HHS Public Access Author manuscript Author Manuscript
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01. Published in final edited form as: J Pain Symptom Manage. 2016 April ; 51(4): 690–696. doi:10.1016/j.jpainsymman.2015.10.020.
Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S
Author Manuscript
Arif H. Kamal, MD, MHS, Janet H. Bull, MD, Steven P. Wolf, MS, Keith M. Swetz, MD, MA, Tait D. Shanafelt, MD, Katherine Ast, MSW, Dio Kavalieratos, PhD, Christian T. Sinclair, MD, and Amy P. Abernethy, MD, PhD Duke Center for Learning Health Care (A.H.K., S.P.W., A.P.A.), Duke Clinical Research Institute, and Duke Cancer Institute (A.H.K.), Durham, North Carolina; Four Seasons Compassion for Life (J.H.B.), Flat Rock, North Carolina; University of Alabama-Birmingham (K.M.S.), Birmingham, Alabama; Mayo Clinic (T.D.S.), Rochester, Minnesota; American Academy of Hospice and Palliative Medicine (K.A.), Rosemont, Illinois; University of Pittsburgh (D.K.), Pittsburgh, Pennsylvania; and University of Kansas (C.T.S.), Kansas City, Kansas, USA
Abstract
Author Manuscript
Context—Many clinical disciplines report high rates of burnout, which lead to low quality of care. Palliative care clinicians routinely manage patients with significant suffering, aiming to improve quality of life. As a major role of palliative care clinicians involves educating patients and caregivers regarding identifying priorities and balancing stress, we wondered how clinician selfmanagement of burnout matches against the emotionally exhaustive nature of the work. Objectives—We sought to understand the prevalence and predictors of burnout using a discipline-wide survey. Methods—We asked American Academy of Hospice and Palliative Medicine clinician members to complete an electronic survey querying demographic factors, job responsibilities, and the Maslach Burnout Inventory. We performed univariate and multivariate regression analyses to identify predictors of high rates of burnout.
Author Manuscript
Results—We received 1357 responses (response rate 30%). Overall, we observed a burnout rate of 62%, with higher rates reported by nonphysician clinicians. Most burnout stemmed from emotional exhaustion, with depersonalization comprising a minor portion. Factors associated with higher rates of burnout include working in smaller organizations, working longer hours, being younger than 50 years, and working weekends. We did not observe different rates between palliative care clinicians and hospice clinicians. Higher rated self-management activities to mitigate burnout include participating in interpersonal relationships and taking vacations.
Address correspondence to: Arif H. Kamal, MD, MHS, Duke Clinical Research Institute (DCRI), 2400 Pratt Street, Room 8041, Durham, NC 27705, USA. [email protected]. Disclosures Drs. Kamal, Swetz, Kavalieratos, Shanafelt, and Mr. Wolf have nothing to disclose. Dr. Bull is a Board Member of the American Academy of Hospice and Palliative Medicine (AAHPM), Dr. Sinclair is President-Elect of AAHPM, Ms. Ast is the Director of Quality and Research for AAHPM, and Dr. Abernethy is a Past President of AAHPM.
Kamal et al.
Page 2
Author Manuscript
Conclusions—Burnout is a major issue facing the palliative care clinician workforce. Strategies at the discipline-wide and individual levels are needed to sustain the delivery of responsive, available, high-quality palliative care for all patients with serious illness. Keywords Burnout; workforce; palliative care
Introduction
Author Manuscript
Many clinicians practice palliative care to create a meaningful difference in the lives of persons with serious illness and their caregivers. Along with the sense of fulfillment garnered by improving the quality of life of those with need is a simultaneous awareness that clinical hospice and palliative care practice may be more inherently stressful and challenging than previously appreciated. Challenges, such as managing a clinical program that is in high demand but under-staffed,1,2 addressing the multiple and complex needs of patients and caregivers often in crisis, and facilitating resolution of conflicts between any combination of patients, caregivers, and the health system, may lead to significant stress.
Author Manuscript
Contrastingly, a high degree of meaning and personal satisfaction felt by palliative care clinicians may obviate this job-related stress, not allowing it to evolve into a more distressing state such as feelings of burnout. Potentially, the naturally rewarding work of palliative care clinicians, alongside the natural selection of those who comprise the field (i.e., those who stay in the field must inherently know how to resolve the emotional challenges), may prevent escalation of normal stress to something more. We do know that in other medical fields, job stress does frequently evolve into overt burnout, which is described as loss of enthusiasm for work (emotional exhaustion [EE]), feelings of cynicism (depersonalization [DP]), and a low sense of personal accomplishment.3 This phenomenon is increasingly studied in health care, both to describe the penetration of this issue across all fields of medicine, while also informing interventions to allay the downstream, negative consequences of unmanaged burnout.4
Author Manuscript
Shanafelt et al. recently described the comparative results of burnout in various physician populations.5 In addition to reporting an overall rate of 46% of all physicians, they noted the highest rates in physicians who must address multiple areas of medical need simultaneously (e.g., family medicine, internal medicine) or those that are asked to focus on a specific condition but often in high-acuity situations (e.g., emergency medicine, obstetrics). Furthermore, others have described higher rates of burnout among critical care physicians,6 where high-acuity situations are the norm, and outcomes not always successful. Palliative care shares many characteristics with these other medical disciplines that experience high rates of burnout, including balancing distress across multiple diseases or domains, while frequently being called to high-acuity or rapidly evolving situations. Previous evaluations of burnout in palliative care have either described burnout in qualitative ways or using small samples sizes7,8 or were conducted in a different era of clinical palliative care.9,10 To complement these efforts, we planned a large, nationwide survey to
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01.
Kamal et al.
Page 3
Author Manuscript
evaluate the prevalence, severity, and predictors of burnout in clinical palliative care professionals. In partnership with the American Academy of Hospice and Palliative Medicine (AAHPM), one of the largest palliative care membership organizations in the U.S., we conducted a membership-wide survey to understand the prevalence and correlates of burnout among clinicians. The purpose of this research was to ultimately inform the development of future interventions to reduce the burnout experienced by the dedicated palliative care professionals who care for at least six million persons and their caregivers every year.11
Methods
Author Manuscript
We conducted an electronic survey of demographics and burnout among specialty hospice and palliative care clinicians in the U.S. Participation was voluntary, and no remuneration was offered. The study was reviewed and approved as exempt by the Duke University institutional review board (Pro00045381). The survey concept was approved by the AAHPM Board of Directors, but members did not have influence over the content of the survey itself. Participants We invited all members of the AAHPM with available electronic mail addresses to participate in the survey (N = 4456). Nonclinician respondents were excluded from the analysis. AAHPM provided a roster of member e-mail addresses who were active members as of June 1, 2013. Survey Procedures
Author Manuscript
The electronic survey was conducted over six months using an initial electronic invitation letter and two follow-up letters. Additionally, invitations via Facebook posts, Twitter messages, blog posts, and electronic newsletters were sent throughout the survey period. Other participating social media outlets used to disseminate invitations to the study included the Palliative Care Network, National Hospice and Palliative Care Organization, PalliMed, GeriPal, and the Society of General Internal Medicine End-of-Life Interest Group. Survey Development and Validation
Author Manuscript
Our palliative care–focused burnout survey was modeled after similar surveys conducted by the American Society of Clinical Oncology and the American College of Surgeons.12,13 The survey included 52 questions. Eight questions involved clinician demographics or practice setting, four involved career choice and work/life balance, three questions from the SF-1214 queried quality of life, nine addressed clinical experience and credentials, five involved job characteristics, and one queried self-care. To measure burnout, we used the Maslach Burnout Inventory Human Services Survey3 (license/permission was obtained from Mind Garden, Inc., Menlo Park, CA). This 22-question survey (MBI-22) has been used frequently in other studies examining burnout in health care workers, including physicians and nurses. The MBI-22 uses a seven-point Likert scale to score the frequency of feeling each of 22 components used to measure burnout. Thus, for each of the 22 questions, a score of 0
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01.
Kamal et al.
Page 4
Author Manuscript
through 7 is recorded. For example, one question within the MBI-22 Human Services Survey is, “I feel emotionally drained from my work.” Respondents can answer a frequency of feeling this way, from “never” (scored as 0) to “every day” (scored as 7). Thus, the minimum score possible is 0 and the maximum is 154. Our survey did not explain the scoring system within the text of the questions. To assess for each subdomain of burnout (e.g., depersonalization and emotional exhaustion), we used the scoring and cutoff criteria of the MBI-22. To calculate a score, each domain had a selected set of questions on which to focus; additive scores from these questions represented a total subdomain score. Depersonalization was scored as “high” for a total score of 13 or higher across five questions; seven or higher constituted “moderate.” Emotional exhaustion was scores as “high” for a total score of 27 or higher across nine questions; 17 or higher constituted “moderate.”
Author Manuscript
The electronic survey was twice reviewed for face and content validity by six palliative care physicians, one expert in health care–associated burnout, and one data analyst. After the first review, iterative updates were made to reflect suggested changes and improvements. Statistical Analysis Descriptive statistics were used to investigate the demographics, job characteristics, and burnout symptoms of palliative care clinicians. We investigated the pattern of data missingness and found that it was random and not informative. We imputed missing responses from the MBI-22 questionnaire for those who left more than 33% of the MBI-22 questionnaire blank, or participants who had less than 10 answered responses (note that the EE and DP subscales used 14 of the 22 MBI-22 questions) were removed from the analyses.
Author Manuscript
We modeled burnout by dichotomizing our outcome variable to high EE or DP. We used Spearman correlation to check for correlation between high EE or DP, EE, DP, and the MBI-22 scales. We implemented a multivariable logistic regression model to predict risk of burnout (high DP or EE). We used variables from the literature and those hypothesized to ameliorate burnout including marital status, children living at home, numbers of colleagues in practice (three or less vs. four or more), physicians versus nonphysicians, and hours per week worked (>50 hours vs. 71
17 (1.7)
Gender [352] Male
355 (35.3)
Female
650 (64.7)
Author Manuscript
Marital status [343] Married
780 (76.9)
Single, never married
67 (6.6)
Partnered
52 (5.1)
Divorced
93 (9.2)
Widowed
22 (2.2)
Children living in the home [346] Yes
459 (45.4)
No
552 (54.6)
Highest clinical degree [337] MD/DO
691 (67.7)
NP/PA
113 (11.1)
Author Manuscript
MSN/CNS
34 (3.3)
RN
66 (6.5)
MSW
36 (3.5)
Chaplain (MDiv, or equivalent)
21 (2.1)
Other
59 (5.8)
How long have you worked in hospice or palliative care, yrs [319] 0–5
354 (34.1)
6–10
340 (32.8)
11–20
230 (22.2)
21–30
83 (8.0)
31–40
31 (3.0)
Clinical responsibility as component of total effort [329]
Author Manuscript
≥75%
430 (41.8)
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01. Published in final edited form as: J Pain Symptom Manage. 2016 April ; 51(4): 690–696. doi:10.1016/j.jpainsymman.2015.10.020.
Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S
Author Manuscript
Arif H. Kamal, MD, MHS, Janet H. Bull, MD, Steven P. Wolf, MS, Keith M. Swetz, MD, MA, Tait D. Shanafelt, MD, Katherine Ast, MSW, Dio Kavalieratos, PhD, Christian T. Sinclair, MD, and Amy P. Abernethy, MD, PhD Duke Center for Learning Health Care (A.H.K., S.P.W., A.P.A.), Duke Clinical Research Institute, and Duke Cancer Institute (A.H.K.), Durham, North Carolina; Four Seasons Compassion for Life (J.H.B.), Flat Rock, North Carolina; University of Alabama-Birmingham (K.M.S.), Birmingham, Alabama; Mayo Clinic (T.D.S.), Rochester, Minnesota; American Academy of Hospice and Palliative Medicine (K.A.), Rosemont, Illinois; University of Pittsburgh (D.K.), Pittsburgh, Pennsylvania; and University of Kansas (C.T.S.), Kansas City, Kansas, USA
Abstract
Author Manuscript
Context—Many clinical disciplines report high rates of burnout, which lead to low quality of care. Palliative care clinicians routinely manage patients with significant suffering, aiming to improve quality of life. As a major role of palliative care clinicians involves educating patients and caregivers regarding identifying priorities and balancing stress, we wondered how clinician selfmanagement of burnout matches against the emotionally exhaustive nature of the work. Objectives—We sought to understand the prevalence and predictors of burnout using a discipline-wide survey. Methods—We asked American Academy of Hospice and Palliative Medicine clinician members to complete an electronic survey querying demographic factors, job responsibilities, and the Maslach Burnout Inventory. We performed univariate and multivariate regression analyses to identify predictors of high rates of burnout.
Author Manuscript
Results—We received 1357 responses (response rate 30%). Overall, we observed a burnout rate of 62%, with higher rates reported by nonphysician clinicians. Most burnout stemmed from emotional exhaustion, with depersonalization comprising a minor portion. Factors associated with higher rates of burnout include working in smaller organizations, working longer hours, being younger than 50 years, and working weekends. We did not observe different rates between palliative care clinicians and hospice clinicians. Higher rated self-management activities to mitigate burnout include participating in interpersonal relationships and taking vacations.
Address correspondence to: Arif H. Kamal, MD, MHS, Duke Clinical Research Institute (DCRI), 2400 Pratt Street, Room 8041, Durham, NC 27705, USA. [email protected]. Disclosures Drs. Kamal, Swetz, Kavalieratos, Shanafelt, and Mr. Wolf have nothing to disclose. Dr. Bull is a Board Member of the American Academy of Hospice and Palliative Medicine (AAHPM), Dr. Sinclair is President-Elect of AAHPM, Ms. Ast is the Director of Quality and Research for AAHPM, and Dr. Abernethy is a Past President of AAHPM.
Kamal et al.
Page 2
Author Manuscript
Conclusions—Burnout is a major issue facing the palliative care clinician workforce. Strategies at the discipline-wide and individual levels are needed to sustain the delivery of responsive, available, high-quality palliative care for all patients with serious illness. Keywords Burnout; workforce; palliative care
Introduction
Author Manuscript
Many clinicians practice palliative care to create a meaningful difference in the lives of persons with serious illness and their caregivers. Along with the sense of fulfillment garnered by improving the quality of life of those with need is a simultaneous awareness that clinical hospice and palliative care practice may be more inherently stressful and challenging than previously appreciated. Challenges, such as managing a clinical program that is in high demand but under-staffed,1,2 addressing the multiple and complex needs of patients and caregivers often in crisis, and facilitating resolution of conflicts between any combination of patients, caregivers, and the health system, may lead to significant stress.
Author Manuscript
Contrastingly, a high degree of meaning and personal satisfaction felt by palliative care clinicians may obviate this job-related stress, not allowing it to evolve into a more distressing state such as feelings of burnout. Potentially, the naturally rewarding work of palliative care clinicians, alongside the natural selection of those who comprise the field (i.e., those who stay in the field must inherently know how to resolve the emotional challenges), may prevent escalation of normal stress to something more. We do know that in other medical fields, job stress does frequently evolve into overt burnout, which is described as loss of enthusiasm for work (emotional exhaustion [EE]), feelings of cynicism (depersonalization [DP]), and a low sense of personal accomplishment.3 This phenomenon is increasingly studied in health care, both to describe the penetration of this issue across all fields of medicine, while also informing interventions to allay the downstream, negative consequences of unmanaged burnout.4
Author Manuscript
Shanafelt et al. recently described the comparative results of burnout in various physician populations.5 In addition to reporting an overall rate of 46% of all physicians, they noted the highest rates in physicians who must address multiple areas of medical need simultaneously (e.g., family medicine, internal medicine) or those that are asked to focus on a specific condition but often in high-acuity situations (e.g., emergency medicine, obstetrics). Furthermore, others have described higher rates of burnout among critical care physicians,6 where high-acuity situations are the norm, and outcomes not always successful. Palliative care shares many characteristics with these other medical disciplines that experience high rates of burnout, including balancing distress across multiple diseases or domains, while frequently being called to high-acuity or rapidly evolving situations. Previous evaluations of burnout in palliative care have either described burnout in qualitative ways or using small samples sizes7,8 or were conducted in a different era of clinical palliative care.9,10 To complement these efforts, we planned a large, nationwide survey to
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01.
Kamal et al.
Page 3
Author Manuscript
evaluate the prevalence, severity, and predictors of burnout in clinical palliative care professionals. In partnership with the American Academy of Hospice and Palliative Medicine (AAHPM), one of the largest palliative care membership organizations in the U.S., we conducted a membership-wide survey to understand the prevalence and correlates of burnout among clinicians. The purpose of this research was to ultimately inform the development of future interventions to reduce the burnout experienced by the dedicated palliative care professionals who care for at least six million persons and their caregivers every year.11
Methods
Author Manuscript
We conducted an electronic survey of demographics and burnout among specialty hospice and palliative care clinicians in the U.S. Participation was voluntary, and no remuneration was offered. The study was reviewed and approved as exempt by the Duke University institutional review board (Pro00045381). The survey concept was approved by the AAHPM Board of Directors, but members did not have influence over the content of the survey itself. Participants We invited all members of the AAHPM with available electronic mail addresses to participate in the survey (N = 4456). Nonclinician respondents were excluded from the analysis. AAHPM provided a roster of member e-mail addresses who were active members as of June 1, 2013. Survey Procedures
Author Manuscript
The electronic survey was conducted over six months using an initial electronic invitation letter and two follow-up letters. Additionally, invitations via Facebook posts, Twitter messages, blog posts, and electronic newsletters were sent throughout the survey period. Other participating social media outlets used to disseminate invitations to the study included the Palliative Care Network, National Hospice and Palliative Care Organization, PalliMed, GeriPal, and the Society of General Internal Medicine End-of-Life Interest Group. Survey Development and Validation
Author Manuscript
Our palliative care–focused burnout survey was modeled after similar surveys conducted by the American Society of Clinical Oncology and the American College of Surgeons.12,13 The survey included 52 questions. Eight questions involved clinician demographics or practice setting, four involved career choice and work/life balance, three questions from the SF-1214 queried quality of life, nine addressed clinical experience and credentials, five involved job characteristics, and one queried self-care. To measure burnout, we used the Maslach Burnout Inventory Human Services Survey3 (license/permission was obtained from Mind Garden, Inc., Menlo Park, CA). This 22-question survey (MBI-22) has been used frequently in other studies examining burnout in health care workers, including physicians and nurses. The MBI-22 uses a seven-point Likert scale to score the frequency of feeling each of 22 components used to measure burnout. Thus, for each of the 22 questions, a score of 0
J Pain Symptom Manage. Author manuscript; available in PMC 2017 April 01.
Kamal et al.
Page 4
Author Manuscript
through 7 is recorded. For example, one question within the MBI-22 Human Services Survey is, “I feel emotionally drained from my work.” Respondents can answer a frequency of feeling this way, from “never” (scored as 0) to “every day” (scored as 7). Thus, the minimum score possible is 0 and the maximum is 154. Our survey did not explain the scoring system within the text of the questions. To assess for each subdomain of burnout (e.g., depersonalization and emotional exhaustion), we used the scoring and cutoff criteria of the MBI-22. To calculate a score, each domain had a selected set of questions on which to focus; additive scores from these questions represented a total subdomain score. Depersonalization was scored as “high” for a total score of 13 or higher across five questions; seven or higher constituted “moderate.” Emotional exhaustion was scores as “high” for a total score of 27 or higher across nine questions; 17 or higher constituted “moderate.”
Author Manuscript
The electronic survey was twice reviewed for face and content validity by six palliative care physicians, one expert in health care–associated burnout, and one data analyst. After the first review, iterative updates were made to reflect suggested changes and improvements. Statistical Analysis Descriptive statistics were used to investigate the demographics, job characteristics, and burnout symptoms of palliative care clinicians. We investigated the pattern of data missingness and found that it was random and not informative. We imputed missing responses from the MBI-22 questionnaire for those who left more than 33% of the MBI-22 questionnaire blank, or participants who had less than 10 answered responses (note that the EE and DP subscales used 14 of the 22 MBI-22 questions) were removed from the analyses.
Author Manuscript
We modeled burnout by dichotomizing our outcome variable to high EE or DP. We used Spearman correlation to check for correlation between high EE or DP, EE, DP, and the MBI-22 scales. We implemented a multivariable logistic regression model to predict risk of burnout (high DP or EE). We used variables from the literature and those hypothesized to ameliorate burnout including marital status, children living at home, numbers of colleagues in practice (three or less vs. four or more), physicians versus nonphysicians, and hours per week worked (>50 hours vs. 71
17 (1.7)
Gender [352] Male
355 (35.3)
Female
650 (64.7)
Author Manuscript
Marital status [343] Married
780 (76.9)
Single, never married
67 (6.6)
Partnered
52 (5.1)
Divorced
93 (9.2)
Widowed
22 (2.2)
Children living in the home [346] Yes
459 (45.4)
No
552 (54.6)
Highest clinical degree [337] MD/DO
691 (67.7)
NP/PA
113 (11.1)
Author Manuscript
MSN/CNS
34 (3.3)
RN
66 (6.5)
MSW
36 (3.5)
Chaplain (MDiv, or equivalent)
21 (2.1)
Other
59 (5.8)
How long have you worked in hospice or palliative care, yrs [319] 0–5
354 (34.1)
6–10
340 (32.8)
11–20
230 (22.2)
21–30
83 (8.0)
31–40
31 (3.0)
Clinical responsibility as component of total effort [329]
Author Manuscript
≥75%
430 (41.8)
