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Rapid review summary

Background

Staff burnout in aged care was deemed a priority topic for the sector during discussions between ARIIA and the Aged Care Quality and Safety Commission. People with work-related burnout may experience overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense that they are ineffective and lack competence in performing their role. [1] Other symptoms associated with burnout include depressed mood, guilt, muscle pain, and poor sleep quality. [2] Burnout is also described as an imbalance between the demands of the job and the resources required to meet those demands. [3] Multiple factors may contribute to creating this imbalance: 

  • Excessive workloads  
  • A sense of being under-staffed or under-resourced to perform tasks 
  • Feeling unrecognised and unrewarded 
  • A lack of sense of community with colleagues and managers  
  • Perceiving the workplace as unfair or being asked to act against personal values or ethical principles   
  • Compassion fatigue (long-term exposure to the trauma of others).  [4, 5] 

In developing content for the Knowledge and Implementation Hub on this issue, the Knowledge and Implementation Hub team conducted a rapid scoping review to determine what is known from the existing research literature about staff burnout in the aged care context, both before and since the onset of the COVID-19 pandemic. The following is a summary of the methods and findings of this scoping review. A full report will be published in the formal journal literature.

Methods

We searched for relevant research using the databases Medline (Ovid), APA PsycINFO, Scopus, and CINAHL (EBSCOhost). We used a broad strategy involving two concepts: burnout and related issues AND aged care settings. Searches were executed on 8 November 2022. The search strategy for Medline (Ovid) is provided in a separate PDF document below.

Studies were eligible for inclusion if they:

  • Investigated the impact of burnout on aged care staff (home care and residential aged care) 
  • Reported findings from settings in countries with developed long-term care systems for older people, as defined by Dyer et al. [6]  
  • Measured staff burnout or explored individuals’ experiences of staff burnout  
  • Were published between 2012 and 2022 in a peer-reviewed English language journal 
  • Reported findings from primary research or a review of primary research.

Studies were excluded if they:

  • Reported work-related issues such as occupational stress, intention to leave, or mental health outcomes, without reporting an association with staff burnout or one of its domains 
  • Reported staff in multiple workplace settings where it was not possible to identify the specific results for the aged care sector workforce 
  • Were pilot studies, feasibility studies, study or review protocols, tool validation studies, dissertations, magazines, conference papers or posters, editorials, commentaries, or case studies 
  • Were published in a non-English language, or before 2012.

Results

From 1308 retrieved citations, 147 reports met the eligibility criteria. Most described cross-sectional studies (n=83) and research conducted in the residential aged care setting (n=134), also referred to as nursing homes, long-term care, retirement homes, elderly care facilities and care homes for the elderly. Only nine studies were controlled trials of interventions. Studies focused largely on staff burnout among nurses (n=41), and personal care workers (n=56), with 31 studies including both groups. Other groups investigated for burnout include administrators/managers and allied health professionals.

Many studies used the Maslach Burnout Inventory, considered the gold standard tool for assessing staff burnout, [7] which measures three components of the syndrome: emotional exhaustion, depersonalisation, and reduced personal accomplishment. [1] Other tools for measuring burnout include additional components such as depression, guilt, muscle pain, poor sleep quality, and cognitive weariness. [2]

Studies focused on different parameters of staff burnout, including prevalence; potential causes or predictors; consequences for the worker, residents/clients and their families, and the organisation; protective personal/interpersonal and organisational factors; effectiveness of interventions; and the impact of the COVID-19 pandemic on workforce burnout. This report uses these categories to provide a summary of the review’s findings.

The international research evidence reports varying rates of staff burnout across the aged care sector prior to the COVID-19 pandemic. These range from low to moderate [8, 9] and moderate to high levels of burnout in aged care settings [10, 11] with approximately 30-50% of staff providing direct care reportedly affected. [12-15] Before the 2020 pandemic hit the sector hard, this rate was also shown to be gradually increasing. [9, 10] Younger care workers appear to be more susceptible to burnout. [16] However, those who have been working longer in aged care also show high rates of burnout. [17, 18]

Staff burnout is a complex occupational phenomenon that appears to have interrelated personal, interpersonal, and organisational dimensions. While many of the studies identified in this review could only suggest potential causes of burnout, workplace stress and how a person responds to it appear to be important risk factors.

Personal factors 

Some factors associated with burnout reflect the worker’s personal circumstances. For example, people with high levels of burnout tend to:  

  • Speak English as a second language [8, 19] 
  • Have personal health issues, including musculoskeletal pain or mental health concerns [19, 20] 
  • Experience poor sleep quality. [21] 

How the individual reacts to workplace issues can also influence their level of stress and the potential to experience burnout. Significant risk factors of this kind include: 

  • Feeling moral distress at witnessing situations, or being required to work in ways, that clash with personal values and ethics [22-25] 
  • Experiencing unresolved grief when a client/resident dies [26-31] 
  • Relying on dysfunctional or avoidance coping strategies under pressure. [21, 28, 32, 33] 

Interpersonal factors

The relationships between staff and residents/clients, their friends and family members, [28, 31, 34] and with managers and co-workers [33, 35, 36] can contribute to stress and lead to burnout. Staff who develop close relationships with the people they care for may experience strong grief at their death which can impact their mental health if dismissed as trivial by management and co-workers. [37]

Staff who provide care to people living with dementia are reported to experience burnout when they feel they lack the training and skills to deal with responsive behaviours or experience distress at not being able to communicate with those in their care. Witnessing continued deterioration can also contribute to feelings of stress.  [19, 28, 31, 38-40]

Staff also report stress at being unable to discuss changing goals of care with a person’s family and/or friends as the end of life approached. [29] Verbal or even physical abuse from residents, their family or friends can also cause distress and lead to burnout symptoms. [26, 41-44]

Lacking a sense of team or feeling isolated from colleagues through lack of contact and information sharing are further risk factors for staff burnout. [31, 33] Management can contribute to staff stress and burnout by not recognising and rewarding their work [35, 36] or by being highly controlling and not allowing them to exercise decision-making or voice concerns over working conditions and client care quality. [17, 45-47]

Organisational factors 

How care delivery is structured at the organisational or facility level can put staff at risk of burnout. Frequently reported sources of risk in aged care workplaces include:

  • Workloads that staff perceive as heavy [33, 36, 48] 
  • Long working hours [32, 33, 35, 36] 
  • Time pressures, [11, 13, 36, 49-51] especially when they interfere with providing person-centred care [33] 
  • Not having adequate material resources to do the job well [17] 
  • Sense of job insecurity [36, 52] 
  • A sense that one has not received adequate training for the job [22, 33, 35, 50] 
  • Inadequate staff mix leading to working outside one’s scope of practice [50] 
  • Lack of belief in the quality of care provided by the organisation. [53, 54]  

For the worker, burnout reduces their level of job satisfaction [15, 25, 46, 47, 55-60] and work-life balance, [61-63] leading potentially to an intention to leave the organisation. [64-72] Burnout has been linked to longer-term chronic conditions such as coronary heart disease and type 2 diabetes [73] and may impact staff mental health and wellbeing, leading to depression and anxiety. [9, 74] When staff feel stressed, they are also more prone to errors in decision making and task performance. [75-77]

Burnout reduces organisational productivity through staff absenteeism [12, 33, 78] and may lead to high rates of workforce turnover. [66] It also has serious implications for quality of care [25] with staff affected reporting that they are less patient-centred in their approach [79] and more likely to delay or miss providing some essential care tasks altogether. [14, 15, 80, 81] Staff with burnout may demonstrate more hostile behaviour [82] or become abusive towards those in their care. [83]

Research studies on burnout suggest a range of actions that organisations might undertake to protect their staff from burnout. Many of these focus on reducing workload and increasing resources for staff to feel they have provided a high quality of care. They suggest: 

  • Assessing and reducing levels of work stress [84]
  • Providing appropriate levels of material resources [52, 85]
  • Creating flexible work schedules that work in well with people’s non-work responsibilities [86]
  • Enabling staff to spend enough time with care recipients to perceive they have provided good care [33, 84]
  • Facilitating rather than giving lip service to person-centred care practices [87]
  • Fostering a strong sense of team by providing staff with opportunities to engage with co-workers. [17, 45, 60, 68, 88]

Other actions involve increasing the individual worker’s sense of confidence and competence in their role. These actions include:  

  • Providing adequate job training opportunities [17, 83, 85]
  • Authorising staff to make decisions [89]
  • Creating work roles with enough complexity to provide challenge and enhance their sense of professional accomplishment [28]
  • Acknowledging and rewarding the hard work of staff [17, 45, 46, 49, 60, 84, 85, 88-91]
  • Providing staff with a voice to express concerns about care quality. [92]

Research indicates working conditions for aged care staff working in residential facilities deteriorated at the onset of the global COVID-19 pandemic. [93, 94] New occupational stresses were added to existing ones with staff, including facility managers, required to work longer hours to cover for staff shortages due to illness or self-isolation. [95-98] New and challenging tasks were introduced to protect residents such as wearing personal protective equipment (PPE) and routine disinfecting, screening for symptoms, and enforcing restrictions on visits to the facility from family and friends. [96, 99] Staff were also required to keep up with and adhere to new and constantly changing public health advice and regulations aimed specifically at the sector. [94, 96] Early in the pandemic, aged care managers struggled to acquire adequate quantities of PPE and cleaning supplies which added to the weight of responsibility they felt for staff and residents. [94, 95, 100] This led them to feel anxious and ‘burned out’. [93, 101] Staff also describe feeling distressed and emotionally exhausted from:

  • A constant fear of bringing the virus into their home or the facility [94, 97, 98, 100, 102, 103]
  • Seeing residents inactive, understimulated and isolated from their families and friends [95, 100-102]
  • Witnessing the confusion and distress of people with dementia who did not understand the changes [93, 102]
  • Having no time to provide person-centred care [93, 96]
  • Experiencing high rates of resident deaths and not having time to mourn this loss [96, 97]
  • Dealing with relative anger and distress [93, 97, 100, 102]
  • Being stigmatised by the media and coming under intense public scrutiny. [93, 94]

COVID-19 was also a catalyst for change for some aged care organisations. [95, 98] Staff were provided with additional training opportunities, [98, 100] increased communication from management, [95, 98, 100, 104] and gained more contact time with colleagues through an increase in meetings and social time spent together. [95, 97] Management-initiated support groups, meditation classes and quiet spaces may have also increased awareness of the importance of staff mental health and wellbeing and personal coping resources. [100, 104]

A variety of interventions to help prevent and address staff burnout are available. Most focus on staff providing care to people living with dementia [84, 105-111] and many measure staff burnout as a secondary, rather than primary outcome. This seems to imply that if care recipients are managed appropriately, staff will be less likely to experience burnout. Interventions that appear effective in reducing rates of staff burnout include self-efficacy [108] and self-care skills and compassion fatigue awareness training. [112] At the time of the COVID-19 pandemic, a web-based stress management programme focused on nurses’ work-related stress was found effective. [113]

Aged care providers have an obligation to provide safe workplaces for their staff. Burnout rates are particularly high in aged care settings and are likely to have worsened since the COVID pandemic, although the evidence of this is, to date, largely from qualitative studies. Organisations can make a raft of changes to improve staff mental health and wellbeing while simultaneously improving efficiency through reduced staff absenteeism and turnover. The evidence suggests that addressing burnout will also lead to improved care quality and better outcomes for residents and clients.

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