Journal of Dental Infection Control and Safety

BURNOUT AND PATIENT SAFETY

Cindy Winfrey, MSN, RN, VA-BC, CIC, IP-BC, FACDONA

ABSTRACT
The relationship between healthcare worker burnout and healthcare‐associated infections has
previously been reported. The work environment of today requires reconciling cost-efficiency and
accountability with the desire to provide patient-centered care, often creating conflicting job demands.
This type of conflict has been linked to increasing burnout and decreased performance affecting
cost, quality, and safety. Stress and burnout for physicians, including dentists, and other healthcare
providers have repercussions for patient care and the health and well-being of the professional
community. Patient safety is at risk when providers are investing most of their time, effort and
resources in dealing with stress. Studies have shown that programs that improve communications
skills, staff empowerment and resiliency have positive outcomes including staff and patient
satisfaction, patient safety, quality, decreased costs. This article discusses the need for investment
in creating healthy work environments that support individuals and healthcare teams in an effort to
improve infection control compliance and patient safety.

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It was the best of times, it was the worst of times.1 That statement could certainly describe dental
care, today. It is easy to become distracted by the many responsibilities of providing care or to
become exhausted and frustrated by the changes in regulations and legislation that affect care
delivery. The work environment of today requires reconciling cost-efficiency and accountability with
the desire to provide patient-centered care, often creating conflicting job demands. This type of
conflict has been linked to increasing burnout and decreased performance affecting cost, quality,
compliance with infection control strategies and safety.2 This article will explore how stress can lead to
burnout and affect patient safety and some strategies that can mitigate the effects of stress.

STRESS AND BURNOUT

Stress costs the American workforce about 300 billion dollars per year.3 What stress costs the dental
community is more difficult to measure. Job stress is commonly defined as the harmful physical
and emotional responses that occur when the demands of the job exceed the capabilities, needs or
resources of the worker.3 Stressors in the workplace include low salaries, heavy workloads, lack of
opportunity for growth and advancement, unrealistic job expectations and job insecurity.4 Additional
on-the-job stressors include lack of participation in decision-making, ineffective management style, and
unpleasant work environments or safety concerns.5 Working overtime, including having more than one
part-time job, can result in poor mental performance, increased illness and workplace injuries.4 Salary
cuts, and heavier workloads have added to the stress in workers’ personal lives, especially as they
confront strained financial issues and compressed time allotment for family obligations.
According to a sentinel report by Michael Baime, Clinical Associate Professor of Medicine at the
University of Pennsylvania School of Medicine and founder and Director of the Penn Program for
Stress Management, “Stress flows both ways. Stress is accumulated over time and additive between
different domains. The stress that someone has at home, relating to their health or financial situation,
comes with them into the workplace. And when they leave work at the end of the day, the stress from
their job also goes home with them.”6 Studies bear this out. Many employers report that stress due to
work/life balance creates stress in the following ways: job demands have interfered with their ability
to fulfill family or home responsibilities, difficulty in balancing work and family life, and work interfering
with their personal time.3, 4, 5, 6
Stress and burnout for physicians, including dentists, and other healthcare providers have repercussions
for patient care and the health and well-being of the professional community. Sources of professional
stress include: situational (workload, sleep deprivation, and poor working environment); personal
(finances, family, and isolation); and professional (information overload and overwhelming patient
responsibility).7 The nature of providing compassionate care, in a setting where there can be perceived
or actual limited physical and or emotional support resources and chronic exposure to human suffering,

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can lead to burnout. Burnout results from stressors in the work environment and has three primary
characteristics: emotional exhaustion, alienation from job-related activities and reduced performance.6
The syndrome of burnout (i.e., emotional exhaustion, depersonalization, and reduced personal
accomplishment) can lead to negative outcomes for the individual experiencing the burnout, the people
receiving the care provided and the community at large.8 Emotional exhaustion is the feeling of being
depleted of one’s emotional resources. Depersonalization may manifest as negative, callous or detached
responses to persons receiving service or care and reduced personal accomplishment and may manifest
as feelings of inadequacy or lack of competence.9 The prevalence of burnout has been studied in dentists
and studies show that greater than 26 percent of dental staff are at severe risk of burnout.10

BURNOUT AND PATIENT SAFETY

Burnout is associated with lower career satisfaction, reduced job commitment, decreased job
performance and stress-related problems.11 A workplace culture of self-sacrifice may seemingly be
admirable, but it may compromise the quality of the care provided. When professionals experience
the symptoms of burnout more errors are likely and these errors can, in turn, contribute to worsening
burnout that can be compounded by the professional not wanting to be perceived as weak, vulnerable
or ineffective.12 This workplace culture fosters an inability to seek help when needed, and blocks the
willingness and ability to participate in self-reflection and apply compassionate self-care.13 Burnout is
viewed as a threat to patient safety because emotional exhaustion, depersonalization, and reduced
personal accomplishment are linked to poorer interactions with patients.11 Clinicians with burnout
are more likely to admit to mistakes or delivering substandard care.11 The connection between
burnout and safety is set into motion by fatigue or lack of motivation and impaired cognitive function
(i.e., attention, memory and executive function) that can diminish recall and attention to detail such
as lapses in safe injection practices or basic hand hygiene14. Burned-out clinicians can become
progressively more detached from their work, develop negative attitudes towards patients promoting
a lack of investment in the patient-provider relationship, and lose pertinent information necessary for
decision making. This, in turn, places them at higher risk for errors.13 An important measure of the

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work environment is the perceived effort‐reward imbalance (ERI), characterized by a state of failed
reciprocity, (i.e., high effort spent but low rewards received). This imbalance can to lead to anger,
frustration and perceived unfairness with resultant sustained autonomic nervous system activation
contributing to physical disease (e.g. cardiovascular disease and mental disorders)15.
The relationship between healthcare worker burnout and healthcare‐associated infections has
previously been reported15. The evidence for burnout as a negative unique incremental predictor
of healthcare workers, including dentists, self‐reported compliance with infection control measures
suggests that burnout, by predisposing to non‐compliance with infection control measures, could lead
to an increase in transmissible occupational infections in addition to failure to notice and intervene to
prevent infection control lapses.

WHAT CAN BE DONE?

Developing positive self-care strategies is important for prevention of burnout. Commitment to
self-care includes adequate hydration, nutrition, sleep, and exercise. Other self-care approaches
such as yoga, massage, meditation or journaling may be considered.16 A promising program aimed at
developing a culturally acceptable mental health program to help clinicians cope with excessive stress
is mindfulness-based training.17 Mindfulness is defined as “paying attention in a particular way; on
purpose, in the present moment and non-judgementally”.17 Mindfulness is a form of self-reflection and
involves developing the ability to be aware of our current thoughts, feelings, and bodily sensations
with kindness and understanding. It creates a psychological space between one’s perceptions (e.g.,
stressful stimulus) and response (e.g., thoughts, speech, actions) allowing a thoughtful wise response
rather than reacting impulsively with negative emotions.17
Promotion of wellness for healthcare professionals may be the best way to prevent burnout not only
during their training but throughout their careers. With the understanding that responsibility lies with
both the provider and the organization, there are several ways organizations can promote wellness:
Provider health committees (with equal stature as other key committees)
Mentor programs
Confidential support groups facilitated by an outside professional
• Sabbatical programs
• Continuing education programs relating to wellness
• Involvement of providers in the design of their own practice environments
• Flexible scheduling allowing time for personal and family needs
• Availability of leaves of absence to pursue personal interests18

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Studies have shown that programs that improve communications skills, staff empowerment and
resiliency have positive outcomes including staff and patient satisfaction, patient safety, quality,
decreased costs and recruitment and retention of engaged workers.10, 12,16, 19 Resilience is defined
as “the capacity to keep functioning physically and psychologically in the face of stress, adversity,
trauma, or tragedy”.19 Learning resiliency skills can improve self-awareness, enhance supportive
relationships, improve communication and teamwork, and decrease stress.
Failure to communicate effectively increases the risk of error and can be a source of frustration and
stress.20 Courses such as Team STEPPS® can improve individual and team communications skills.

CONCLUSION
It is important that clinicians and leaders gain competence in identifying burnout and implementing
intervention strategies. Research clearly documents a link between healthy work environments
and improved infection control and patient safety. Equally important, is the need for investment
in creating healthy work environments that support individuals and healthcare teams. This article
described burnout as one result of the changing landscape of healthcare and suggested a variety of
interventions aimed at improving self-care and the work environment. Creating such a work culture
may help individuals reconnect to their personal mission and ultimately the altruistic goal of safe
patient care.

Additional Information Resources:

Enhancing Caregiver Resilience: Available at: http://www.dukepatientsafetycenter.com/
The Basics: Strategies For Coping With Stress and Building Personal Resilience for
Physicians. Ontario Medical Association https://mentalhealthforall.com/2016/06/22/strategies-for-
coping-with-stress-and-building-personal-resilience-for-physicians/

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TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety):
is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving
communication and teamwork skills among health care professionals. Available at: http://www.ahrq.
gov/professionals/education/curriculum-tools/teamstepps/index.html
Making Just Culture a Reality. Available at: https://psnet.ahrq.gov/perspectives/perspective/50/
making-just-culture-a-reality-one-organizations-approach
Mindfulness Meditation: Getting Started. Available at: http://www.mindful.org/meditation/
mindfulness-getting-started/

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