The Hidden Part of the Iceberg for Emergency Department Staff: The Burnout Syndrome

Stressed patients and relatives, risk of verbal and physical offensive, irregular working hours, poor physical conditions, pressure of responsibility and difficult decisions, noisy environment, stress of malpractice, risk of acquiring infectious diseases, and vast patient diversity are among the challenges emergency department staff have to cope with. Physicians, nurses, and other ancillary health staff who complete vocational training and begin working in emergency department can overcome all these difficulties after a certain adaptation process. In fact, these challenges are the hidden part of the iceberg for the emergency department staff. In my opinion, the real threat to emergency department staff is the burnout syndrome which we may call the hidden part of the iceberg, a condition that develops insidiously over years and affects both emergency department staff and patients who are served.

How much are we, the emergency department staff, aware of the great danger waiting for us?
Stressed patients and relatives, risk of verbal and physical offensive, irregular working hours, poor physical conditions, pressure of responsibility and difficult decisions, noisy environment, stress of malpractice, risk of acquiring infectious diseases, and vast patient diversity are among the challenges emergency department staff have to cope with. Physicians, nurses, and other ancillary health staff who complete vocational training and begin working in emergency department can overcome all these difficulties after a certain adaptation process. In fact, these challenges are the hidden part of the iceberg for the emergency department staff. In my opinion, the real threat to emergency department staff is the burnout syndrome which we may call the hidden part of the iceberg, a condition that develops insidiously over years and affects both emergency department staff and patients who are served.
Burnout syndrome is a process defining emotional, mental, and physical fatigue, which develops insidiously over time. Burnout term was first used by Freudenberg in 1975 [1][2][3]. Nowadays, it is a very common syndrome, particularly in those working environments with a high work-related stress and a constant high workload. Burnout could be defined as "a health care staff's perception of his job and patient care in emergency department as a burden" [4]. It is typically the last step of a process appearing with loss of vocational excitement, dissatisfaction, and a negative attitude towards patients calling for help. The symptoms appear in forties. Studies have demonstrated that burnout results in many serious problems in a broad spectrum comprising work loss, social problems, domestic relationship issues, cigarette, alcohol, and substance abuse, and even psychiatric diseases [5,6,7].

Is working in emergency department a factor increasing the risk for Burnout when compared with other hospital departments?
Emergency departments are the busiest and most stressful units in hospitals. Emergency department staff is under constant stress because of crowded working environment, the severity of patients given care, and working schedules designed as shifts. In addition to these factors, problems arising from professional relationships, inadequate hospital resources, dealing with patient relatives, unsafe working environment, and inability to spare some time to familial and social relations further escalate the stress [8]. Furthermore, services offered in emergency departments have an important difference from other services offered in other hospital facilities. This difference is that all operations and procedures related to patient care are in limelight and they all can be monitored by physicians from other departments and patient relatives. This poses further stress on health care workers [4]. Studies have shown that caring for an excess number of patients, patient deaths, worsening sleep pattern, and prolonged working hours are major risk factors for health care staff [9]. For all these reasons, burnout syndrome is common among emergency department staff. There are clinical studies in the literature indicating a higher burnout syndrome frequency in emergency department staff compared to other health care staff in the hospital [8,10,11].
Are negative working conditions in the working environment the sole determinants for burnout syndrome?
Working conditions at the workplace are not the only causative factor for burnout syndrome to develop. The characteristics of the staff as much as workplace conditions affect emergence of the burnout syndrome. The personality structure of health care staff has an important impact on the possibility of experiencing the burnout syndrome. Those who are perfectionist, idealist, competitive, contentious, uptight, censorious, impatient, or those keeping self-personal interests on top of everything, believing in external forces such as fortune and destiny ruling their lives, having expectations difficult to meet, and having difficulty in developing empathy with others are at increased risk for burnout [12,13]. Furthermore, it has been detected that females compared to males, singles compared to married ones, and those having no children compared to those having children experience more burnout syndrome [13,14,15]. In addition, facing stressful events in multiple areas such as working life, familial life, and social life and having a personality structure prone to experience stress facilitate development of burnout syndrome. In summary, even under same conditions it may be observed that some individuals get burnout but some not, owing to all these personal causes.

What are the symptoms of burnout syndrome?
Burnout syndrome is a slowly developing coil of symptoms. The person experiencing burnout generally lives the mess of vocational dissatisfaction and exhaustion. But symptoms are frequently ignored owing to the difficulty in expressing these emotions as well as the insidious development of the symptoms over months to years. Ignorance of the symptoms of the burnout syndrome causes it to progress and to become overwhelming. Therefore, it is of paramount importance to understand the process of burnout syndrome and to take necessary measures by a timely diagnosis. Burnout symptoms may be examined under three titles, namely the physical, emotional, and behavioral symptoms [16,17].
Physical symptoms manifest themselves firstly as mild symptoms such as tiredness and fatigue, headache, dizziness, and sleep disturbances. If no measures are taken, lingering common cold attacks, weight loss or obesity, generalized body aches and pains, gastrointestinal disorders, hypertension, high cholesterol, muscle spasms, and palpitations may ensue in the following process [1,2,14]. If these or similar disturbances are continuously complained, they should not be ignored and measures should be taken in a timely fashion as these symptoms may be harbinger of the burnout.
Emotional symptoms are less pronounced when compared to the other symptoms. They include a sense of restlessness and nervousness of unknown cause, impatience, a decrease in self-esteem, a sense of hostility against the society, vocational hopelessness, criticism of other people, apathy, an increase in familial problems, developing negative attitudes against life, groundless doubts and paranoia, depression, and helplessness. These symptoms typically show themselves as an intention to quit the job and unwilling to go to the job [1,2,5,14].
Behavioral symptoms are the symptoms which are easier to observe by others. They may appear as general reactions such as amnesia, sense of failure, familial conflicts, low concentration, losing temper easily, sudden anger explosions, frequent weeping fits, desire to be alone, resentfulness, and sense of un-appreciation. Beyond these, some symptoms specific to the workplace such as slowing down the work, a decrease in service quality, wrong interventions to patients and an increase in the number of the complaints of patients, document forgery, being sarcastic and accusing to colleagues, tendency to get a new vocational education, going not to the work by malingering, and being late to the work frequently may be encountered [1,2,5,14]. Particularly these kinds of symptoms should be alerting for the emergency service administrators for the development of burnout syndrome.

What are the management solutions in burnout syndrome?
There are a lot of responsibilities for both the affected person per se and the emergency service administrators in the management of the burnout syndrome. The first thing to do is to determine the causes of the burnout syndrome. If any stressful factors are present in emergency service it is essential to eliminate them or to transform them into less stressful forms. For instance, the sounds emitted from certain monitors and devices found in emergency departments are important factors increasing the stress level of the staff. It is essential to make necessary adjustments to the monitors to minimize the audible sounds and to use sound-proof building materials when designing emergency services [4].
All personnel working in the emergency department should be educated about the difficulty of the task being done, the risks of the work, and the symptoms of the burnout before starting the job and these educations should be repeated at regular intervals [4]. Every emergency department staff should know the borders of his/her responsibilities to protect him/her from carrying too much burden [4,8]. One should sometimes move away the workplace and engage various physical and mental activities and hobbies. Emergency department staff should necessarily take vacations and leisure times. They should participate in various social activities outside the workplace with their work friends or social friends and share their feelings with both their friends and family members [4,8,10].
In institutional scale, the emergency department directors should endeavor to reform the physical structure to an optimal level, define the duties and responsibilities of the staff clearly, shorten the prolonged working hours, solve the salary problems if any, increase vocational and social facilities, and support team work. They should have an indulgent, flexible, participating, and sharing management perspective. They should also provide the staff with the in-service educational opportunities which help the staff develop themselves and increase motivation [4,8,10].
In conclusion, burnout syndrome appears as a phantom menace awaiting emergency department staff. It is a condition which should be taken seriously due to flaws in service quality it creates as well as the physical and psychological trauma it induces in the staff. Emergency department staff who feel comfortable and well both physically and psychologically will be more efficient for their patients. Thus, every type of measure taken to improve the working conditions and to keep the staff away from the stress will both increase the quality of patient care and contribute to long professional career of the emergency department staff.