
It appears many risk factors for burnout in physiotherapists are potentially modifiable or avoidable (36), however does this require a change from individuals, workplaces, or the physiotherapy profession as a whole? To shed further light on this complex and common problem in the profession, I conducted a series of interviews with health professionals and surveys through my social media channel (@kywynnephysio).
Getting further perspectives on the topic.
I chose to interview a number of healthcare professionals, some of which are happy to identify themselves, and others which will remain anonymous in their contributions. While I primarily posed questions to physiotherapists, I also reached out to several psychologists to get a varied perspective on this complex issue. Additionally, I posed the question to my social media channel around the impact of burnout. The first figure below details results showing that burnout caused a high number to reconsider their career as a health professional, re-enforcing the importance of addressing this complex issue.
The second figure describes some of the themes that emerged in my interviews with health professionals regarding this topic. I have expanded on these themes below.
When I quizzed a number of physios they all reported not recognising the signs immediately, only realizing their level of burnout as it progressed. Multiple physios also reported it occurring early in their career, similar to my experience. Interestingly, many of these physios also reported having more than one occurrence of burnout. The causes and signs described by interviewees are well-matched to the literature, re-iterating the complex multifactorial nature of burnout in this population. Senior musculoskeletal physiotherapist Emma Johnson reported observing a key sign in herself when being burnt out which she fittingly called ‘tiny violin syndrome’, referencing a loss of ability to empathise with her patients. Senior sports physiotherapist John Contreras also identified that multiple episodes of burnout has given him a higher level of awareness and helped him better manage symptoms, illustrating a need for regular self-monitoring and early assessment.
The health professionals I interviewed were strong on mindset and psychological growth when combatting burnout. Sport Psychologist Eddy Sheeky discussed burnout in high performance environments and something that stuck with me from his interview was the impact that mindset can have on an individual’s risk of burnout. In particular, beliefs around achieving performance outcomes and an individual’s goals can increase risk. Along with established self care routines, having ‘side businesses’ outside of work was reported as a way to mitigate burnout risk. Additionally, having frank and honest communication with managers regarding the factors contributing to burnout was recommended as a method to address workplace influences.
When quizzing multiple parties on who’s responsibility it is to address the high burnout rates in physio, the consensus is that shared ownership is needed to tackle this complex problem. Joe Rinaldi, a physiotherapist and performance coach expressed the importance of individual ownership and advocacy, explaining “it’s on us as individual clinicians to make sure that we advocate for ourselves and build the lives we want”. Emma currently manages a large team of physios, and reported almost all of her staff having signs of burnout at some stage. She expressed that as a manager she has both a responsibility and an opportunity to implement workplace strategies that assist in mitigating the risk. The final sections of this article delver more into factors that individuals and workplaces can adopt to improve burnout outcomes.
Evidence-based management strategies for burnout:
The final section of this article looks at addressing the complex issue that is burnout in physiotherapy. If you have made it this far, well done! It is important to state that it is far beyond the scope of this article to ‘solve’ this multifactorial problem. This section is more designed to get you thinking, and hopefully, spark some progressive change in both individual healthcare professionals and the industry as a whole.
What worked for me:
After experiencing burnout multiple times, I have identified a few strategies that have worked for me, some that haven’t, and some that I may look to implement in future. Firstly, I am a massive advocate for taking time off, whether that be a few days, or a ‘6-month career break’ like I did in 2022. This allows you to refresh, ‘forget about work’, and re-evaluate your life and career goals. I have used holidays and time off during both occurrences of burnout to help me recharge. I have also leant strongly on social supports and mentors, particularly mentors outside of my workplace. Low social support is a risk factor for burnout and is a key area to address when trying to combat this syndrome. I have also left work roles due to their impact on burnout. This might not be for everyone, however I have found that sometimes a change of environment is key to addressing the causative factors. Additionally, finding hobbies and ‘side hustles’ outside of physio has been a good way for me to feel less ‘trapped’ by the negative elements of the profession. Finally, I am a huge advocate for self-care, including exercise, mindset & resilience training, and general physical/mental health strategies.
A few photos from my career break in 2022.
What hasn’t worked as well? Pushing through! Trust me, I’ve tried this multiple times. Not addressing the risk and causative factors. Taking time off alone is great to refresh, however addressing the underlying drivers leading to burning out in the first place is a must! What would I consider doing differently in the future? Eddy Sheeky (Sport Psychologist) discussed the term ‘psychological growth’ during my interview with him. Many people are drawn towards physical growth, myself included, however we may shy away from the work required to improve our psychological health. I know I have scope for improvement in the area, and it is something I continue to work on, burnt out or not.
What the evidence suggests works:
The evidence doesn’t show one ‘quick fix’ or a ‘silver bullet’ to managing burnout. However, there are numerous evidence-based considerations and strategies that can be implemented. I have broken the evidence base into two parts, strategies that an individual can implement, and things that a workplace can modify. These are displayed visually in the figure below. While not every recommended strategy from research studies will apply to everyone, this list highlights the variety of strategies available and modifiable nature of many risk factors.
STRATEGIES FOR THE INDIVIDUAL:
When looking at strategies an individual physio can implement, self-care activities (e.g. sleep, exercise, work-life balance) and prioritising psychological growth are both important to address burnout risk and improve job satisfaction (8, 15 30, 37). This evidence is well-matched to my interviews with healthcare professionals. Personally, after reviewing the literature, and my interactions with other professionals, I believe positive psychological growth warrants further consideration, both as an intervention to treat burnout, and as a preventative measure (more on this later).
Additionally, managing workload is particularly important early in a physio career where other risk factors are higher (5, 18, 38), and distancing of care from patients is a difficult but necessary strategy at times (15). Furthermore, having a work role where you can manage patients objectively, set and achieve clear goals, while working collaboratively in a team, has been shown to improve job satisfaction (5, 6, 18, 26). Don’t forget to give back through teaching e.g. supervising students, as this can improve job satisfaction (18). Finally, some burnout situations require a break, either in the form of a holiday (5), or a role/career change (5, 18, 21, 38).
STRATEGIES FOR THE WORKPLACE:
This list also demonstrates that this isn’t just a task for the worker to consider. Many of the strategies are best implemented or modified from a workplace or management level. Higher employee engagement and job satisfaction leads to lower levels of burnout (8, 10, 15, 26) and greater staff retention (38). Additionally, when workers feel like the workplace isn’t meeting their ‘obligations’ around supporting their career, building workplace culture and allowing them to meaningfully impact in their role, individuals become less satisfied and uncommitted (39). This creates a strong incentive for workplaces to implement strategies to address this risk.
The importance of a positive organizational culture should not be underestimated, leading to improved workplace relations and improved job satisfaction (6, 8, 18, 25, 39). Additionally, workplaces that support and mentor staff, particularly working on utilizing their physio’s strengths, will likely have higher employee satisfaction and less burnout (5, 18, 21, 37-39). Flexibility of hours, rosters and role (8, 18, 21, 37, 38), along with inputting regular breaks or scheduled time for admin tasks will help reduce the risk of burnout (1, 8, 18, 38). Finally, one of the key aspects of reducing physiotherapy burnout revolves around acknowledgement of staff performance. This involves recognising contributions, skills/experience, and the ‘little wins’, as this is an important factor for job satisfaction. While remuneration is a form of acknowledgement and a key component to job satisfaction, recognition shouldn’t be limited to just financial incentives (6, 18, 21, 37-39). The ability to progress professionally, and having clearly defined career development opportunities, are also central to mitigating the high job dissatisfaction and burnout rates in the profession (18, 24, 39).
New graduates are a high-risk population, requiring additional considerations to mitigate burnout. The figure below details a number of the evidence-based (8, 18, 19, 21, 22, 34, 37, 38) strategies to support and assist early career development.
A way forward? Proposed action points to address this complex problem.
Based upon the presented evidence, discussions with a range of physiotherapists and healthcare providers, along with my personal experience, I have proposed a few points for discussion, and some action areas I believe warrant considerations for individuals, workplaces and the profession as a whole. These are displayed visually in the figure below and broken down in the subsequent paragraphs.
I have proposed that ‘traditional’ models of care may need to change. In particular, many private and public settings have therapists largely working ‘solo’ when caring for patients. Team collaboration and joint involvement in decision-making is a good tool for prevention of work-related stress & burnout by mitigating the emotional investment and increasing employee job satisfaction (6, 21, 26). Physiotherapists often see patients for a ‘moment in time’ during their recovery, and rarely see them over a full rehab continuum. There are a variety of factors contributing to this, including financial barriers, access to services, models of care and discharge pressures, just to name a few. However, a model of care is proposed that allows physiotherapists to see patients over a longer timeline, setting and actually achieving treatment goals with patients, as this been shown to be a key factor in physiotherapist job satisfaction (5, 6, 18, 26). Additionally, embedding strategies and methods of celebrating ‘patient wins’ when goals are achieved is recommended (26).
Another consideration is moving beyond a purely ‘fee for service’ model in private practice would likely reduce ethical considerations for therapists who can be conflicted between ‘best practice care’ and personal renumeration (3, 8). This would also improve the ability of patients to commit to a full rehab timeline, thus improving recovery and therapist job satisfaction. Finally, physiotherapy education programs should look to increase clinical placements for students in private practice settings to match the career pathways many graduates take (18). I am proud to have played a small part in developing a physiotherapy program that was designed to address this factor.
When considering psychological growth, I must acknowledge I have no training in psychology, thus this isn’t within the scope of my practice. Based upon the evidence and interviews I have conducted, there is a need to embed formal resilience training into university, along with further development in workplaces (8, 30). There is a need and scope for educational programs or modules to be developed in these areas. The evidence strongly supports ‘self-care’ activities including exercise, sleep, wellness, and social interaction to mitigate burnout risk (8, 15, 37). Education and implementation of self-care strategies should be included in curriculum development, workplaces and in mentoring sessions. Finally, professional psychologist involvement should be considered not only when an individual reports experiencing symptoms of burn out, but also for those looking to improve their ‘psychological health’.
Workplaces should strongly consider how to improve workplace culture (6, 8, 18). This includes implementing strategies centred around increasing employee engagement, positive work environments, a focus on ‘patient-centred care’ over financial targets, and fostering support from management and co-workers for staff (1, 5, 8, 10, 15, 18, 26, 37-39). Additionally, allowing greater flexibility in the form of roles, rosters, admin breaks, time-off, and autonomy of work is recommended (8, 18, 21, 24, 37-39). Supporting access to career development opportunities for staff, along with structuring roles to ‘work to their strengths’, will likely improve job satisfaction and reduce attrition rates (18, 21, 24, 37-39). Finally, acknowledging and recognising staff performance, including contributions, skills/experience, and the ‘little wins’, is vital for boosting job satisfaction. While remuneration is a form of acknowledgement, recognition shouldn’t be limited to purely financial means (6, 18, 21, 37-39).
Career pathways and organization structures are limited in the wider physio profession, especially in private practice settings. Furthermore, physiotherapists often reach a ‘ceiling’ of financial reward along with limited career progression despite their experience and efforts in pursuing ongoing education. These factors increase job dissatisfaction and burnout risk (18, 21, 38). It is recommended that workplaces and governing bodies look towards creating opportunities for recognition and reward to acknowledge those with specialised skillsets and experience. In particular, implementation strategies and pathways to allow greater progression of salary, particularly outside of income being tied to amount of patients being seen (8, 17, 18, 21, 38). These are complex and difficult pathways to navigate, therefore this likely required ongoing advocation from professional bodies. Possible considerations may include career pathways, physiotherapist recognition, and burnout considerations as detailed above.
Summary:
In summary, while this article is comprehensive, it only begins to scratch the surface of this complex yet common problem. The goal of this blog is to spark discussion around burnout in physiotherapy, a topic that I am passionate about helping to address. If you are an individual physiotherapist, I encourage you to consider how to implement evidence-based strategies focused on reducing your burnout risk and improving job satisfaction. If you are a business owner or manager, the evidence suggests a multitude of considerations that will likely reduce staff burnout and improve employee engagement. Finally, I urge you to be proactive in seizing opportunities to disrupt current models and reduce the impact of burnout in our profession.
RESOURCES:
The Maslach Burnout Inventory (MBI) assessment tool - see here
Career break blogs: - Taking a career break blog - Ky Wynne - When a break can heal - John Contreras
Beating Burnout in Physiotherapy - Joe Rinaldi
Burri et al., 2022 - Risk factors associated with physical therapist burnout: a systematic review - Poster PDF of the article above
Harvard Business Review: - How to measure burnout accurately and ethically - The 3 Things Employees Really Want: Career, Community, Cause
INTERVIEW CONTRIBUTIONS with thanks:
John Contreras (Senior Sports Physiotherapist and S&C Coach) – https://johncontreras.physio/about
Emma Johnson (Senior Musculoskeletal Physiotherapist) - Emma Johnson LinkedIn Profile
Eddy Sheedy (Sports Psychologist) - www.esperformancepsychology.com
Joe Rinaldi (Physiotherapist, Performance Coach & Business Owner) - Instagram @joearinaldi
Further contributors wished to remain anonymous.
REFERENCES: