Commentary

By Rochelle Furtado & Hana Marmura 

Due to an increasingly demanding health care system with higher expectations, health care professionals such as rehabilitation therapists (physical, occupational, speech and language), are at a higher risk of burnout than most careers (2). Burnout has been recognized by the World Health Organization (1) as an occupational hazard occurring when workplace stress is not appropriately managed. Burnout has been attributed to communication problems, low work engagement, low-quality patient care, and disruptive behaviour (2). Many clinicians, including newer graduates, do not have adequate training or resources to recognize the warning signs. They continue to push through symptoms which can negatively impact their health and careers in the long run (2).

Despite having less clinical exposure time, younger therapists face higher risks of burnout. Beyond the pandemic, younger therapists face an increased workload, time pressures and a need to establish a reputation (3). In a recent study by Rogan et al. (3), age was correlated negatively with burnout in physiotherapists. Senior physiotherapists (over age 40) were less likely to be affected by burnout, compared to their younger colleagues. The study findings reported that older generations have learnt to handle issues encountered at the onset of their careers, whereas younger therapists were shown to have higher expectations of their physical performance at work, causing rapid emotional exhaustion (3). Emotional exhaustion is the inability to cope at a psychological level (13), which can trigger emotional overload in younger therapists (3). Despite emotional exhaustion being one of the hallmark signs of burnout (13), it is often missed and may be simply thought of as “part of the job”. Negative consequences of emotional exhaustion include tension, lack of concentration and insomnia, which can affect a therapist’s practice (3). Therapists often overestimate their awareness of burnout, as there continues to be a lack of training, research, and resources for physiotherapists (3,13). Further, there is a clear gap in explicitly incorporating any strategies to prevent burnout in recent graduates from employers or institutions (13). This commentary has summarized three potential approaches to reduce burnout in new physiotherapy graduates, based on the available literature: 1) increasing self-awareness and reflection as a clinician, 2) professional development post-graduation, and 3) clinical mentorship.

Self-awareness and Self-reflection

Self-awareness is one way to recognize emotional exhaustion and prevent burnout. However, early career therapists may often feel overwhelmed by financial, work and/or personal stresses post-graduation, which prevents intentional practices of self-awareness. Identifying stressors can help integrate context into the emotions a therapist may be feeling, and link the stressor and/or emotion to cursory signs of burnout. Therapists who are self-aware will be more likely to monitor and recognize warning signs of burnout than those who do not. Signs of burnout include: emotional exhaustion, addiction to work, onset of depression or anxiety, insomnia, and difficulty separating work from personal life (11). Awareness of these symptoms can help clinicians reach out and seek support from a colleague, employer, mentor, or companion (3,4,13). Other preventative/management strategies may include taking a break or reducing the current workload (11). It is important to remember that working as a therapist is a marathon, not a sprint to the finish line.

Self-reflection is another important tool for clinicians when managing burnout. Self-reflection means having the ability to witness your own cognitive, emotional, and behavioural processes. According to a study by Pustułka-Piwnik and colleagues (5), newer graduates tend to face burnout because of the difficulties that arise when trying to satisfy all patient needs. Often, novice therapists struggle with the thought of not knowing all the answers to patients’ questions. This leads to negative views of their capabilities and an increase in mental fatigue. It is important for novice therapists to understand when another clinical referral may be needed to provide patients with optimal care. This is helpful for mitigating feelings of inadequacy and associated emotional exhaustion.

Complex clinical cases are a great opportunity to use self-reflection as a method to reduce the risk of burnout. Further, reflecting on a negative, stressful, or overwhelming clinical occurrence, as it is happening, can help prevent the accumulation of stress and exhaustion. This accumulation from many small incidents tends to culminate in burnout. Reflection can be done in a step by step process involving (8):

1.  Thinking about the situation itself, how it made you feel and why it happened.
2. Reflecting on what could have been done differently in the moment and then in the future. Formulate future action plans for a similar situation based on your reflection of how things could have gone differently. Steps 1 and 2 can be done by writing in a personal journal during your next break or at the end of the day.
3. Chatting with a colleague or friend about the experience. This can be about anything you shared in your journal or just overall thoughts from this experience.
4. Integrate your reflections and future action plan in your next clinical encounter if a similar situation occurs. This allows you to test the hypothesis that your future action plan will yield a better outcome. This integration and real-time problem solving can increase comfort with and prevent similar situations in the future (8).

Resources: The University of Edinburgh has a toolkit for reflection, including toolkits specific to “reflecting for self-awareness” (https://www.ed.ac.uk/reflection/reflectors-toolkit/self-awareness), “reflecting on experience” (http://www.ed.ac.uk/reflection/reflectors-toolkit/reflecting-on-experience), and others. These tools are useful for novice clinicians looking to enhance their reflection skills within their career.

Professional development post-graduation

In Canada, the education process to become a therapist is generally a two-year program at an academic institution. Despite completing these two years, novice clinicians can still feel overwhelmed with a full case load of complex patients. Novice clinicians are continuously failing, learning, and adapting as they familiarize themselves with new cases, diagnoses, and treatments every day. This constant cycle can lead to emotional exhaustion, and feelings of being overwhelmed or ill-equipped for the profession. One way to reduce these feelings, is by enrolling in professional development which can widen a therapist’s tool box and list of competencies. Continued professional development has become a keystone and requirement of many rehabilitation professions11. Professional development courses, workshops, etc. are opportunities to learn best practices and provide an environment to network and discuss experiences. The sense of belonging and learning with others is likely to have positive effects on mood, sense of competence, and willingness to reach out for help in the future11. For example, a study by Khan and colleagues10 found that within university professors/academics in Pakistan, having post-graduate professional development lead to lower levels of burnout symptoms, including emotional exhaustion and disengagement10. Using the practice of self-reflection outlined previously in this article, isolating areas where therapists feel their knowledge or skills could be improved, and targeting professional development to these areas can help prevent the accumulation of emotional exhaustion. Some steps to choose the right course(s) are: 1. Self-reflect in a journal or with a mentor what areas of practice you seem to need more confidence in, i.e. a new technique, treatment, certification or professional/leadership skill. 2. Once you have chosen an area, look to your professional bodies or speak with a senior therapist on the professional courses available to you. 3. When filtering through courses, it is important to assess the benefits, current work environment, and your individual professional toolbox. 4. Set realistic timelines when choosing a course. While it can be easy to fill your schedule with all possible courses, it is important to start small and pick one or two courses to make sure you can balance responsibilities at home, work and personal life.

Resources: A great place to start looking for courses can be your professional association. Most courses or webinars are at discounted rates for recent graduates, so it is easy to take advantage of the pricing benefits. For example, the Canadian Physiotherapy Association has a network of areas to choose from.

Canadian Physiotherapy Association Professional Development Resources
Canadian Physiotherapy Association	https://physiotherapy.ca/events
Leadership Division	https://physiotherapy.ca/divisions/leadership-professional-development
Animal Rehab DivisionCanine Equine	https://physiotherapy.ca/animal-rehab-division/professional-development-canine https://physiotherapy.ca/sub-sub-division-page
Cardiorespiratory Division	https://physiotherapy.ca/divisions/cardiorespiratory-professional-development
Global Health Division	https://physiotherapy.ca/global-health-division/professional-development
Neuroscience Division	https://nsdphysio.ca/category/webinar/
Oncology Division	https://physiotherapy.ca/divisions/oncology-physiotherapy-professional-development
Orthopaedic Division	https://www.orthodiv.org/education/upcoming-courses/
Private Practice Division	https://cpaprivatepractice.ca/webinars/
Sport Physiotherapy Division	https://www.sportphysio.ca/sportphysiou/

Clinical mentorship

A key component in preventing burnout and feeling understood is reaching out for help and guidance from other therapists, otherwise referred to as clinical mentorship. Mentorship can be formal or informal, with the main goal of passing information from the more to less experienced within a field. Previous research has reported the benefits of a strong mentor and mentee relationship, as it enhances skills and confidence, reduces isolation, and provides guidance to manage work-related stress (6). As young graduates build and navigate their relationships with strong mentors, they can develop a deeper insight into their clinical practice and professional identity. A qualitative study by Roe-Shaw and colleagues (12), highlighted the importance of a strong mentor relationship within the workplace. The results show that the level of support provided by a mentor directly correlates with the motivation level of the young therapist. Conversely, they found that the lack of a mentor resulted in graduates having no feedback or supervision, which left mentees feeling like they were “thrown in the deep end” and “having to sink or swim” (6).

Finding an appropriate mentor can be challenging immediately after graduation (7). Recommendations for finding a mentor include approaching a senior therapist in your current practice, a past professor, or reaching out to your college for local programs that match mentors with mentees (7). For example, the Canadian Physiotherapy Association hosts events within their organization for younger therapists to mingle with senior therapists. These events are aimed for novice clinicians to find a mentor and help them network among different colleagues within the profession.

Resources: Checking with your professional bodies’ websites for events or using platforms like LinkedIn or Twitter can be a way to reach out to senior therapists with similar interests.

Complex clinical cases are a great opportunity to use self-reflection as a method to reduce the risk of burnout!

Clinicians will be regularly challenged by the pressures of clients’ cases and their overall workload. Burnout is an occupational hazard that clinicians need to be more aware of, including its definition, signs and symptoms, and strategies to prevent and mitigate effects. Strategies such as self-awareness, self-reflection, continued professional development, and mentorship can provide clinicians with the confidence, knowledge, and self-efficacy to have long and successful careers. We hope this commentary provides a starting point for novice clinicians in recognizing and counteracting burnout in the workplace.

Acknowledgements

Featured illustration by Amy Zhu for rehabINK.

To refer to this article, it can be cited as: 

Furtado R, Marmura H. From Student to Therapists- Is the Burnout Inevitable? rehabINK. 2022:12. Available from: https://rehabinkmag.com

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References

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