Burnout Syndrome and Communication

Introduction

Many publications, articles, professional studies and other literature have been written about the
burnout syndrome. The occurrence of the burnout syndrome is commonly observed in occupations that
include an emotional interaction with people who are in some way dependent on the
profession. Burnout is often associated with human service providers such as educators, health
professionals, social workers, over-the-counter workers and the rescue system. One of the important
stressors contributing to emotional burnout is lack of an efficient communication. Both verbal and
nonverbal communication play a role. Interventions aimed at improving communication skills are
one way to mitigate the risk of developing burnout.

People-Oriented Professions and Burnout Syndrome

Nowadays, the labour sector is in an alarming situation in terms of mental health. Problems
described as chronic stress, anxiety, burnout or depression affect 1 in every 10
employees. (Puertas-Molero, 2018)

The best-known Maslach Burnout Inventory, the Freudenberger Burnout or the Mental Burnout
Questionnaire are often used to test for burnout. (Honzák, 2013) There are also means to determine
the level of burnout, for example Schirom and Melamed scales.

The Ptáček study presented a significant difference in burnout manifestations between the
sexes. Women reported higher levels of burnout, both general and physical and mental. No
significant gender difference was found at the level of emotional burnout. The study further
describes that the average burnout level decreases with increasing age and no significant effect of
age on the burnout level was found. (Ptáček et al., 2017)

Burnout syndrome is known as a symptomatic response to chronic work-related stressful situations
and occurs commonly in the caring professions as well as in other professions that require direct
contact with others. The history of this concept dates back to 1974, when Herbert
Freudenberg observed working with drug addicts that most volunteers experienced progressive energy
loss, exhaustion, symptoms of anxiety and depression, and demotivation at work. (Lozano, 2018)

These are therefore people-oriented professions. Among these professions, the prevailing norm is
selflessness and prioritizing the needs of others. The organizational environment of these
occupations is shaped by various social, political and economic factors, which result in a work
environment characterized by high demands and low resources. The three key aspects of the burnout
syndrome are overwhelming exhaustion, feelings of cynicism and depersonalization, and feelings of
inefficiency and failure. (Maslach, 2016)

Classic examples of professions exposed by their nature are teachers of all levels of education,
doctors and medical staff and professions in the field of security and service as well. In
the field of health care providers typical examples include staff providing acute care (ARO,
intensive care units) and care for cancer patients or psychiatry.

In the field of education, despite the widespread beliefs of burnout being a challenging problem
only for primary and secondary school teachers, it is also faced by university professors. (Zhang,
2008)

Among university teachers, 25% of them describe their work as exhausting and extremely
stressful. Work overload, responsibility for the quality of teaching and a formation of future
professionals, continuous participation in research and continuous contact with students and
colleagues influence and invade their individual private lives. As a result, it reduces empathy,
accentuates cynical attitudes and depersonalization, and other manifestations of burnout
syndrome. (Puertas-Molero, 2018)

Research concerning with the manifestations of burnout in psychiatrists has shown that there is a
link between burnout and poor care. There are changes in appearance (fatigue), behaviour
(avoidance, weaker eye contact) and moods (irritability, poor communication).

Psychiatrists' work with demanding patients and their families is closely linked to the level of
exhaustion and depersonalization. Burnout can also occur when a psychiatrist is the target of
anger, hatred, and even violence as a result of negative transference. Workplace-related
variables play a more stressful role than other factors and are therefore more likely to sustain
burnout. These variables include overwork, long working hours, chronic staff shortages, heavy
administrative burdens and lack of management support. Special risk factors related to psychiatry
is the main work with clients who have experienced psychosocial trauma. The demands of these
clients may cause "compassion fatigue". (Maslach, 2016)

The frequency of depressive disorders and suicides is higher among physicians than the general
population. One of the risk factors is burnout. According to a survey by the college of surgeons,
suicidal thoughts are associated with burnout, depressive symptoms and medical errors in the last 3
months. Many doctors, especially surgeons, suffer in silence and neglect the opportunity to connect
with colleagues who have similar experiences.

Communication is paramount for identifying and addressing burnout, depressive symptoms, and suicide
risks. Prompt communication, compassion, and sharing experiences is the first step in identifying
distress and reducing stigma within the medical community. (Kashyap, 2019)


Communication as a tool to mitigate the risk of developing burnout

One of the important stressors contributing to emotional burnout is lack of communication. Both
verbal and non-verbal components of communication play a role. On the contrary, interventions aimed
at acquiring communication skills are one of the ways to mitigate the risk of developing a burnout
syndrome.

Physicians should pursue to understand the way how the patient integrates and interprets often
quite complex biomedical information in their daily lives.  Otherwise, the dialogue between them
takes place mostly as two parallel and separate monologues. Problematic communication with patients
is thought to contribute to emotional burnout and low job satisfaction, as well as high
psychological morbidity in clinicians. Ineffective communication also has a negative effect on
patient care and causes stress in interactions between nursing staff, with colleagues, patients and
their relatives. Given that a significant proportion of healthcare is provided by multidisciplinary
teams, communication between and within teams must be clear and unambiguous in order to avoid
mistakes. (Fallowfield, 2006)

Good communication occurs when members of both care-providing teams (surgical versus ICU) feel that
they are being listened to and at the same time work with a common goal for the
patient. Communication is then possible despite the many barriers existing between these
teams. Poor communication then occurs when team members feel that their knowledge and experience
are underestimated. Communication has the most meaningful effect on patients. (Kashyap, 2019)

The research on relationship between communication and burnout emphasizes a positive correlation
between verbal aggression, impression manipulativeness, questioningness, and emotional repertoire
with components of burnout such as personal dissatisfaction or motivation to leave. On the
contrary, precision in communication has a positive effect on the social climate component of the
burnout syndrome. (Lozano, 2018)

Integrated humanized patient care requires effective communication, especially in highly
psychosocially stressful situations (such as terminal conditions and emergencies), where
comprehensive communication between health professionals, patients and family members is
inevitable. In addition to stress, professional dissatisfaction and emotional exhaustion, lack of
communication between healthcare professionals can lead to confusion and loss of trust among team
members. (Lozano, 2018)

Nursing staff must be open to communication, which should be accurate (through the adequate
interpretation of other people's thoughts, feelings and attitudes), with cognitive empathy, so that
they are able to provide humanized care. It is therefore recommended to organize training
in communication styles for nurses and to develop personal competencies that humanize their
professional behaviour, cognitive empathy and accuracy in communication. (Lozano, 2018)

When analysing above mentioned communication skills among health professionals, doctors and nurses
are rated best. Nursing support staff showed the weakest results. Men achieved higher levels of
communication skills with the exception of empathy, personal success at work, and self-employment
than women. Both sexes achieved the same levels in emotional exhaustion and depersonalization. The
communication skills of the surveyed health professionals were related to less emotional exhaustion
and depersonalization and greater job satisfaction as well as self-employment. (Lozano, 2018)

An example from the field of nonverbal communication was the analysis of the effect of burnout
syndrome on teachers.

Nonverbal immediacy usually includes a smile, vocal variations, eye contact, gestures, and relaxed
body position.

The results of this study revealed a significant impact of teacher¢s burnout and nonverbal
immediacy on student motivation and effective learning. Conscious nonverbal immediacy can mitigate
the negative effect of a burnout syndrome on a teacher's motivation and effective learning, and can
thus show a way to counter the syndrome and mitigate its consequences. The use of immediate
behaviour (nonverbal immediacy), such as smile, eye contact and voice work etc., can increase
students' motivation. (Zhang, 2008)

Non-verbal aspects of communication play a key role in lectures and contribute to building a
successful relationship. The teacher's successful performance and learning process depends to a
large extent on the teacher's ability to adequately improvise and maintain a close relationship
with his students. In this context, it is necessary to highlight the paralinguistic manifestations,
especially the tone of the voice, which enhances the teaching process and attracts students'
attention. (Puertas-Molero, 2018)

Emotional preservation and clarity are positively reflected in non-verbal communication. The
explanation for this is that people who often and adequately use body language are better able to
understand and express their own feelings, as well as the feelings of others. Social relationships
that encourage conflict resolution in stressful situations are much easier to generate using body
language. The development of cynical attitudes is based on feelings of emotional exhaustion
from work and generates defensive and self-protective behaviour. (Puertas-Molero, 2018)

The inability to communicate at one level can exacerbate the situation at many other levels with
significant, long-lasting consequences. Understanding and realizing the value of effective
communication is undoubtedly an important factor for the well-being of physicians, maintaining job
satisfaction and minimizing the risk of burnout. (Kashyap, 2019)

By implementing adequate interventions and programs it’s possible to significantly reduce emotional
exhaustion, professional effectiveness and perceived stress. Positive trends in terms of
satisfaction with communication skills, leadership skills and working relationships are also
evident. (Kashyap, 2019)

For nursing staff dealing with oncology care, communication behaviour plays an important role
in meeting the cognitive and affective needs of cancer patients. Inadequate communication skills
can reduce a patient's openness, increase anxiety and reduce their satisfaction with treatment.

The communication problems are not rare and reported rate of nurses, who experienced communication
problems with agitated patients, reached 84%. Furthermore 70% of them reported difficulties in
communicating with terminally ill patients. (Onan, 2015)

The nurses do not perceive themselves as stressed. Such perceptions are influenced by individual,
work and employee characteristics. The nurses themselves evaluate their communication skills
positively, but when asked about communication difficulties, they state the difficulties in many
areas. These areas include communication with agitated patients, bad and anxious families, patients
suffering from pain and those who are in the terminal phase and refusing care. As the perceived
level of stress increases, the nurses evaluate their own communication more
negatively. Interventions to improve nursing communication reduce stress and risk of burnout. When
nurses evaluate their general communication skills positively, decrease in the frequency of
psychological symptoms and somatization can be observed. Therefore, improving their communication
skills can support their own mental health and reduce the quality of care by reducing their
communication problems. (Onan, 2015)

Ethics in connection with the burnout syndrome

Healthcare providers are involved in various medical organizations (e. g. hospitals, clinics) as
well as non-medical structures (government programs) that significantly affect what health care is
provided and to what extent. Healthcare professionals often question these commitments and may be
frustrated and stressed by administrative, bureaucratic and financial pressures that go
beyond ethical or value-oriented care to meet the above commitments. Examples of such situations
are pressures to dismiss patients too soon, pressures to prevent patient admission due to expected
costs and type of health insurance, ensuring a reduced scope of care for patients without
sufficient insurance coverage, avoiding "less desirable" patients, failure to provide the necessary
information and reserving insufficient time for visits. (Gabel, 2011)

The importance of ethical behaviour is also shown in the area of ​​nursing care. A positive
correlation was found between ethical decision-making and burnout syndrome in nurses, namely
between burnout syndrome and the need to discontinue treatment, refuse treatment, and proceed
to terminal sedation. Insufficient involvement of nurses in ethical decision-making was identified
as a risk factor for this burnout. (Teixeira, 2013)

When there is a feeling of lack of professional values ​​or unethical behaviour, many health
professionals develop an internal conflict. The difficult reconciliation of their values ​​and the
critically perceived values ​​of its organization then represents an incongruity of values.

Incongruence of values ​​and moral strain are other, less known, means or ways
to burnout. Incongruence of values ​​predicts all three components of the burnout syndrome -
exhaustion, cynicism and feelings of inefficiency. (Gabel, 2011)

Practices aimed at maximum profit and limiting the availability of resources may seem
unethical in terms of value orientation and commitments of health professionals.

Some professional practices are considered unethical by almost all health professionals. An example
is earning personal income for sending patients on certain examinations and procedures that are of
financial interest. Non-acceptance of financially uninteresting patients with government insurance
also belongs to this issue. However, opinions on some practices, such as sponsorship of symposia by
pharmaceutical companies, may differ. When healthcare professionals see their colleagues in similar
situations, they may experience feelings of conflict and confusion over ethical principles and
values ​​and potentially lead to burnout.

Providing health care is a moral act. The feeling of health care that it is not possible to provide
such care as they consider good and what they consider their duty causes the conscience to
stress. Stress of conscience in research has shown that it is able to explain up to 60 % of the
variance in emotional exhaustion in the MBI (Maslach Burnout Inventory). (Gabel, 2011)

The possibility of influencing such a risk and increasing moral and work commitment lies
in confronting a doctor, other health care professional or an organization perceived as unethical
and helping to change these practices through professional discussion, negotiation and conflict
resolution. The benefit of ethical and value orientation in the provision of health care does not
only consist in satisfying the work performed ethically, but also in reducing the risk of
developing the burnout syndrome with its personal and work consequences. (Gabel, 2011)


Conclusion

Interventions aimed at acquiring communication skills are one way to mitigate the risk of
developing burnout. Interventions can be implemented at the level of individual, working groups or
entire organizations. Many individual strategies include changes in the work system, the
development of coping skills, the acquisition of social support, the use of relaxation strategies
and the development of self-knowledge. (Maslach, 2016)

The path of self-knowledge can also be a prevention of burnout. It stabilizes the awareness of
one's qualities, abilities, shortcomings, feelings, needs and desires. People are then able to
orient themselves better, describe what bothers them, what they would like and what they would need
in situations or conditions. One can get to know oneself, for example, in the form of
self-reflection, feedback from the environment, interviews with experts, questionnaires and various
tests.

The development and implementation of training programs to support communication skills related
to personal and emotional competencies have proven to be effective in reducing mild mental
disorders in situations with a high emotional impact. In clinical practice, mindfulness training or
interventions aimed at improving soft skills are used. (Molero, 2021)


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Markéta Veselá, M20574