Burnout and Building Resilience
A year ago, I started NP Reasoning with several goals in mind. I aimed to create a free educational platform for aspiring and practicing nurse practitioners to keep up with evolving practice patterns. I wanted an outlet to write about diagnostic reasoning principles and share my passion with others. It was also a way to address my imposter syndrome as a relatively novice practitioner. Reflecting back on the past year, I’ve felt a creeping sense of imposter syndrome coupled with burnout. This made me stop to think – how do people stay in our profession and not burnout? While I’ve previously written about imposter syndrome and burnout, my current focus is on building resilience. To do this, we first need to recognize burnout, reflect on its causes, and develop strategies to mitigate it—primarily through fostering resilience.
What is Burnout?
Burnout is a syndrome resulting from chronic workplace stress (1). It is characterized by exhaustion, low energy, negativity or cynicism towards one’s job, and diminished professional efficacy (1). While burnout can affect professionals across various fields, healthcare workers are particularly vulnerable (2). Approximately one in three physicians experiences burnout at any given time, with those in family medicine, general internal medicine, and emergency medicine being at the highest risk (2). Nurse practitioners in primary care are also affected by burnout (3). Burnout symptoms manifest in stages and occur along a spectrum. The widely recognized 5-stage model for burnout development is a valuable tool for self-reflection. From my own experience, I noticed a growing sense of anxiety, irritability, self-doubt, fatigue, low motivation, indifference, and diminished enthusiasm for patient care. This was alarming – I knew something needed to change.
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As nurses, our training often reinforces the idea that we must be perfect and that mistakes are unacceptable—messages that create unrealistic self-expectations, instill fear rather than foster better nursing, and can ultimately lead to burnout.
What causes burnout?
The answer is not straightforward. We live in a society that demands a lot from us—to provide better care, perform better, work harder, and work longer. As nurses, our training often reinforces the idea that we must be perfect and that mistakes are unacceptable ("If you make a mistake, you'll lose your license"—how many times have I heard this? It instills fear rather than fostering better nursing). These messages create unrealistic self-expectations and can ultimately lead to burnout. Further, burnout is influenced by both external and internal factors. One key factor is the mismatch between personality and job demands. For instance, research on primary care physicians has shown that traits such as high neuroticism, agreeableness, and conscientiousness are correlated with burnout (4). To put this into perspective, a person who is highly risk-tolerant may thrive in high-risk medical specialties, such as general surgery or critical care, while someone who is risk-averse might be better suited to lower-risk fields, like family medicine or public health. It is crucial to reflect on external and internal factors contributing to your burnout and identify which ones you can change. Let’s explore some common external and internal factors.
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A note on Cognitive distortions and Burnout
I spent time reflecting on how cognitive distortions can impact burnout. These types of thoughts can become so automatic and ingrained in our psyche that we don’t realize we are experiencing them. Reflecting on these thought patterns can be the first step in managing internal causes of burnout. Let’s review 10 common cognitive distortions described by Dr. David Burns (5).
All-or-nothing thinking: a tendency to evaluate your personal qualities in extreme, black-or-white categories, which forms the basis for perfectionism. It causes you to fear any mistake or imperfection because you will see yourself as inadequate.
Overgeneralization: you arbitrarily conclude that one thing that happened to you will happen over and over again (thoughts come in the form of “always” and “never” statements).
Mental filter: you pick out a negative detail in a situation and dwell on it exclusively – disregarding other facts in the situation.
Disqualifying the positive: the persistent tendency to transform positive or neutral experiences into negative ones. An example is if you provide excellent care to a patient, and chalk it up to a fluke.
Jumping to conclusions: you arbitrarily jump to a negative conclusion that is not justified by the facts of the situation. Mind reading is when you are convinced that other people are looking down on you based on assumptions, and fortune telling is when you imagine something bad is going to happen based on assumptions and not facts.
Magnification: is when you blow things out of proportion, and commonly occurs when you look at your own errors, fears, or imperfections.
Minimization: is when you downplay your successes and strengths (just like imposter syndrome!)
Emotional reasoning: you take your emotions as evidence for the truth (e.g. “I feel like I dud, therefore I am a dud”).
Labeling and Mislabeling: personal labeling means creating a negative self-image based on your errors (e.g. I made a mistake looking after my patient, therefore I must be stupid).
Personalization (the mother of guilt): you assume responsibility for a negative outcome even when there is no basis for doing so. You conclude that what happened is your fault or reflects your inadequacy (e.g. something bad happened to my patient solely because of my mistakes).
As humans, it's likely that we all experience these thinking patterns—I certainly do. They can be detrimental and counterproductive. For example, if I spend half my energy ruminating over patient cases, it not only fails to improve patient care but also becomes exhausting! It's normal to occasionally have a stressful patient case, but if you come home every day worried about patients, it's important to address this. The good news is self-reflection can be incredibly effective and liberating. Once you recognize that you're experiencing burnout, you can identify the underlying causes and take proactive steps to address them. Building resilience is a key strategy for combating burnout.
Personalization (the mother of guilt): This is a common cognitive distortion in medicine. You assume responsibility for a negative outcome even when there is no basis for doing so. You conclude that what happened is your fault or reflects your inadequacy (e.g. something bad happened to my patient solely because of my mistakes).
What is Resilience?
Resilience has been described as the ability to adapt positively to stressful circumstances, being able to remain functionally stable despite ongoing stress, and the process of adapting well in the face of adversity or significant stress (6). We all have different levels of resilience, but the good news is that resilience can be improved. Strengthening your resilience can help you address both internal and external causes of burnout.
How do I become more Resilient?
Self-reflection, or metacognition, involves being aware of and understanding your own thoughts, and is a crucial step in building resilience. This can be done in a variety of ways. You can read (e.g. books, articles on psychology, resiliency, burnout), you can journal, you can seek external feedback from people you trust. Reflect on whether you have too much on your plate. If your plate is too full, is there something you can give up, even temporarily?
Self-reflection, or metacognition, involves being aware of and understanding your own thoughts, and is a crucial step in building resilience.
Once you’ve established a true sense of self-awareness and what is contributing to your burnout, you can strategize specific ways to make change over time (resiliency cannot be learned overnight!) Once I was able to accept that my resiliency was teetering on the lower end of the spectrum, I was able to self-reflect and come up with active strategies to make change.
There are several strategies for building resilience. Cognitive-behavioral therapy (CBT) and mindfulness-based resiliency interventions can be moderately effective (6). These interventions can be self-guided or conducted with a professional, such as a social worker, psychologist or psychotherapist. CBT involves bringing awareness to and changing thoughts, emotions, and behaviours with a variety of strategies. Mindfulness-based interventions focus on self-awareness, self-regulation, and acceptance. One may argue, who has the time to see a therapist? I would counter, there are 168 hours in a week, with 112 waking hours for the average person – can you take 1 hour to devote to self-reflection and/or therapy each week? If it’s what’s going to help you change for the better in the long run, it’s worth it.
Building connections with others is crucial – whether it be with your friends, family, colleagues, or joining a community group. Working in healthcare, it’s important to be able to talk with people experiencing similar things so you don’t feel alone. It might seem obvious, but taking care of yourself is just as important. If we don't sleep well, eat healthily, stay physically active, and engage in activities we enjoy outside of work, we often end up with a half-empty attitude when we arrive at work. Ultimately, if we can’t make the time for ourselves, how are we expected to give our best to our patients?
Lastly, once you’ve identified the external factors contributing to burnout, you can develop strategies to manage them. If something in your work environment is causing you stress, it’s important to address it directly; ignoring the issue will not lead to a resolution. However, it's also crucial to recognize that some external factors are beyond our control. Reflecting on these factors may lead to the realization that the job might not be the right fit for you—and that’s okay (something I learned early in my career!) Fortunately, there are plenty of job opportunities in healthcare.
Key take home point: recognize burnout, reflect on internal and external causative factors, and strategize how you can build resiliency.
References/Readings:World Health Organization (2019, May 28). Burn-out an “occupational phenomenon”: International classification of diseases. World Health Organization. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseasesDe Hert S. Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local Reg Anesth. 2020 Oct 28;13:171-183. doi: 10.2147/LRA.S240564. PMID: 33149664; PMCID: PMC7604257.Abraham CM, Zheng K, Norful AA, Ghaffari A, Liu J, Poghosyan L. Primary care Practice Environment and Burnout among Nurse Practitioners. J Nurse Pract. 2021 Feb;17(2):157-162. doi: 10.1016/j.nurpra.2020.11.009. Epub 2021 Jan 11. PMID: 33658908; PMCID: PMC7920210 Brown PA, Slater M, Lofters A. Personality and burnout among primary care physicians: an international study. Psychology research and behavior management. 2019;12:169-77.Burns, D.D. (2009). Feeling Good: The New Mood Therapy. Harper Collins.Joyce S, Shand F, Tighe J, Laurent SJ, Bryant RA, Harvey SB. Road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open. 2018 Jun 14;8(6):e017858. doi: 10.1136/bmjopen-2017-017858. PMID: 29903782; PMCID: PMC6009510.