Abstract
Although each of us at one point or another has likely experienced occupational burnout in our work lives, contemporary scientific investigation of occupational burnout and its implications for human health has only been pursued for the past six decades. The earliest and most frequently recognized uses of the term in contemporary occupational health and psychology literature arose from the work of Bradley, 1 Freudenberger, 2 and Maslach 3 to understand human services workers’ experiences of work-related exhaustion that ultimately resulted in physical and mental illness. Felton 4 published a landmark paper extending concepts of occupational burnout to health care workers as well as the deleterious impacts on workers, patients, and the whole health care enterprise. The 2019 World Health Organization 5 International Classification of Diseases: 11th Revision (ICD-11) included occupational burnout as “a syndrome . . . resulting from chronic workplace stress that has not been successfully managed” and resulting in energy depletion or exhaustion, increased distance from, cynicism about, or negativity related to one’s job, and perceptions of ineffectiveness on the job. While medical organizations still do not recognize occupational burnout as a diagnosable disorder, we have known for years that it is a prevalent and complex syndrome, particularly among health care workers.
The recent pandemic challenged health care workers to manage high stress and substantial biopsychosocial hazards and made managing occupational burnout in an overstretched health care workforce a policy priority, with notable advocacy from the U.S. Surgeon General.6,7 The U.S. Department of Labor 8 reported that health care workers experienced a 249% increase in work-related injuries and illnesses from 2019 to 2020. In-depth analysis from Nigam et al. 9 indicated some startling risks of being a health care worker in the United States: (1) they have continued to experience some of the highest rates of injury and illness among occupational groups; (2) reported incidents of harassment in clinical settings doubled during the pandemic, and estimates of depression, anxiety, and occupational burnout were five-to-six times higher among those reporting harassment than those not reporting harassment, and (3) between 2018 and 2022, turnover intention among health care workers was three times higher than the general public. Moreover, many of these trends also unfolded across the world. Mahmud et al. 10 in a recent meta-analysis estimated an overall international prevalence of anxiety, depression, stress, and insomnia in health care workers to be about 40%. Unfortunately, we are likely witnessing the occupational burnout of health care workers for years to come.
Emerging evidence also indicates that these trends are unfortunately the same among sonographers. Decades of research has indicated that sonographers are at high risk for injury, illness, and occupational burnout, and the current figures are no less startling than those describing the overall health care workforce. Recent studies of sonographers have indicated that most sonographers experience moderate-to-high levels of occupational burnout,11 -13 as well as a nearly 90% prevalence of factors related to occupational burnout including work-related musculoskeletal disorders (WRMSD) over the past year 14 and instances of sexual harassment over the past 2 years. 15 A recent systematic review of studies over the past two decades also highlighted the relationship of high workloads and the burden of adverse interactions in patient encounters with occupational burnout. 16 At this point, we have compelling evidence of specific problems that need immediate attention. Where can we go from here to continue assessing and conceptualizing occupational burnout in the sonography workforce and ultimately address it?
Assessing and Conceptualizing Occupational Burnout in Sonography
One of the primary challenges of studying occupational burnout is that multiple operationalizations of it exist in the literature. The earliest definitions evolved into one from Maslach and Jackson 17 that emphasized workers’ experiences with three facets including emotional exhaustion, depersonalization, and reduced personal accomplishment as a persistent state leading to mental and physical health challenges, and this remains the most common conception in practice and in research across industries and disciplines. The Maslach Burnout Inventory (MBI) 18 based on this conceptualization and first released in 1981 has the most validity and reliability evidence of all existing occupational burnout assessments. In sonography, Daugherty 19 presented one of the earliest studies of sonographer occupational burnout in 2002 and utilized the MBI to determine the level of occupational burnout in sonographers as well as individual, work, and stress-related factors associated with the three facets of occupational burnout and found a relationship between increased exams performed and increased levels of emotional exhaustion. A more recent study from Singh et al. 20 demonstrated an association between increased overtime hours worked and higher levels of emotional exhaustion, reflecting the association between increasing job demands and emotional exhaustion from Daugherty. 19
The Oldenburg Burnout Inventory (OLBI) 21 is another commonly cited assessment and posits that occupational burnout consists of two facets: exhaustion and disengagement from work. When understanding burnout in sonographers, a notable advantage of the OLBI in comparison to the MBI is that the OLBI items capture physical and cognitive experiences, in addition to affective experiences, of exhaustion and disengagement from work in respondents. 22 Thus, the OLBI could be particularly well-suited to study physical and cognitive strains among sonographers that are leading to occupational burnout. For example, Bagley et al. 23 recently applied the OLBI to demonstrate occupational burnout’s association with WRMSD in sonographers, leveraging the OLBI’s ability to more closely associate burnout with experiences of physical strain than other occupational burnout assessments can. Beyond sonography, Hwang et al. 24 also demonstrated the OLBI’s utility in highlighting associations between burnout and a variety of physical and psychological symptoms related to depression, anxiety, stress, and fatigue in a heterogenous sample of clinical and administrative health care workers. Future projects in sonography may seek to include widely used measures of depression such as the Patient Health Questionnaire-9 25 or of anxiety such as the General Anxiety Disorder-7 26 along with the OLBI to extend our understanding occupational burnout’s association with physical and cognitive in addition to affective factors.
Currently, my team utilizes the Copenhagen Burnout Inventory (CBI). 27 The CBI is distinct from both the MBI and the OLBI in that it conceptualizes occupational burnout as primarily an experience of fatigue and exhaustion attributable to personal, work-related, and client domains of work.27,28 In other words, the CBI may be particularly well-suited to study how burnout interacts with sonographers’ experiences in the workplace at the individual, interpersonal, and work environment levels. A recent sonography study from Yi et al. 15 highlighted associations between experiences of sexual harassment and adverse psychological outcomes such as depression, sleep loss, and anxiety. Others may also seek to use the CBI to assess client burnout’s relationship with hazards arising from interpersonal domains of work such as verbal, physical, and sexual harassment. Duarte et al. 29 also recently used the CBI to demonstrate associations between personal, work-related, and client burnout on one hand and specific internal and external factors on the other hand among a heterogenous sample of health care workers during the pandemic. For example, higher education levels were associated with higher levels of work-related burnout, possibly due to increased administrative strain at higher-level positions. Conversely, being married was associated with a higher level of personal burnout, possibly due to worry about infecting family members at home or greater work-life conflict.
Future Directions for Occupational Burnout Prevention and Intervention
As discussed, foundational research in sonography has identified some factors related to occupational burnout, but much less literature about an intervention exists. Younan et al. 16 offered a comprehensive systematic review of causes of occupational burnout as well as suggested directions for prevention and control of the syndrome. Their first recommendation is to address workloads by limiting exams per shift, scheduling longer appointments, and limiting work and on-call hours. Their second recommendation is to manage experiences with giving adverse news to patients by defining protocols and offering additional support and training to manage these stressful encounters. However, no evidence from observational or trial studies exists to support these recommendations. Advancing longitudinal research and follow-up studies of existing cross-sectional cohorts to observe changes over time in a variety of sonographer outcomes as suggested by Evans et al. 30 and Bagley et al. 23
In terms of specific workplace supports that may reduce sonographer occupational burnout, Callpani et al. 13 pointed out that only 5% of participants reported using mental health services available at work, despite 74% of participants reporting availability of such services and 81.4% of participants reporting moderate-to-high levels of occupational burnout on the OLBI. Moreover, Callpani et al. 13 directed us toward studies in sonography education 31 and palliative care 32 that model possibilities to applying mindfulness training more widely to sonography workplaces and mitigate stress, a factor initially identified in Daugherty 19 as potentially associated with emotional exhaustion. It may be useful to explore not only potential effectiveness of mindfulness programs that have worked in occupational groups facing demands similar to those of sonographers but also how to adapt and implement them in the workplace with approaches from implementation science.33,34
Finally, involving sonographers in decision-making may help tailor program and policy interventions for specific workplaces. A wealth of literature and evidence about participatory programs and worker engagement exists in the Total Worker Health® community. For example, Punnett et al. 35 offers a framework for integrated approaches to worker health promotion that explicitly model how to build participatory engagement of workers into initiatives, with notable examples in corrections, 36 health care, 37 and education. 38 They offer a wealth of resources and evidence-based approaches to engaging workers in addressing health-related concerns.
Conclusion
Overall, there are abundant opportunities to continue developing research about occupational burnout among sonographers. Recent experiences with the strains of the pandemic have increased the visibility and urgency of issues related to occupational burnout among health care workers, including sonographers. Carefully choosing assessments and factors to study and elevating the quality of studies to include robust longitudinal, observational, and trial designs may move us toward better addressing occupational burnout.