“Burnout, at its core, is a work-related problem, created by the workplace. Too often efforts to reduce burnout are focused on the employee, putting the burden of solving the problem on the individual.”
The concept of professional burnout originated in the 1970s and by 2019 was classified as a disease by the World Health Organization. It is described as a syndrome “resulting from chronic workplace stress that has not been successfully managed.”1 It is estimated that 50% of human physicians experience burnout symptoms of varying degrees, 1.6 times greater than that of the general population.
The 2020 Merck Wellbeing Study found that, even with fewer working hours, “veterinarian burnout scores were nearly 40% higher than physician burnout scores.”15 While the “prevalence and predictors of burnout among veterinarians have been studied extensively, the consequences of burnout have been largely ignored.”2 This article will explore burnout: what it is, why it happens, and what can be done to lessen this devastating occupational hazard.
What is Burnout?
“Burnout is a psychological syndrome, emerging as a prolonged response to chronic interpersonal stressors on the job”4, and is characterized by “emotional exhaustion, depersonalization and a sense of reduced personal accomplishment.”5 When a person experiences burnout, they are emotionally and physically exhausted, often feel isolated, defeated, and that their efforts don’t make a difference. They become cynical and may begin to treat others as objects, minimizing them and treating them with detachment. They may self-identify as ‘becoming crispy’.
The Cost of Burnout
Burnout comes with a high price tag. Burnout in healthcare has been shown to negatively impact patient care, doubling the risk of medical errors and increasing the likelihood of being named in a malpractice lawsuit by 17%. Patients report decreased satisfaction when their healthcare providers are experiencing burnout. There is a negative impact on doctor-to-doctor interactions, which further inhibits a team-based approach to patient care. Studies have found burnout leads to “decreased productivity, job dissatisfaction and more than a doubled self-reported intent to leave one’s current practice for reasons other than retirement.”6 A Gallup poll found that employees experiencing burnout are 2.6 times more likely to be looking for another job.
Burnout is not position-specific; it occurs at all levels in all organizations. It contributes to absenteeism, reduced productivity, poor workplace culture with increased toxicity, conflict, and unhappiness. Ultimately, it results in increased employee turnover. It is estimated that the cost of physician turnover in human medicine is 2-3 times a physician’s annual salary7 and similar statistics have been quoted for veterinarians. The cost of losing a veterinary team member is often 1.5 to 2 times their annual salary.8
The cost of burnout to the individual is most alarming, resulting in mental and physical distress, including complaints such as chronic fatigue, insomnia, amplified suicide ideation, increased risks of alcohol and substance abuse, broken relationships, and physical ailments such as chronic pain and more frequent illness.
What Causes Burnout? (Use the highlighted section below as a pull quote)
Burnout, at its core, is a work-related problem, created by the workplace. Too often efforts to reduce burnout are focused on the employee, putting the burden of solving the problem on the individual. While self-care is an important component in addressing the negative feelings of burnout, it is an insufficient remedy. Changes to the workplace are necessary if burnout is to be positively addressed.
There are six main causes of workplace burnout1: unsustainable workload, perceived lack of control, insufficient rewards for effort, lack of a supportive community, lack of fairness, and mismatched values and skills. Let’s explore each of these in the context of a veterinary practice environment.
1. Unsustainable Workload: Research by Gallup has shown that the risk of workplace burnout increases significantly when employees work 50 hours or more a week. An important finding was that how people experience their work has a greater effect on burnout than the amount of time spent at work. The increased demand for pet health care services as well as additional hours worked to cover for co-workers who were ill or needed to physically distance resulted in sustained, increased workload for veterinary hospital employees. A survey conducted by VHMA in December 2020 found that 28% of practices reported increased doctor hours and 49% reported increases in staff hours.10 Compounding the long hours was high work intensity, due to a worsening of existing inefficiencies in veterinary hospitals, simultaneous competing demands on employees’ time, frequent interruptions and stressed, verbally abusive clients.
2. Lack of Control: Job control is “the extent to which individuals have control or discretion over performing their work task.”2 Perceived lack of control is a large contributor to burnout in veterinary hospitals, often increasing anxiety due to the uncertainty, disorder and confusion that arises when employees lack autonomy. In veterinary hospitals, this includes the overwhelming numbers of pets needing services. This extends the workdays for most employees, leading to insufficient ‘recovery time’ and increases in work-home conflicts. The majority of veterinary employees have little to no control over workplace issues, such as what their responsibilities are, how appointments are scheduled and how often they are pulled in different directions when conflicting needs arise.
3. Insufficient Rewards for Effort: Insufficient rewards for effort aren’t limited to external rewards, such as pay or bonuses. It is also the recognition by coworkers and hospital leaders that the employee’s efforts make a positive difference to their team members, clients and patients. A feeling of being insufficiently rewarded for effort is compounded when employees feel devalued, are treated as a commodity and not an individual, and believe that they can’t ask for help.
4. Lack of a Supportive Community: Social support is the “understanding and encouragement received from others during stressful times.”2 Support during times of anxiety by people who are undergoing the same stressors is an important coping mechanism. When the entire veterinary hospital is stressed due to workforce shortages, poor culture and organizational inefficiencies, it can be hard for employees to support each other. ‘Companionate love,’ defined as the degree of “affection, caring and compassion that employees feel and express toward one another”11 is critical in lessening feelings of anxiety in the workplace. When companionate love is expressed, employees feel more supported, less judged and emotionally safe.
5. Lack of Fairness: A lack of perceived fairness is a by-product of organizational culture. It occurs when there is a mismatch between the personal and professional values of the employee and the veterinary facility. The value of a healthy workplace culture is often overlooked in veterinary hospitals, yet the author believes it is the single largest determinant of hospital success, influencing all aspects of hospital operations. Leadership can contribute unknowingly to workplace burnout by not ensuring that policies and procedures are equitably enforced for all employees, without any perceived favoritism due to an employee’s personal circumstances.
6. Mismatched Values and Skills: Burnout can occur when an individual is constrained by a job description, and unable to focus on the work that they find most meaningful. An example would be the credentialed technician that has a passion for ensuring that surgeries and dental procedures are delivered in a seamless, efficient, safe and low-stress manner. They find meaning in this work and yet are required to spend time in examination rooms assisting the veterinarian, because of hospital policies. Studies in human medicine have found that physicians that focus at least 20% of their efforts on work that is meaningful to them are at a significantly reduced risk of becoming burned out.8
In addition to the six main causes of workplace burnout, there are some additional factors that contribute to burn out in veterinary hospitals: chaotic work environments, production-based pay, feminization of the veterinary profession, client economic limitations, unique challenges facing veterinary technicians, and possibly the corporatization of veterinary medicine.
7. Chaotic Work Environments: Chaotic work environments are those that “on the organizational level represent a mismatch between needed systems and provided systems.”12 Chaotic veterinary hospitals are those in which employees have a low level of control over their work, and teamwork and professionalism are low, if not absent. Inefficient processes create blockages that disrupt patient flow, as seen when clients have prolonged wait times during check in or out, when picking up medications, and when calling for service. There is a higher rate of errors, including medical and billing mistakes. Adherence to preventive care recommendations is low because chaos limits or prevents client education.
8. Production-Based Pay: Production-based pay in human medicine has been associated with increased physician burnout6. To increase productivity, individual doctors must spend less time with clients so they can see more cases, order more diagnostics and perform more procedures, or work longer hours. Consequences of the first two behaviors include increased cost and decreased care while the third, working longer hours, increases the risk of burnout. Production-based pay creates an inducement to ‘overwork’, especially when recently graduated veterinarians are faced with overwhelming educational debt.
9. Feminization of the Veterinary Profession: The feminization of the veterinary profession brings with it the increased risk of burnout. In human medicine, it is found that work-life integration presents a large challenge for married female physicians with children, who on average “spent over 100 extra minutes per day on childcare and household activities when compared to their male counterparts, even when adjusting for work hours.”14 Studies3 evaluating work-home conflict in the veterinary profession have found veterinarians score more poorly in this category when compared to other professions. Further complicating this concern is that, as small businesses, there is often a lack of parental leave and support in most veterinary hospitals for working parents.
Other factors associated with higher rates of burnout include age, with younger professionals of both sexes being at a higher risk for burnout.6,15 When children younger than 21 lived at home, there was a 54% increase in burnout in human doctors.6
10. Client Financial Limitations: Client financial limitations are a primary contributor to burnout in the veterinary profession. In one study, “77% of respondents reported that the economic limitations of clients were either a moderate or primary contributor to their level of professional burnout.”16 During the pandemic, “72% of small animal emergency hospitals reported that clients had more financial limitations”17 than previously noted. This is yet another factor that contributed to increased veterinary team burnout during the pandemic.
11. Burnout in Veterinary Technicians: There are many reasons for the high rate of burnout in veterinary technicians. The first is gender; in one study18 94% of the veterinary technician respondents were women. Being female has been associated as a risk factor for burnout syndrome.
A unique contributor to technician burnout is the “lack of societal awareness of the key role of the veterinary technician in animal care” as well as the devaluation of the professional nature of the role in the workplace, resulting in the “lack of an established professional identity with clear boundaries.” We need to look no further than responsibilities that cast technicians into a variety of roles, such as animal restrainer and as a janitor, to understand the confusion experienced by this valuable team member.
12. Corporatization of Veterinary Medicine: It is possible that a final contributor to veterinary burnout could be the corporatization of veterinary medicine. In human medicine, there is a positive association between small, independent practices and lower rates of burnout19. One likely explanation is that when physicians retain clinical decision-making autonomy and workplace control there are higher levels of job satisfaction, which buffers feelings of burnout.
Remedying the Root Causes of Burnout
As stated before and illustrated by its causes, burnout is a work-related problem, created by the workplace. Until positive changes take place in the workplace, burnout will be unmanaged and continue to wreak its insidious and destructive behaviors.
The antidote to burnout is engagement. Engaged employees find purpose and meaning in their work, are energized and derive personal satisfaction in their workplace contributions. They are deeply committed to their organizations and co-workers. Workplace modifications that result in better employee engagement and less burnout include the following six strategies20: workload, reward, control, fairness, community and value alignment.
- Workload: When people are engaged and feel supported, “they do more work — and that work is significantly less stressful on their overall health and wellbeing. In other words, it’s not just the number of hours you work; it’s how you’re managed and how you experience work during those hours.”9 Excessive workload is largely an organizational problem, worsened by inefficiencies and administrative tasks.
Some strategies that can be implemented to lessen excessive workload include:
**Lessening Medical Record Inefficiencies: In human studies, for every hour that inpatient physicians spend with clients, they spend two hours updating medical records, filling prescriptions and communicating treatment plans.21 Medical record inefficiencies can be lessened by the use of dedicated exam room scribes or voice-to-text tools, the use of electronic medical records and using standardized examination templates created within the practice management software systems.
**Using a team-based model of care: When team members are leveraged to work at the ‘top of their license’, it helps to share the workload. When the right work is done by the right team member at the right time efficiency is improved, as well as team member engagement. One way to help relieve stress and workload for veterinary technicians and assistants is to stop the practice of using them as janitorial staff and hire an outside cleaning service. The cost savings to the hospital is significant in two ways: it reduces overtime hours paid when the staff needs to clean at the end of the day, and by treating our technicians and assistants as the professionals they are, helping to create a professional identity.
**Block appointments in the schedule to accommodate ill or injured animals: Chaos fueled by inefficiencies further impacts workplace processes. Some ways to reduce the ‘out of control’ appointments that are prevalent in veterinary hospitals include blocking appointments in the schedule to accommodate ill or injured animals. These appointments should be booked the same day they are available to ensure they are reserved for needy patients. Another option is to have extra capacity built into your schedule. This might be in the form of a part-time or relief doctor that only sees urgent care appointments. Finally, there should be a clearly defined policy for owners who call toward the end of the day for care. Can your team realistically provide thoughtful service to them, after working all day? Is it fair to the client, patient and team members to expect them to stay late to service these emergencies? At what point is your front desk team empowered to refer clients to emergency hospitals for care?
2. Reward: Production-based pay creates an inducement to ‘overwork’ and is associated with higher levels of burnout when physicians are compensated on their production, rather than on salary. When veterinarians are compensated on production, there is increased competition among veterinarians for more medically challenging appointments that result in larger financial transactions. Veterinarians ‘case hoard’ and are hesitant to allow other doctors to co-manage cases due to lost income. Technological advances allow veterinarians to access patient medical records and diagnostic results remotely, resulting in a cohort of veterinarians that never really ‘disconnect’ and manage cases while on days off. Many veterinarians are hesitant to take vacation, as they are not earning compensation if they aren’t working.
Production-based pay has a negative impact on workplace culture, as it creates an underlying environment of competition, rather than collaboration. Because it is transactional in nature, it has a negative impact on teamwork. Why should a veterinarian compensated on production invest in training team members or in community outreach? There are costly ramifications to the doctor when doing anything that distracts from profit-based work. The result is a perfect recipe for burnout in veterinarians.
An alternative is to create a “Salary + Merit-Based Bonus”22 Compensation structure. There are two components to this plan: a sustainable, livable salary and a merit-based bonus. The merit-based bonus involves engaging employees in the process, rather than dictating a bonus plan to them. It creates a mechanism for veterinarians to earn additional income while growing new competencies and finding new passions. Because veterinarians can tailor their workload to meaningful work within the merit-based bonus structure, it increases engagement and lessens burnout. It allows veterinarians to have an active role in shaping their personal and professional fulfillment.
The merit-based bonus structure can also be used with non-veterinary team members as a quarterly bonus system. Think about how each of your team members and your hospital could benefit by picking, designing and completing a goal that is meaningful to them. It provides a way for veterinary team members to earn additional rewards such as money or time off while positively contributing to the workplace. With the rates of burnout and turnover in our profession, we need to create a path toward better engagement, and offering our teams pathways to professional and personal improvement is a great start! For more information on how to design and implement this alternative to production-based pay, please watch the webinar “A Prescription for Change”13 located in the ASPCA Pet Health Insurance Veterinary Resource Center.
A factor in reward-based burnout is the failure to appropriately develop and compensate veterinary team members with varying levels of experience. Too often, pay is predicated by the length of time an employee has worked at the veterinary facility, not by skill level. This practice creates challenges and conflicts when hiring new employees with higher skill and experience levels, who should be earning a higher salary.
One way to build an equitable reward-based system is to create different position-specific mastery levels. For example, if technicians within a hospital are designated as level 1, level 2 and level 3, with clearly outlined differences in skill and responsibility, compensation can be aligned appropriately within the levels. Each technician has a clear understanding of the skills that need to be mastered to reach the next level, which creates transparency to advancement, as well as pathways for continued growth and accomplishment within the same position. It allows employees to be appropriately compensated based on their proficiency, removing the artificial barrier of employment tenure. Most importantly, it creates a learning culture, which encourages and rewards the acquisition of new skills, knowledge and the opportunity to teach, via mentorship, less experienced team members. These benefits: engagement, learning new skills and receiving rewards are all proven strategies to decrease burnout.
Showing appreciation is a behavior that helps employees to feel rewarded. This is not the same as recognition, which is often a top-down reward; appreciation is expressed equally by coworkers, leaders and clients. When expressed, it helps individuals to feel valued and that their efforts in the workplace make a difference. Appreciation can be expressed in a variety of ways: verbally, through statements like “great job” or “thank you”, non-verbally through winks, smiles, high fives, pats on the back and fist bumps, or through tangible methods, such as written appreciation expressed by clients on review forms and thank you cards, homemade baked goods, flowers, and by the pictures of their pets that clients give to trusted team members.
- Control: To be worth living, life needs to have meaning. Because veterinary professionals spend so much time at work a large part of this psychological need will be fulfilled through what their tasks are, and how they do them. Being able to perform work with autonomy, which fulfills the basic psychological desire to have control of work, leads to a sense of satisfaction and creates meaningfulness. The loss of control and autonomy has been identified as one of the factors most closely associated with burnout in physicians14.
A basic way to provide autonomy in veterinary medicine is to create more options in how we work. Consider changes in work schedules that allow for part-time work, and job or task sharing. Compressing work schedules allow employees to work fewer, but longer, shifts with more time off. Some veterinary team members, especially those with families, could benefit from more frequent, shorter shifts that align with school schedules. It is time to challenge the notion of ‘cookie cutter’, stagnant schedules and create flexibility around employees’ needs. Consider creating flex time which would allow employees to work extra hours, as dictated by hospital needs, and ‘bank’ them for extended vacations or personal leave. This is a unique way to incentivize employees to provide coverage for the unexpected absences of other teammates.
Another option to provide autonomy is to ‘job craft’. In veterinary medicine, we hire employees for positions. Too often, we are rigid in the roles they fill and don’t allow them to spend their time doing what motivates them, within the broader job description. Job crafting is an individually driven approach to transform jobs from prescribed, inflexible roles and responsibilities into the jobs the employee wants. By looking for ways to make different contributions in their role, employees can make their presence within the hospital feel more meaningful. Outcomes of job crafting include improved well-being, collaboration, productivity and more organizational loyalty23. Job crafting is a bottom-up approach, and to be successful it must be supported by hospital leadership.
- Fairness: An important driver of employee burnout is a perceived lack of fairness in the workplace. Ways to promote fairness in the veterinary facility revolve around communication and transparency.
Clear communication is essential in creating a feeling of fairness. Examples of effective and transparent communication include clearly stated policies and procedures that help to create consistency in hospital operations. These include how clients receive preventive care education, what preventive services should be offered at each life stage, surgery and anesthesia protocols, and diagnostic testing procedures. Client management expectations should be addressed, such as how clients are treated, how to de-escalate an interaction with an unhappy client and adherence to payment policies. There should be a well-defined process for employee scheduling, requesting time off and an unambiguous path to career development and advancement.
When creating these guidelines, it is critical that all employees have a voice in processes that impact how they do their work. Top-down directives that fail to clearly explain how and why the decision was made can lead to a perception of unfairness. Inconsistency in adhering to and applying the policies and procedures are seen an unjust, creating a lack of organizational trust.
How we communicate is important in fostering a sense of fairness. Leaders should practice active listening in the workplace to identify signs of stress, at both the organizational and individual level. Tools to facilitate listening opportunities include team huddles, focused not on workflow but on how people are feeling. The emotions that people bring to work and display at work are impactful on the entire team. It is worth actively listening to the feelings expressed in these huddles, because they are contagious. Remember the role of empathy in conversations with your team; research has found that “communicating empathetically increases job satisfaction, reduces burnout and is highly correlated with enhanced well-being.”1
- Community: It is not uncommon to see job ads for veterinary team positions that start with ‘join our family’ or that describe the work environment as ‘one big family’. Given that most people spend around 30% of their waking hours at work24, being part of a healthy work community helps reduce the risk of burnout.
“Community” is defined as “a feeling of fellowship with others, as a result of sharing common attitudes, interests, and goals.”25 To build this emotion among coworkers, leaders need to create opportunities for employees to interact in meaningful ways. Due to the focused and fast-paced nature of veterinary care, activities to build community must be built into work schedules. What are some ways to do this?
In veterinary medicine, a lack of professional identity and depersonalization are contributing factors to veterinary technician burnout.18 In human medicine, it has been found that when peer groups within hospitals had twice monthly meals together, they built stronger social connections, developed healthy professional identities and experienced less depersonalization.
These meals should be scheduled and treated as ‘protected’ time. In deference to personal life boundaries, the meals and associated activities should take place during working hours. The veterinary hospital should pay for the employee’s time and meals, as these are ‘working’ events.
During these events, there should be guided activities that help the group to establish connections. These activities can include exercises where trust is built by learning about their co-workers’ individual values and beliefs. Group resilience practices such as mindfulness, stress management managed by deep breathing exercises, and physical activity like a group walk facilitate a sense of comradery. It has been found that expressing gratitude to co-workers helps to “build patience, perseverance and social bonds.”26 Use these meals to form gratitude groups where participants share what they are grateful for, both at work and outside of work. It is helpful for peers to discuss topics related to their professional experiences and what is meaningful in their work.
Other ways to build community include social events during the workday, such as ice cream and coffee breaks at work, paired with a short team huddle where team members complement each other on tasks well done or express what they like about working with their team members. These huddles could also focus on what is going well in the hospital. Called ‘positive rounds’, they have been found to promote teamwork and a culture of feeling safe.19
- Value Alignment: We all have a need to find purpose in our lives, and to feel appreciated for the work we do.
Some ways to foster this within veterinary hospitals include:
**Align employees’ work to what motivates them. Remember the statistic that I shared earlier in this webinar with you? Physicians that spent more than 20% of their time doing the work that was most meaningful to them experienced lower rates of burnout. Work with your employees to identify ‘what motivates them’ and arrange their work responsibilities around those interests. One way to know what motivates your employees is to observe what tasks they are doing when they seem most engaged and happiest. You can ask them what tasks are easier for them to do, and which ones they dread or delay doing. For those who are demotivated to perform, how can those responsibilities be shifted within the workforce so that each employee has work that aligns with their purpose?
**What are your hospital’s values and how do you know? The values of the hospital are often a reflection of the beliefs of the team members. It is important to collectively define what core values are important at an organizational level. To identify these, ask your employees to describe the personality of the hospital in 3 words. If there are words that are similar, such as ‘educate’/‘education’/’educator’, group those together. Present all of the words to the team and ask them to select the top 4-6 words that they collectively agree best match the beliefs of the hospital at an organizational level. These are the organizational core values, the guiding principles that dictate how decisions are made and people and pets treated.
Another way to identify hospital values is to ask your team “How is what we are doing helping people, pets, and making the world better?” Listen carefully to responses and identify the core values that support the team’s statements.
To help each individual to understand if they have alignment with the organizational values, each team member should define their personal core values. This is accomplished by providing a list of values to each employee with directions to pick the 3-5 words that they feel best describe their personal beliefs and values. Once each employee understands what is important to them, they can compare them to the hospital core values and check for compatibility.
**Do your hospital’s values align with the organization’s actions and work environment? One way to assess if your practice is staying true to its ideals is to look for the core values in action. Pick a core value at the beginning of each week; at the beginning of the next week, ask team members how they saw this core value brought to life. This has an additional benefit, in that it is an expression of gratitude and appreciation to the team member who was seen to live the value.
For example, if a core value is compassion, an employee might say “Jessica lived this core value last week. Mrs. Smith received horrible news about Fluffy’s prognosis, and Jessica was kind, compassionate and supportive as she helped Mrs. Smith absorb this unexpected and sad news. She even helped Mrs. Smith to her car after the appointment.”
Client surveys can provide insight into what’s going well and what could be better. Look for ways the clients’ comments align, and misalign, with the hospital’s stated values.
Conclusion
Burnout is a devastating organizational hazard. It has negative impacts on hospital relationships with clients, patient care, sustainability of the veterinary profession and most importantly, on the individuals that experience burnout.
Hospital leaders must recognize and address burnout as an organizational problem, rather than an individual’s problem indicating a need or individual action. A workforce with minimal burnout and maximal professional fulfillment is a goal worth working towards. It starts by choosing one idea from this article and acting on it, then choosing another. Big change happens with small, incremental steps; start the journey today.
Wendy Hauser, DVM is the founder of Peak Veterinary Consulting and has practiced for 30+ years as an associate, practice owner and relief veterinarian. She is highly engaged in AAHA leadership having served as a member of the Board of Directors, as the Board Vice-President and currently serves as the AAHA Delegate to the AVMA House of Delegates. Dr. Hauser, passionate about education and innovation, is a regular presenter at veterinary conferences, facilitating workshops on hospital culture, associate development, leadership, client relations and operations. Frequently published, she is the co-author of “The Veterinarian’s Guide to Healthy Pet Plans.”
Reprinted with permission from ASPCA Pet Health Insurance.
Don’t miss Dr. Hauser’s webinar on Tuesday, Dec. 7 at 12pm, “Communicating the Cost of Care With Your Client.”
References