- What are the sources and consequences of burnout among service providers addressing substance use disorders?
- What interventions have been implemented to manage the impact of burnout among service providers addressing substance use disorders?
Key take-home messages
- Main burnout components experienced among service providers addressing substance use disorders include emotional exhaustion (feeling drained of all available emotional capacity), depersonalization (experiencing cynicism, helplessness and detachment), and lowered sense of personal accomplishment (belief that one’s work is not significant) (1, 2).
- Sources of burnout include high patient volumes (3-5), workload (4, 5), the amount of time required to address substance use disorders (3, 5, 6), managing work and community commitments (7, 8), as well as a negative work environment (9) and a lack of co-worker support (7, 8).
- Successful interventions to reduce burnout among service providers include the use of acceptance and treatment therapy (ACT) (9) and cognitive behavioural therapy (CBT) (10, 11), having high quality clinical supervision (12), having access to coworker support (4), and taking part in pleasurable activities (13).
The issue and why it’s important
Impacts of the current opioid crisis can be found across Canada with a reported opioid related death occurring every two hours in Canada in 2018, with a total of 4,588 deaths that year (14). The rate for apparent opioid-related deaths in Ontario in 2018 was 10.3 per 100,000 individuals (14). The magnitude of opioid related deaths in Canada has resulted in an increased number of harm reduction strategies across the country including supervised consumption sites (15, 16). This increase in overdoses and responses can result in increased burnout among personnel working in such settings (5, 17). Burnout can lead to negative consequences such as poorer quality of care for clients (4, 5) and increased turnover intention among service providers (7, 12) which can become costly for employers (18, 19).
What we found
Burnout is defined as a psychological syndrome which is a response to continuous stress at work (11). The three main components of burnout are defined by the Maslach Burnout Inventory (1), which include emotional exhaustion (feeling drained of all available emotional capacity), depersonalization (experiencing cynicism, helplessness and detachment) and lowered sense of personal accomplishment (belief that one’s work is not significant) (1, 2).
Sources of burnout
The increasing responsibilities of service providers include high patient volumes (3-5), workload (4, 5), and the amount of time required to address substance use disorders (3, 5, 6). Exposure to higher numbers of overdoses within the community was identified as a source of trauma which led to emotional exhaustion or compassion fatigue (5, 20) and decreased empathy (5). Such trauma was particularly noted among peer workers who witnessed the overdose of family or friends within their community (20, 21). Studies also found a lowered sense of personal accomplishment among service providers who questioned whether their work efforts were worthwhile (4). This was particularly true for younger employees with shorter tenure potentially due to the fact that they have less experience coping with work demands and related stressors (11). Older employees with longer tenure were found to experience less exhaustion and have a higher sense of personal accomplishment (9). This higher sense of personal accomplishment may be due to the fact that having more years of work experience resulted in service providers being more confident in their work abilities (22). One study found that service providers experiencing high levels of depersonalization and emotional exhaustion did not have a reduced sense of personal accomplishment (22). A rationale for this was that service providers learn to be satisfied with small improvements in their clients’ wellbeing leading to higher levels of satisfaction even when experiencing other stressors (22). Another study found that service providers with stigmatizing views about their clients with substance use disorders was associated with lesser job satisfaction, but this was not significantly related to burnout (23).
Sources of burnout can also include balancing work demands with family and community commitments. A study based in Australia reported that one in ten Indigenous service providers surveyed experienced high levels of emotional exhaustion, slightly more than their non-Indigenous co-workers, citing lower levels of mental health and difficulty balancing work and family circumstances as sources of their stress (7).
Issues related to work organization and co-worker relationships were identified as other sources of burnout among service providers. Such issues include experiencing workplace conflicts (4), experiencing low job satisfaction (24), a negative work environment (9) and a lack of co-worker support (7, 8).
Consequences of burnout
Studies indicate that experiencing burnout can lead to consequences such as voluntary turnover among service providers (7, 12). Service providers report that their quality of care is reduced when experiencing burnout due to their higher workload (4, 5). One study found that poor quality of care due to burnout can result in clients having a difficult time building a relationship with their service providers (4). Studies found that emotional exhaustion, job satisfaction, and poor work environments among service providers were positively associated with the intent to leave their job (7, 10). Higher rates in turnover can result in increased stress among remaining service providers and can further increase their perception of not having supportive relationships in the work place (18). High turnover rates may also lead to financial strains for organizations that then have to recruit and train new service providers (18, 19). One study stated that service providers are less likely to use skills gained from training when they experience high levels of burnout, which suggests that employer resources should target issues related to burnout prior to providing clinical related training (25).
Interventions to reduce burnout
A meta-analysis of burnout interventions found that person-directed interventions were more effective than those directed at the organizational level (26). Another study noted that active coping strategies were effective in reducing burnout among sexual or substance abuse counsellors (27). Work related interventions include having providers make use of specific therapies. One study identifies acceptance and treatment therapy (ACT) which consists of using mindfulness and behaviour change to assist service providers with identifying their work related values (9, 28) which can be useful for coping with stress (9, 29, 30). Other studies focused on having service providers learn about cognitive behavioural therapy (CBT) (31) or the use of CBT in their work with clients (11). CBT focuses on re-evaluating thinking and incorporating helpful behavioural responses (11, 32). CBT can be associated with lower levels of burnout as it can give service providers a greater sense of control over their work (11).
Interventions related to the work environment include having:
- Positive clinical supervision (12). Clinical supervision among service providers was negatively associated with emotional exhaustion and their intent to leave their jobs (12). It can increase workers’ sense of organizational commitment to their workplace (33).
- Work climates where service providers can approach their supervisors with concerns, which fosters a supportive environment that reduces job frustration and can decrease burnout (34).
- Service providers interact with their co-workers to discuss potential ways to deal with burnout (4).
- Peer support groups or access to professional counselling to support service providers (17).
- Positive personal habits to reduce burnout. Service providers reported taking paid time off (3), taking part in self-care activities such as meditation (4), or participating in activities they enjoy such as reading or listening to music as ways to alleviate burnout (13).
- A holistic approach to address burnout – particularly among Indigenous service providers – such as having flexible work arrangements so that Indigenous service providers can successfully balance work, community and family obligations (7).
As the majority of studies identified are cross-sectional or ethnographic, only correlations could be identified. Further longitudinal research is recommended to identify causative relationships between specific interventions and reductions in burnout among service providers. Such long term studies can be used to identify best practices for service providers to manage work related stressors while serving clients with substance use disorders.
Factors that may impact local applicability
Studies identified take place in various high-income settings including Canada, all of which have varying policies and services for substance use disorders. This can shape the ways in which service providers experience their work and work related stressors. Burnout is a psychological syndrome and experiences of burnout can vary from person to person. The success of interventions to reduce burnout may vary depending on various factors such as the location of service providers and the stressors they are experiencing.
What we did
We searched Medline (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations) and PsycInfo using a combination of (text terms [drug use* or opioid* or Drug Overdose*] or MeSH terms [exp Drug Abuse/ or exp Drug Usage/ or exp Drug Abuse Prevention/ or exp Intravenous Drug Usage/ or exp Morphine/ or exp “Opioid Use Disorder”/ or exp Addiction/ or exp Drug Addiction/ or exp Drug Overdoses/ or exp Opiates/ or exp Methadone/]) AND (text terms [stress* or grief or burnout* or burn-out* or burn out or trauma*] or MeSH terms [exp Occupational Stress/ or exp Stress/ or exp Stress Management/ or exp “Stress and Coping Measures”/ or exp “Stress and Trauma Related Disorders”/ or exp Grief Counseling/ or exp Grief/ or exp Emotional Trauma/ or exp Trauma/]) AND (text terms [physician* or nurse* or doctor* or healthcare worker* or social worker* or harm reduction or caregiver* or front line or frontline or personnel* or team* or provider* or health care worker*] or MeSH terms [exp Caregivers/ or exp Health Personnel/ or exp Teams/]). Searches were conducted on October 17, 2019, and results limited to English articles published since 2010. Reference lists of identified articles were also searched. Google (grey literature) searches using terms of burnout, substance use, and provider were also conducted. The search yielded 2,131 references from which 34 were included.
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Rapid Response Service. Burnout among service providers addressing substance use disorders. Toronto, ON: Ontario HIV Treatment Network; November 2019.
Nicole Andruszkiewicz and David Gogolishvili