Provider “burnout” is an increasing concern in today’s healthcare system, best defined as symptoms of exhaustion, decreased productivity and cynicism. Burnout can lead to medical errors potentially resulting in patient harm, while also being detrimental to the quality of life of healthcare professionals. EMS personnel have been reported to display increasing signs of burnout across the industry1, which is validated herein by a survey conducted of EMS personnel across America. While direct causes for this phenomenon may not be obvious, a surge in documentation requirements, lack of rest and increased physical and emotional stressors are likely associated factors, creating a chronic professional motivational challenge. This paper will address the causes of burnout, offering suggestions to reduce its impact upon EMS professionals.
EMS professionals are increasingly victims of burnout. This condition is now considered in the International Classification of Diseases and points to chronic workplace stress.2 Physicians and psychologists can diagnose burnout based upon the criteria of energy depletion, work dissociation and lack of professional ambition.3 For each individual, a variety of reasons for personal burnout may be present, however. In EMS systems, many causes of burnout appear to be common across the field. Some of the common etiologies include:
- Low wages
- Heavy workloads while on-shift
- Poor career recognition
- Lack of rest and chronic fatigue4
- Juggling multiple jobs5
- Documentation challenges6
- Physical demands of the job
- Possible target of violence
- Emotional burden7
- Effective support systems8
This study aimed to better understand what burnout is and why it is occurring in EMS providers. Through this inquiry possible solutions may be found to mitigate the occurrence and severity of this condition.
The authors performed a literature search, including editorials, on the subject of burnout, conducted first-hand interviews with EMS professionals and engaged a licensed psychologist actively involved in the subject. Articles were selected based upon their relevance to the subjects of EMS provider burnout broadly, the causes of burnout and what is being done currently to address this condition.
An online survey addressing the subject of burnout was disseminated to a group of EMS medical directors of some of the largest cities in the world (the “Eagles”), who then distributed the survey to EMS personnel within their systems. The survey was sent via email to EMS professionals, and the responses were collected and analyzed. Charts were created using Microsoft Excel software.
One thousand five hundred forty-seven (1,547) EMS personnel completed the Eagles burnout survey. In responding to the statement “I feel burned out in my EMS work,” more than 60% strongly agreed or agreed, while some 28% disagreed to some extent. (See figure 1) A follow-on question asked if the respondents agreed with the statement: “I don’t want to do EMS work anymore.” Approximately 36% agreed with the statement, with a larger proportion “somewhat” agreeing. Eleven percent had no opinion, while some 51 percent disagreed. (See figure 2)
“Burnout” is a poorly defined set of symptoms that broadly appear to be increasing across the field of medicine, with EMS personnel being no exception. Burnout has been defined by some sources as physical, mental and emotional exhaustion due to severe stress over extensive periods of time,1,9,10 while other sources have defined it as a state of simply going through the motions of one’s practice11 or even as “moral injury.”12 A noted emergency medicine physician has been quoted as stating that “burnout is the response of a normal person to a toxic environment.”13 Probably no one all-encompassing explanation exists for the cause of burnout. Even the list quoted above is not exhaustive and many individuals describe more personal reasons for burnout.
Strategies for EMS organizations to manage provider burnout have included the implementation of focus groups,1 Critical Incident Stress Management programs (CISM),14 and Employee Assistance Programs (EAP).15 The intent of these programs includes assisting medics who have experienced traumatic events on shift, providing them with a coach and/or counselor who can work with them on grief management techniques and therapy options.
A lead paramedic instructor at our university stated that these programs can only go so far for the medics for multiple reasons.16 First, medics feel they are required to have a “thick skin,” that seeking help is “taboo” and is often seen as a weakness. Secondly, these classes and support groups take significant time and may only be offered free up to a certain amount of sessions, following which the medics must either pay for them or simply quit the programs altogether. Finally, the offered classes may not be specific enough for these highly situationally associated cases.
Although CISM and EAP’s provide some support for medics burdened by emotional trauma, committing to the monetary and time aspects of support groups/classes may be difficult given their work/life balance. An advocacy group known as the “Code Green Campaign” was developed to bring awareness to the mental health concerns surrounding the EMS profession.17 Its aim is to reduce the stigma of getting help within the field, including how to find assistance for those seeking aid. Such a group may provide a better option for those who desire to receive more specialized help or simply prefer to speak with members of the same field.
The key objective in the job of an EMS professional is to take care of each patient that presents in a high quality manner. One study found that professionals who had reported serious medical error within the last three months also reported symptoms of burnout and poor safety grades.18 Of interest, in those systems where the professionals are feeling dissatisfied, there is a lower satisfaction rating among the patients as well.19 With so many professionals feeling burned out, the key objective of patient care is on the line. How can patients be taken care of if the providers can’t take care of themselves? It is vital that the well-being of EMS professionals is supported in order to maintain the utmost care for the vulnerable in the surrounding communities.
Many of the aspects of EMS practice which may induce burnout are difficult to address, such as heavy work loads, poor professional recognition, lack of rest, juggling many jobs and balancing life situations. “Top down mandates” such as documentation, patient volume quotas and cost-conscious care in the field may cause stress as well. Thus, the EMS professionals caring for their patients are distracted by these burnout-inducing issues rather than being solely focused on the person in need of care.
A novel way to consider burnout is through the perspective of “moral injury.” An individual experiencing a situation that violates basic beliefs and convictions may develop internal turmoil.20 For EMS professionals this may occur when conflict arises between the commitment to excellence in the EMS field and the barriers that may arise to fulfilling this commitment. This inability to complete ones calling/task leads to internal moral and emotional dissonance.
One of the authors in this paper has presented three key fundamental concerns underlying burnout.21 First, time management is critical in order to mitigate stress on and off the job, including the amount of free time one has and what that time is being spent on. This effort allows for the elimination of less important tasks in order to make time available for more beneficial activities. The creation of a schedule may help put tasks into focus, thus creating a more efficient use of time.
Energy is the second key point: Learning where people expend energy can be helpful in maintaining a positive outlook. Identifying the activities where energy is being expended and whether these activities are providing a positive or negative effect can be helpful to the individual. Using this assessment and trying to incorporate activities associated with a positive effect can be helpful to alleviate burnout symptoms.
The third key point is learning the areas of life over which one has control, which can help alleviate stress and help one focus energy. If it is found that a situation exists over which no control exists, then the mental “letting go” of that situation may work to alleviate stress. This letting go allows for the conservation of mental energy and encourages the individual to focus energy instead onto things that can be controlled, recognizing that this control may vary from situation to situation.
Thus, learning to adapt and thrive in the EMS environment comes from a key understanding of time efficiency, selective streaming of energy and individual control. While many aspects of the EMS environment are simply out of the hands of the EMS professionals, an ability to refocus and give consideration to the ideas mentioned above can provide a highly efficient way to confront and alleviate burnout.
Recommendations and Solutions
The EMS professional hoping to prevent or reduce burnout might utilize the following nine questions to aid in gaining personal insight:
- Do I dread going to work?
- Where do I gain energy?
- How do I handle situations where I do not have control?
- What can I cut out in order to make more time for energy yielding activities?
- What aspects of my life contribute to my quality of life and can I apply these in my work?
- Do I have the ability to change the aspects of my work that I don’t like?
- Where do I find my support and am I getting enough?
- What goals do I have in my field and how can I accomplish them with the environment I work in?
- What are the top priorities in my life?
Burnout is pervasive among EMS professionals and has become increasingly recognized as a significant concern. Initiatives to address burnout including the setting up of specialized programs that assist providers within organizations. Similarly, advocacy groups are bringing increasing awareness to burnout. Although these are steps in the right direction, significant headway is necessary to mitigate burnout in the future. As pointed out above, it has been said that burnout is the response of a normal person to a toxic environment. Thus, it is vital that providers are able to self-reflect and discern their time management, energy use and sense of control within their careers and in their personal lives.
- Singh R, Marlowe D. Provider burnout. StatPearls (Internet), 2019.
- World Health Organization. (May 28, 2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. In World Health Organization. Retrieved July 13, 2019, from https://www.who.int/mental_health/evidence/burn-out/en/.
- Prior R. (May 27,2019). Burnout is an official diagnosis, World Health Organization says. In CNN. Retrieved July 5, 2019, from https://www.cnn.com/2019/05/27/health/who-burnout-disease-trnd/index.html.
- Calams S. (March 4, 2019). 7 reasons why EMS providers flee, and how to combat them. In EMS1. Retrieved july 6, 2019, from https://www.ems1.com/defying-ems-retention-crisis-why-are-great-people-leaving-ems/articles/393539048-7-reasons-why-EMS-providers-flee-and-how-to-combat-them/?NewsletterID=893226&utm_source=MailChimp&utm_medium=email&utm_content=Feature1Title&utm_campaign=EMS1Weekend&cub_id=usr_wcYOZ9DxyUvbKPES&utm_source=EMS1+Member+Newsletter&utm_campaign=c93e753a8d-EMAIL_CAMPAIGN_2019_03_19_08_53&utm_medium=email&utm_term=0_dcef1702d6-c93e753a8d-40249287.
- Gordon S. (May 7, 2019). I did the math: full-time, full-service doctors cannot ever have work-life balance. In Op-Med. Retrieved June 2, 2019, from https://opmed.doximity.com/articles/i-did-the-math-full-time-full-service-doctors-cannot-ever-have-a-work-life-balance
- Mosheni A. Why I quit emergency medicine. 2018;40(10):1,12,13-14.
- Frediani D. (August 21, 2016). 5 signs you’re a burnt out paramedic. In EMS1. Retrieved June 4, 2019, from https://www.ems1.com/health-and-wellness/articles/134785048-5-signs-youre-a-burnt-out-paramedic/.
- Boland L, Kinzy T, Myers R, Fernstrom K, Kamrud J, Mink P, Stevens A. Burnout and exposure to critical incident in a cohort of emergency medical services workers from minnesota. 2018; 19(6):987-995.
- Farina A. (Nov. 19, 2015). EMS burnout: Try this 4-step cure. In EMS1. Retrieved June 3, 2019, from https://www.ems1.com/mental-health/articles/30289048-EMS-burnout-Try-this-4-step-cure/.
- Mayo Clinic Staff. (n.d.). Job burnout: how to spot it and take action. In Mayo Clinic. Retrieved june 24,2019, from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642.
- American Addiction Center (2016) EMS burnout: causes, prevention and stress reduction tip. In Medium. Retrieved May 5, 2019, from https://medium.com/first-responders/ems-burnout-causes-prevention-and-stress-reduction-tips-860f02e41aa1.
- Damania Z. (March 8,2019). It’s not burnout, it’s moral injury. In ZDogg MD. Retrieved May 8,2019, from https://zdoggmd.com/moral-injury/.
- A.C. Broders, MD. Personal Communication, August 12, 2019.
- CISM International. Understand CISM. In Critical Incident Stress. Retrieved April 23, 2019 from https://www.criticalincidentstress.com/what_is_cism_.
- NAEMT. (2019). NAEMT resilience guide. In NAEMT. Retrieved June 12,2019, from http://www.naemt.org/docs/default-source/ems-preparedness/naemt-resilience-guide-01-15-2019-final.pdf?Status=Temp&sfvrsn=d1edc892_2.
- Chris Thompson LP. Personal Communication, June 6, 2019.
- Code Green Campaign. (n.d.). The code green campaign. In Code Green Campaign. Retrieved july 13, 2019, from https://codegreencampaign.org.
- Tawfik D, Profit J, Morgenthaler T, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clinic. 2018;93(11):1571-1580.
- McHugh M, Kutney-Lee A, Climiotti J. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs. 2011; 30(2):202-210.
- Talbot S and Dean W. (July 26,2018) Physician aren’t burning out. They are suffering from moral injury. In Stat. Retrieved June 12, 2019 from https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
- Mona Robbins PhD. Personal Communication, May 8, 2019.