Background

The WHO defines burnout as an occupational syndrome resulting from chronic workplace stress that has not been successfully managed.1 It encompasses emotional exhaustion, cynicism and a sense of ineffectiveness.1 Emotional exhaustion is a state of feeling emotionally depleted and fatigued. Initially described as depersonalisation, cynicism is a state of irritability and includes negative attitudes towards others. Inefficacy, described initially as a reduced personal accomplishment, is a state of low morale affecting productivity and the ability to cope.2

First described in the scientific literature in 1974 by Freudenberger, followed by Maslach in 1981,2 the prevalence of this syndrome has since reached ‘epidemic’ levels in the USA.3 Previous to the COVID-19 pandemic, nearly 50% of physicians reported living with burnout.3 Similar prevalence rates were also observed among nurses and physician assistants.3 The COVID-19 pandemic imposed significant challenges to the healthcare system, and in turn, burnout prevalence among qualified healthcare professionals (QHP) has skyrocketed globally.4–8

As a multidimensional syndrome, the clinical manifestation of burnout spirals down to a cascade of adverse outcomes affecting QHP, patients and healthcare systems. QHP—anyone who, by their education, training and credentials, is permitted by law to evaluate and care for patients, such as physicians, nurse practitioners, nursing care professionals and the allied health professionals (occupational therapists, physical therapists, social workers, among others)9—experience a myriad of physical and emotional symptoms, such as fatigue, pain and disengagement.3 As a result, their empathy levels—a crucial component of person-centred care—are likely to be affected.3 This leads to patients who receive suboptimal care and are more prone to rate their hospital experience and satisfaction as poor.3 Healthcare institutions report increased errors, decreased quality of care and high employee turnover rates.3 10 11

Burnout management includes a plethora of interventions and can target either the organisation or the individual.11 12 Organisational-tailored strategies include fostering systems of support, a culture that enhances well-being, engaged leadership and highly functioning interprofessional teams.13 Individual-tailored strategies include, but are not limited to, timely response to the emotional challenges faced by the QHP and other forms of psychological support, such as the promotion of self-care.13

Systematic reviews and meta-analyses published in the last decade about interventions to mitigate burnout yielded contradictory results. Both individual and organisational-tailored interventions appear to be effective.11 14–19 However, while some authors suggested that both intervention types led to small burnout improvements11 14 others proposed that organisational-tailored interventions are more effective than individual-tailored interventions,15 17 whereas another group of studies found combined interventions to be the most effective strategy.16 18 One systematic review suggested that the effectiveness of different kinds of organisational-tailored interventions varied.19 For instance, strategies promoting teamwork were effective in reducing burnout. On the other hand, interventions focused on schedule modifications showed little to no effect.19 Of interest, Awa et al, suggested that regardless of the type of intervention, effects are likely short-lived.16 In addition, interventions varied greatly in regard to content, duration, intensity and length of follow-up, making identification and comparison of their active ingredients difficult.15 20

These reviews shed some light on whether interventions are effective; however, they do not give us any indication of how these interventions work and what specific elements drive burnout reduction. Furthermore, none focused on the mix of healthcare professionals working in the hospital setting. Instead, to control for heterogeneity, many studies either focused on physicians’11 15 17 19–23 or nurses’ burnout.18 24–26 Considering that in a healthcare environment, such interventions are delivered to all employees regardless of their professional background, having a representative sample that includes nurse practitioners, physician assistants and allied healthcare professionals is crucial to understanding the actual effect of burnout interventions.

As a result, actionable recommendations for the management and prevention of burnout among QHP are lacking.15 We are unable to understand—or unpack—burnout interventions because we are most likely tackling this issue using a methodology that is not aligned with the problem. Systematic reviews and meta-analysis methodologies follow a reductionist approach in which there is a linear association between an isolated intervention and an intended outcome, also expressed as a simple cause and effect relationship.27 Burnout, however, is a complex syndrome requiring a bundled intervention strategy.25 Likewise, according to Wiederhold et al,21 a successful burnout intervention should consider various causes and incorporate various therapeutic tools.

Pawson advocates that a realist review—rooted in a critical realist epistemology—is the methodology best suited to evaluate complex interventions. Instead of evaluating effectiveness, a realist review aims to explain the interaction among contextual factors (ie, barriers and facilitators of the intervention mechanism of interest), mechanism (ie, the process through which interventions work) and the outcome (ie, the desired change). In addition, a realist review incorporates a broader range of sources than systematic reviews and meta-analyses, as well as stakeholder input.28 29

A preliminary search of PROSPERO, MEDLINE and the Cochrane Database of Systematic Reviews identified one realist review on this topic.30 Eligible participants, however, were those acting in critical care. In addition, this realist review excluded grey literature sources as well as single studies, commentary articles and clinical overviews. As suggested by Pawson et al, ‘realist review is much more likely to make use of grey literature rather than relying solely on articles in academic journals’.28 In addition, two realist review protocols related to the Care Under Pressure Project were identified.31 32 While one focuses on organisational interventions to improve physicians’ mental ill-health,31 the other focuses on understanding the incidence of mental ill-health among nurses, midwives and paramedics.32

The uniqueness of our study resides in its specific scope and study population. Our study focuses on any intervention to mitigate burnout among qualified healthcare workers working in a hospital environment, which may include physicians, nurses, nurse practitioners, physician assistants, physical therapists, occupational therapists, social workers and child care specialists. The Care Under Pressure studies, in contrast, focus on organisational interventions to improve the mental health of select professional groups (namely doctors, nurses, midwives and paramedics). Also, mental health is a broader construct encompassing a wide range of clinical manifestations, such as depression, anxiety and stress.33

Therefore, to date, a comprehensive realist review of burnout interventions for QHP is lacking. Given the syndrome’s high prevalence across varied healthcare professions and the heterogeneity and complexity of the interventions designed to address burnout, further research is needed to explain what works, for whom, and in what circumstances. This study aims to address this gap.

Ethics and dissemination

A formal ethics review and approval is not required, for this is a secondary data analysis study. Findings will be disseminated in a peer-reviewed journal, through conference presentations and through the development of infographics and relevant educational material to be shared with stakeholders and key institutions. Furthermore, the findings will inform the delivery of current burnout interventions at the collaborating healthcare institution.