Show Summary Details
Page of

Clinician Burnout in HIV/AIDS Healthcare 

Clinician Burnout in HIV/AIDS Healthcare
Chapter:
Clinician Burnout in HIV/AIDS Healthcare
Author(s):

Asher D. Aladjem

, and Mary Ann Cohen

DOI:
10.1093/med/9780199392742.003.0048
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2020. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy and Legal Notice).

date: 13 July 2020

I want to be a good story for my doctor, to exchange some of my art for his…. To most physicians my illness is a routine incident in their rounds, while for me it’s the crisis of my life … just as he orders blood tests and bone scans of my body, I’d like my doctor to scan me, to grope my spirit as well as my prostate…. In learning to talk to his patients the doctor may talk himself into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, then they can share, as few others can, the wonder, terror, and exaltation of being on the edge of being, between the natural and the supernatural.

Anatole Broyard (1990)

In 1990, Anatole Broyard wrote an article, shortly before his death of complications of prostate cancer, that poignantly presents his need to be a “good story” for his doctor. The physicians who work with persons with severe and complex illnesses, such as HIV/AIDS, cancer, coronary artery disease, diabetes mellitus, multiple sclerosis, emphysema, and other illnesses, are subject to the vicissitudes and complications of their patients as well as the complexities of healthcare systems and society. It is hard for physicians to seek out their patients’ stories when pressures of both productivity and technology abound in contemporary healthcare systems. Shanafelt et al. (2015) documented that, when compared to the general population, physicians experienced more burnout and less satisfaction with work–life balance. Burnout as a phenomenon relates to work and occupational psychological distress (Maslach et al., 1997). Because burnout is multifactorial, research has focused on two general categories of contributory or predisposing factors: those related to the individual clinician, and those related to the work environment. These factors are summarized with additional updated components in Table 48.1.

Table 48.1 Factors Predisposing to Burnout

Individual Factors

Work-Related Factors

Meaning of one’s work, dealing with conflicting values

  • Work or case load and/or responsibilities, excessive paperwork

  • Electronic medical records and changes in

  • documentation

  • High regulatory demands

  • Implementation of ICD-10, DSM-5, mandatory electronic prescribing in many states of the U.S.

Balance between work and family and other areas of life

Bereavement overload and unresolved grief

Fit between clinician’s interests and goals and how they integrate at the work environment

Lack of rewards and devaluation of contribution and unstable organizational dynamics

External/internal cognitive/behavior, coping styles, and skills

External locus of control leading to diminished job control by the individual; “responsibility without power,” lack of authority, disempowerment

Overidentification with clients

Increasing number of patients with diagnoses of personality disorders and/or substance abuse

Difficulties discussing patient’s condition with his or her family

Pain management resources

Poor communication among hospital staff and/or clinicians

Witnessing physical deterioration of patients

HIV magnifies physician stress because it involves other multimorbid and concomitant medical and psychiatric illnesses as well as stigma. At the same time that vast strides have led to AIDS becoming a chronic manageable illness, changes in the healthcare environment, from 1981 to the present, have also magnified physicians stress and burnout (Byyny, 2016).

A common assumption is that everyone who works in the HIV/AIDS field is at risk for burnout or will experience burnout. The evidence for this remains somewhat equivocal. A number of studies with a range of healthcare workers in AIDS care, including nurses, social workers, and physicians, have demonstrated a relatively low level of burnout (Cooke, 1992; Kaplan et al., 1989; Levinson et al., 1997; Macks and Abrams, 1992; Stewart, 1995). On the other hand, other studies have shown high levels of burnout among healthcare workers in AIDS care (Catalan et al., 1996; Clever et al., 2006; Gueritault-Chalvin et al., 2000; Stewart, 1995). Another point to consider is whether AIDS healthcare workers experience more burnout than individuals caring for patients with other chronic and severe illnesses, such as cancer. Again, the findings are not unanimous. Several U.S. studies have reported that healthcare workers believed that caring for AIDS patients was more stressful than caring for patients with other serious diseases (Macks and Abrams, 1992; Travado et al., 2005). Yet, several studies conducted in other parts of the world, such as Australia, Germany, Italy, and the United Kingdom, have indicated that AIDS healthcare workers were less prone to burnout than healthcare personnel who work in such fields as oncology and geriatrics (Cooke, 1992; Karam et al., 2012; Kaplan et al., 1989; Lert et al., 2001). Regardless of whether or not physicians who care for persons with HIV and AIDS have more burnout than physicians who care for other severe illnesses, it is clear that HIV physicians are subject at least to the same stressors as other physicians and, therefore, are subject to burnout.

This chapter defines and describes the multifactorial nature of burnout as it pertains to clinicians caring for persons with HIV and AIDS and provides a summary of predisposing factors, protective factors, preventive strategies, and ways to provide support and eliminate burnout. Also addressed is the question of whether changes in healthcare, including pressures for productivity, increasing workloads, and increasing use of technology in documentation, have had more or less of an impact on HIV physicians than on other physicians.

Clinician Distress and Burnout in The Care of Persons with HIV and AIDS

Research on burnout in HIV/AIDS-related work was initially found in the field of nurse professionals; it was subsequently expanded and applied to medicine, dentistry, public health, health education, and social work. The close association between burnout and work differentiates it from more general emotional states such as depression that may pervade every aspect of the clinician’s life. When the focus is on work-related distress, studies of the topic leave the distinction of the boundary between work-related distress from distress related to the rest of the clinician’s life ill-defined. As a result, other sources of distress may be minimized or overlooked and the boundary with psychiatric diagnoses remains blurred. Even though distress may be only work related, distress of any kind clearly has implications for other areas of the caregiver’s life. Although we refer to burnout as a phenomenon that has particular etiologies, a particular course, and identified interventions to address it, the concept still remains that it is not a diagnosable illness or syndrome. Any attempt to medicalize and/or further pathologize such a phenomenon may not yield the desired outcome. Burnout has never been categorized as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders and was initially relatively ignored in the literature of HIV psychiatry (Felton, 1998). Systems focusing on burnout prevention are yet to be acknowledged, generalized, systematized, and implemented in healthcare and in HIV-related care.

The AIDS pandemic, which began in 1981, forced significant changes in the understanding and management of an illness in the context of behavior, social acceptance, and personal and social responsibility. The enormous challenge of HIV/AIDS-related work and constant changes in the field can lead to the onset of clinician distress and, if not addressed, have a negative outcome such as burnout. In addition, there is growing body of evidence that unmanaged secondary stress in healthcare professionals can debilitate anyone at any point in their career, regardless of the patient population being cared for, and has increased in prevalence in recent years. A study done at the Mayo Clinic compared prevalence of burnout and satisfaction with work–life balance among U.S. physicians and a probability-based sample of the general U.S. population in 2011 and 2014 (Shanafelt et al., 2015). Of the 35,922 physicians who received an invitation to participate, 6,880 (19.2%) completed surveys. In an assessment using the Maslach Burnout Inventory, 54.4% (n = 3680) of the physicians reported at least one symptom of burnout in 2014 compared with 45.5% (n = 3310) in 2011. Satisfaction with work–life balance also declined among physicians between 2011 and 2014 (48.5% vs. 40.9%; p < .001). Substantial differences in rates of professional burnout and satisfaction with work–life balance were categorized by specialty. In contrast to these trends in physicians, minimal changes in burnout or satisfaction with work–life balance were observed between 2011 and 2014 in probability-based samples of working U.S. adults, resulting in increasing disparity in burnout and satisfaction with work–life balance between physicians and the general U.S. working population (Shanafelt et al., 2015), as well as in work effort (Shanafelt et al., 2016). Burnout affects the individual physician and the quality of care provided by the institution (Burton, 2016).

Factors Predisposing to Burnout in HIV Clinicians

HIV/AIDS-related work differs from that of other fields in the healthcare delivery system, such as geriatrics, oncology, intensive care, and palliative care, in that, from the beginning, the epidemic affected young, otherwise healthy individuals who suffered high death rates and many of whom were vulnerable to stigma and discrimination. The combination of stigmatized patients affected by a devastatingly feared infectious illness that initially had minimal effective treatments and the fear of occupational exposure created an environment that was more supportive of isolation and distancing from patients than of caring for them. The burden on clinicians was twofold: caring for the stigmatized patients with stigmatized illnesses, and addressing their own fears and stigmatized isolation.

HIV was identified as a risk for all, with a strong impact on high-risk populations and the general public worldwide. Lack of effective treatments magnified both the associated fear and stigma. Ongoing medical research, however, was transformative and changed HIV/AIDS into a chronic, manageable illness, in 1996. The availability of effective antiretroviral therapies and vast improvement in care led to empowerment of clinicians and a decrease in clinician distress, but the diminution of HIV stigma has not approached the level of progress in patient care. Nonetheless, improved HIV health outcomes have increased satisfaction in the overall experience of clinicians in the HIV-related fields.

Still, HIV care can increase the pressures and stress of the already numerous demands of healthcare careers, considering the challenges inherent in the modern, fast-paced healthcare delivery system. Ongoing care entails providing treatment and follow-up, monitoring adherence to antiviral treatment. Furthermore, clinicians may be forced to observe patients’ decline in health, despite all efforts and treatments available. (Issues regarding prisoners with HIV and AIDS are explored in depth in Chapter 9 and are also addressed in Chapter 50 of this textbook.) Ambulatory care has expanded since HIV/AIDS has evolved into a chronic illness. Caregivers in each of these environments face different challenges and stressors and have different risks and rates of reported burnout. The occurrence of burnout has a negative impact on work satisfaction and has been seen in large part as the problem of the individual suffering from it. The organizational context in which clinicians practice is a very important variable in the experience of burnout, but research in this field has been hampered by the absence of instruments to measure organizational factors. Individuals who focus on the negative impact that HIV has had on society will add the risk of burning out as another negative consequence of working with persons with HIV/AIDS. Numerous stressors have been reported in the literature as specific aspects of AIDS-related healthcare delivery and are summarized in Table 48.2.

Table 48.2 Stressors in HIV/AIDS-Related Healthcare Delivery

Patient-Related Stressors

Healthcare Worker–Related Stressors

Systemic Stressors

Societal Stressors

High mortality rates

Unresolved personal losses

High caseload

Social stigma and sense of professional isolation

Increasing number of patients with character disorders

Unrealistic goals for patient outcomes

  • Optimal levels of infection control

  • Fear of exposure

Caring for patients with nontraditional and different lifestyles that clinicians are unfamiliar with

Homophobia and issues of human sexuality

Uncertainty about treatment

Ensuring the availability of support services required for comprehensive care of HIV complications

Homophobia and issues of human sexuality

Issues of substance abuse

Maintaining professional competence in HIV care

Ethical and legal dilemmas

Lack of supports and unmet needs assumed by providers

Inadequacy in treating patients’ suffering and psychosocial and neuropsychiatric symptoms

Issues of substance abuse

While most studies on stress and burnout in HIV/AIDS healthcare have focused on the negative and difficult aspects of this work, these aspects are by no means universal phenomena. Clinicians’ involvement with HIV/AIDS covers the whole spectrum of the illness, from prevention of transmission to exposure, to illness and throughout the course of illness to late-stage illness, palliative care, and, ultimately, death and dying. This is clearly not a homogeneous group of clinicians. As the impact of HIV/AIDS has grown, more services have become available to comprehensively treat persons with AIDS. Caregivers include physicians of every specialty; outpatient and inpatient clinicians; acute care, chronic care, and long-term care clinicians; hospice care, including home hospice clinicians; and others. Service organizations employ individuals from many different types of occupational categories, including health educators, HIV pre- and post-test counselors, nurses, primary care physicians, infectious disease specialists, pediatricians, and other medical and surgical specialists. All of these professionals work together to provide seamless, integrated care for persons with HIV/AIDS and its diverse and complex presentations. The more extended circle of caregivers includes laboratory technicians, psychiatrists, psychologists, and other mental health clinicians, substance abuse counselors and other health professionals, dentists, social workers, case managers, and many dedicated volunteers.

Some clinicians’ involvement with HIV/AIDS-related work may be very brief but very intense and emotional, while other clinicians may care for patients on a long-term basis. Some of the passionate clinicians who have dedicated their careers to the care of HIV/AIDS-affected individuals are approaching the end of their professional careers or have aged and retired from the workforce. Some of the most devoted clinicians were defined by their commitment to the cause and strong advocacy that helped shape the course of the epidemic. Their contributions and impact remain as part of the narrative of the HIV/AIDS experience. With that, there is a loss of the institutional memory of the magnitude of the impact of HIV/AIDS on the patients, clinicians, hospital systems, and communities.

The changing environment of the HIV/AIDS pandemic continues to present new challenges and struggles and to demand responses that are flexible and modifiable. As new knowledge is integrated in clinical care, the resources available remain vulnerable, and constant vigilance is required to ensure responsible allocation of resources to care for persons with HIV/AIDS. By recognizing the challenges and not diminishing or trivializing their contributions, clinicians can continue to have lifelong, satisfying work experience, managing work-related stressors in this environment in an effective manner.

Occupational Exposure in the Care of Persons with HIV

The availability of effective antiretroviral therapy has led to gradual diminution of fear of exposure in the 36 years of the HIV pandemic. In addition to universal precautions, all healthcare facilities are required to maintain a policy and standard operating procedure for dealing with employee exposures. Updated recommendations for occupational post-exposure prophylaxis have been developed by the Centers for Disease Control and Prevention (CDC, 2013). A summary of the U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis is as follows:

  • Post-exposure prophylaxis (PEP) is recommended when occupational exposures to HIV occur.

  • Determine the HIV status of the exposure source patient to guide need for HIV PEP, if possible.

  • Start PEP medication regimens as soon as possible after occupational exposure to HIV and continue them for a 4-week duration.

  • New recommendation—PEP medication regimens should contain three (or more) antiretroviral drugs (listed in Appendix A at https://stacks.cdc.gov/view/cdc/20711) for all occupational exposures to HIV.

  • Expert consultation is recommended for any occupational exposures to HIV and, at a minimum, for situations described in Box 1 at https://stacks.cdc.gov/view/cdc/20711.

  • Provide close follow-up for exposed personnel (Box 2 at https://stacks.cdc.gov/view/cdc/20711) that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity. Follow-up appointments should begin within 72 hours of an HIV exposure.

  • New recommendation—If a newer fourth-generation combination HIV p24 antigen-HIV antibody test is used for follow-up HIV testing of an exposed healthcare professional, HIV testing may be concluded at 4 months after exposure (Box 2 at https://stacks.cdc.gov/view/cdc/20711). If a newer testing platform is not available, follow-up HIV testing is typically concluded at 6 months after an HIV exposure.

Although the implementation of these recommendations will vary from one institution to another, the overall goal of evaluating the incident and, if necessary, providing the exposed person with post-exposure prophylaxis within a 2- to 4-hour window is the gold standard.

The selection of a particular medication regimen for HIV post-exposure prophylaxis must balance the risk for infection against the potential toxicities of the antiretroviral agents used. Given the complexities of choosing and caring for a person taking post-exposure prophylaxis, whenever possible, consultation with a physician who has experience with antiretroviral agents is recommended. If an infectious disease physician is not available, the National Clinicians’ Post-Exposure Prophylaxis Hotline (PEP hotline), 888–448–4911, is operational 24 hours a day.

Exposure prevention remains the primary strategy for reducing occupational blood-borne pathogen infections in the healthcare setting. Universal precautions have been practiced safely; examples of these include standard glove precautions for patient contact, and safer needle and phlebotomy devices to reduce percutaneous injuries.

In summary, although blood and body fluid exposures remain a significant concern, much progress has been made in the prevention of acquisition of hepatitis B, hepatitis C, and HIV in the healthcare environment.

Protective Factors in HIV Clinician Burnout

To identify ways in which stress affected the domestic and social lives of HIV clinicians, Miller and Gillies (1996) conducted a study among HIV clinicians. Of all staff members, one-third of those without a long-term emotional relationship stated that they felt their work-related issues interfered with their developing and maintaining relationships. Most participants reported spending a considerable amount of time discussing work with their partners. Work-related issues caused conflict for just under half of the total sample. Thirty-nine percent reported that their partners complained regularly about their commitment to work, and 25% overall reported their relationship had suffered as a result of their work in HIV or oncology.

At the same time, many clinicians find satisfaction in communication with their patients. When Broyard wrote his article about what he wanted from clinicians, he also stated that “in learning to talk to his patients the doctor may talk himself into loving his work. He has little to lose and much to gain by letting the sick man into his heart” (Broyard, 1990). Evidence bears out the vital role of doctor–patient communication in both patient and physician satisfaction (Halbesleben et al., 2006, 2008; Hall and Roter, 2002; Hall et al., 1988; Jackson et al., 2001; Krasner et al., 2009; Ratanawongsa et al., 2008).

Bennett and colleagues (1991) found that oncology nurses suffered burnout with greater frequency than that of AIDS nurses, although AIDS nurses showed greater intensity of burnout after adjustment for frequency of burnout. Men were as likely to suffer burnout as women, and age significantly influenced burnout inversely (Bennett et al., 1991). Bianchi and colleagues (1997) found that among doctors and nurses on a pediatric service in Rome, there was a correlation between experience and time on the job and lower rates of emotional exhaustion. Clinicians with less than a year on the job showed a higher degree of physical and emotional exhaustion, suffered from a high density of stress factors, and set up a large number of defensive strategies. Clinicians at work for 1 to 3 years showed a moderate degree of physical, emotional, and mental exhaustion, did not suffer from particular stress factors, and perceived a high level of social support from colleagues. Clinicians with more than 3 years of experience did not suffer from particular physical or emotional exhaustion and experienced medium levels. While feeling the action of various daily stressors, they did not use the social support offered at work.

Aiken and Sloane (1997) surveyed 820 nurses working with AIDS patients. Nurses who worked in dedicated or specialized units or in “magnet” hospitals known to possess organizational characteristics attractive to nurses exhibited lower levels of emotional exhaustion than those among nurses working in general, scattered-bed medical units. These differences persisted after nurse characteristics were statistically controlled, but they were accounted for in part by controlling for the amount of the organizational support that nurses perceived was present at the work place.

In a study by Mueller (1997) of a sample of 144 social workers providing care for HIV/AIDS clients, the predictors of burnout included measures of social support, caregiver values, characteristics of the work setting, the nature of the work with HIV/AIDS clients, and demographic factors. Study data demonstrated that burnout was significantly and inversely related to social support received from co-workers, supervisors, the caregiver’s age, education level, income, caseload size, and years of work with AIDS clients. Burnout was significantly and positively associated with the number of recent caregiver client deaths and the proportion of caseload that was comprised of HIV/AIDS clients. Total burnout was not related to spouse support, caregiver’s gender, sexual orientation, HIV serostatus, or theoretical orientation.

Demmer (2002) surveyed the motivations, stressors, and rewards of 180 workers employed in nine AIDS service organizations in New York City. The sample consisted of social service workers (56%), administrative workers (22%), healthcare workers (18%), and other workers (4%). Forty-two percent of the workers had been working in the AIDS field for 5 years or more years. The two main reasons for choosing this line of work were a desire to help others, followed by having experienced the loss of a loved one to AIDS. Overall, respondents rated their level of stressors in their job as moderate. The main category of stress was lack of support. The most important individual stressors were societal attitudes toward AIDS, salary, client deaths, and administrative duties. The most highly valued reward factor associated with AIDS caregivers was “personal effectiveness.” Nurses in AIDS care experiencing high levels of stress in their workplace were significantly more likely to use wishful thinking, planful problem-solving, and avoidance as coping strategies, whereas stress originating from patient care was more likely to be dealt with by using positive assessment and acceptance (Kalichman et al., 2000).

Des Jarlais (1990) reported that caregivers who had worked previously in the area of drug abuse treatment went from working in a drug abuse treatment program to working in an AIDS program without a conscious choice in the matter. Part of the strain in burnout in this group came from the sense that the needs created by the epidemic had completely taken over one’s professional life, not having had the opportunity to make a professional choice.

Measures of Clinician Burnout

The Maslach Burnout Inventory (MBI) has been established as a credible measure of burnout and focuses on the personal experience of work (Enzmann et al. 1995; Lee and Ashforth, 1990). It measures dimensions that include exhaustion–energy; depersonalization–involvement; and inefficacy–accomplishment. The MBI was tested to see if it could be translated to other languages, while preserving its psychometric properties; issues of theoretical flaws and cultural bias need further validation (Enzmann et al., 1995).

Other tools have been used in an attempt to measure and quantify burnout, including the Coping Orientation to Problem Experience (COPE) inventory and the State Trait Anxiety Inventory (STAI). Burnout may include symptoms of depression, anxiety, posttraumatic stress disorder (PTSD), and personality disorders. These boundaries are sometimes blurred, as in efforts to distinguish between depression and demoralization syndrome and burnout using anhedonia or the ability of the individual to experience pleasure. Individuals suffering from depression cannot experience pleasure, whereas individuals suffering from burnout or demoralization should be able to experience pleasure. This distinction is made by self-reporting and is open to a wide range of understanding and interpretations (see Box 48.1).

The expansion in the terminology used to label job-related distress may be due in part to an attempt to avoid the stigma of mental illness, labeling clinically relevant symptoms with more socially acceptable, politically correct, current concepts. The clear intent is to stay away from the better-known entity of psychiatric diagnoses (for example, depression), as these diagnoses are still feared and stigmatized. Responsible and accurate reporting of burnout is necessary to avoid negative, further stigmatizing, and frightening implications that may turn people away from gravitating toward the field of HIV/AIDS healthcare delivery. A study by Van Servellen and Leake (1993), conducted in Los Angeles, examined burnout among nurses working on AIDS special care units (SCUs), oncology SCUs, medical intensive care units, and general medical units and measured the extent to which delivery method, patient diagnosis, or other key personal and work-related characteristic were associated with the level of distress in these nurses. A sample of 237 nurses from 18 units in seven hospitals was surveyed, using the MBI. This study showed no significant differences in burnout scores across nurse samples representing variations in patient diagnosis and delivery method, and all nurses had similar level of distress.

Catalan and colleagues (1996) compared serious disease, psychological stress, and work-related burnout in staff working with AIDS patients and with cancer patients. Seventy nurses and 41 doctors were compared through a self-reported method of assessment, using the MBI, General Health Questionnaire (GHQ), and the Social Adjustment Scale-Modified (SAS-M). One-third of the staff had substantial levels of psychological morbidity and about a fifth had significant levels of work-related stress. The study confirmed the existence of stress but found no difference in stress between AIDS and cancer-related work.

Clinicians’ reactions to stressors are both positive and negative and can be mobilized to enable them to continue in a constructive fashion within their professional and personal lives. People do their best when they believe in what they are doing and when they can maintain their pride, integrity, and self-respect. The best reward is receiving recognition for the things one likes to do. If individuals reach the best fit in terms of their professional preparation and level of personal maturity, introspection, and goals, they should be able to deal with challenges, such as working in the field of HIV/AIDS, and feel a sense of personal reward and professional accomplishment. Burnout is more likely when there is a mismatch between the nature of the job and the character of the person who does the job. When an illness had been as stigmatized and feared as AIDS, it was not always effortless to maintain a sense of pride, and clinicians may suffer attitudes toward them that are similar to those directed toward the disease. Consequently, the clinician may experience a sense of isolation, distance, and trepidation or apprehension.

Visintini and colleagues (1996) studied the role played by psychological stress and sociodemographic factors as predictors of burnout in nurses, administering the AIDS Impact Scale (AIS) and the MBI to nurses in the AIDS field. The sample was composed of 410 nurses from 19 departments for the treatment of infectious diseases. A low level of burnout was indicated by MBI scores, but a small proportion had a high level of burnout, with no significant association between sociodemographic variables and the MBI scales. There was a significant correlation between low burnout rate and the emotional involvement of nurses in their relationships with patients. The results suggest that an empathically involved relationship appears to protect against burnout, in contrast to a frustrating relationship. Moreover, nurses tolerated stress better if they received supportive social rewards.

HIV/AIDS healthcare professionals consist of a very diverse group of physicians and other professionals who care for very diverse patient populations. The nature of HIV infection is that it affects patients as individuals and as groups identified by behavior and not by gender, age, race, or ethnicity. Many HIV/AIDS clinicians have experienced the loss of not only numerous clients but also colleagues and community members, leading to “bereavement overload.” For these individuals the rewards outweigh the stressors and the level of job satisfaction is very high. The most highly valued reward factor is “personal effectiveness.” Burnout among these dedicated individuals weakens their response and contributes to increased strain on the HIV/AIDS care system. The challenge of workload and mastery and management of it have become very evident with HIV/AIDS (Bennett et al., 1994, 1996). The sense of the immensity of the task and the insufficient tools to cover the need is one of the biggest demoralizing factors in this epidemic.

Evolving Mental Health Roles

The role of psychiatrists and other mental health professionals in addressing burnout in HIV caregivers gradually evolved over the past four decades. During the early phase of the AIDS pandemic and with the development of HIV testing in 1985, young individuals were dying from an illness that progressed rapidly (Frierson and Lippmann, 1987). Most available treatments were inadequate to stop or even slow the course of illness. Ignorance associated with fear and prejudice dominated that stage. The role of psychiatrists was to help other clinicians deal with the frustrations, fears, and massive bereavement overload as well as to serve as consultants to their patients.

During the initial period of AZT treatment, there was a shift from hopelessness to testing and engaging patients and staff in treatment. When more effect treatment became available, with the development of combination antiretroviral therapy in 1996, adherence and availability of medications became the focus. Psychiatrists are now in more collaborative roles, with the need for integrated care, to encourage adherence to medical care and antiretroviral therapy and to provide support for patients, families, and caregivers. Psychiatrists in collaborative care are in a unique position to role model and teach doctor–patient communication as well as to preserve trainee and caregiver empathy and compassion (Beach et al., 2006, 2011; Bellini et al., 2002; Bellini and Shea, 2005; Shanafelt et al., 2002, 2005; Testad et al., 2010; Thomas et al., 2007). Through case conferences, walk rounds, and curbside consults, psychiatrists can provide avenues of communication among the members of multidisciplinary teams as well as among the multiple specialists and subspecialists involved in patient care. Through both training and clinical care, psychiatrists and other mental health clinicians can improve patient and caregiver satisfaction and improve adherence and retention in care (Roter et al., 1987, 1997, 2002; Schneider et al., 2004).

Psychiatrists and other mental health clinicians can now provide the necessary support that has been shown to lead to improved outcomes and decreased morbidity and mortality in persons with HIV and AIDS (Mugavero et al., 2014). Please refer to Chapters 1, 2, and 7 of this textbook for more detailed discussion of collaborative care and models of care for persons with HIV and AIDS.

Addressing Burnout

When burnout is recognized and diagnosed, specific institutional and/or individual strategies need to be used. Institutional planning for addressing burnout can be conceptualized as prevention, recognition, and treatment, with the goals of longevity in the field and retention of committed workers who stay healthy and derive satisfaction from their work (Aiken and Sloane 1997; Anagnostopoulos et al., 2012; Argentero et al., 2008; Dyrbye et al., 2010; Felton, 1998. These strategies include administrative policies, a philosophical framework, mechanisms for reward, and educational goals and objectives (AbuAlRub, 2004). These can be achieved by comprehensive orientation for new employees and refresher courses for employees already on the job, effective forums for conflict resolution and shared decision-making, effective vertical communication, and the fostering of collaborative models, as opposed to aggressive, personally competitive styles.

Shifting in funding and costs is indicative of a very fast-paced change in the HIV/AIDS healthcare delivery system. Inpatient virology, tuberculosis, and dedicated AIDS units are being downsized or closed because of length-of-stay issues and the reduced need for long-term, inpatient treatment of HIV/AIDS-related conditions. These changes could lead to anxiety about job loss and to the end of some very resilient and productive careers.

A large source of professional reward and satisfaction is derived from recognizing the monumental achievements in social and clinical aspects of the HIV epidemic. Individually, nurses, doctors, and other professionals face the constant challenge of adapting to new and evolving work environments. Insight and individual coping styles can be supported and enhanced by shared values. This can help balance the institutional–individual fit.

Coping has been described as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus and Folkman, 1984). Strategies for coping in a stressful work environment apply to coping in the HIV/AIDS workplace.

The Role of Religion and Spirituality

Religion and the healing powers of spirituality have not been described as central strategies in the fight against AIDS. From the very first manifestation of the epidemic, moral judgment was attached to the “forbidden behavior” and the “sins” involved in contracting AIDS. Promiscuity, homosexuality, substance abuse, and the sharing of needles have all been unacceptable behaviors for many members of most organized religions. Religious organizations have also been involved in taking care of the dying. It is obvious that “believers” find strength in prayer and in perceived relevant selected passages from the scriptures, but for most of the secular public and healthcare providers, these rituals are not necessarily readily available and are often overlooked as healing tools.

Spirituality, as distinct from religion, has helped workers in finding meaning in their work and value in their contributions and their own experience. Resilience among many workers has been achieved through maintenance of a sense of coherence. Spirituality gives people meaning and purpose in life. While it can be achieved through participation in a religion, it can be much broader than that, such as through involvement in common values such as family, humanism, or the arts.

Keeping alive the spirit of the far-too-many fatalities and continuing a transformed relationship with the deceased lives have become a very effective mode for survivors, significant others, and HIV/AIDS healthcare providers to value, respect, and cherish their lives. December 1 was designated Annual World’s AIDS Day to increase global awareness of AIDS and to pay tribute to the people who lost their battle to the disease. An institutional memorial service, described by Tiamson and colleagues (1998), serves as a model to help clinicians with closure and renewal. The AIDS Memorial Quilt Project was one of the most powerful images of the AIDS epidemic. Tens of thousands of colorful individual panels full of stories of diverse life experiences of men, women, and children were combined together on display to concretize the magnitude of the loss. The quilt panels have become another avenue to channel the overwhelming sense of loss of people and the immeasurable life potential. A letter written by loved ones and a favorite memory accompany each individual panel, made in a way that the individual would have liked as a memorial.

Conclusion

The last four decades of the HIV pandemic have seen change and progress in the medical care of persons with HIV and in social attitudes toward HIV/AIDS, but what remains the same as ever is the impact of the illness and the human experience of it. Caregivers have remained resilient witnesses to the immense loss and suffering brought on by the HIV pandemic. While HIV caregivers and clinicians practice commitment and selfless dedication to the care of persons with HIV/ADIS, burnout has remained a risk. The awareness of burnout can improve adherence to care and lead to better outcomes in persons with HIV and AIDS. In addition, more time for doctor–patient communication and a diminution of work stressors (Bynny, 2016) can help physicians in the care of persons with HIV/AIDS and can help their patients. Resilience in the face of such life-altering experiences is not about going back to the way we were but about the growth experienced by it; no one remains unaffected in the face of such a humanitarian disaster.

References

AbuAlRub RF (2004). Job stress, job performance, and social support among hospital nurses. J Nurs Scholarsh 36(1):73–78.Find this resource:

Aiken LH, Sloane DM (1997). Effects of organizational innovations in AIDS care on burnout among urban hospital nurses. Work Occup 24:453–477.Find this resource:

Anagnostopoulos F, Liolios E, Persefonis G, Slater J, Kafetsios K, Niakas D (2012). Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. J Clin Psychol Med Settings 19:401–410.Find this resource:

Argentero P, Dell’Olivo B, Ferretti MS (2008). Staff burnout and patient satisfaction with the quality of dialysis care. Am J Kidney Dis 51(1):80–92.Find this resource:

Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA (2006). Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 62:347–354.Find this resource:

Beach MC, Saha S, Korthuis PT, et al. (2011). Patient–provider communication differs for black compared to white HIV-infected patients. AIDS Behav 15(4):805–811.Find this resource:

Bellini LM, Baime M, Shea JA (2002). Variation of mood and empathy during internship. JAMA 287(23):3143–3146.Find this resource:

Bellini LM, Shea JA (2005). Mood change and empathy decline persist during three years of internal medicine training. Acad Med 80(2):164–167.Find this resource:

Bennett L, Kelaher M, Ross MW (1994). Quality of life in health care professionals: burnout and its associated factors in HIV/AIDS related care. Psychol Health 9:273–283.Find this resource:

Bennett L, Michie P, Kippaz S (1991). Quantitative analysis of burnout and its associated factors in AIDS nursing. AIDS Care 3:181–192.Find this resource:

Bennett L, Ross MW, Sunderland R (1996). The relationship between recognition, rewards and burnout in AIDS caring. AIDS Care 8:145–153.Find this resource:

Bianchi A, Ferrari V, Soccorsi R, Tatarelli R (1997). The burnout syndrome in a pediatrics department: pilot project. New Trends Exp Clin Psychiatry 13:193–208.Find this resource:

Broyard A (1990). Doctor talk to me. New York Times Magazine, August 26, 1990. http://www.nytimes.com/1990/08/26/magazine/doctor-talk-to-me.html?pagewanted=all Accessed July 24, 2016.

Burton C (2016). Physician burnout affects healthcare facilities, too. Physician’s Money Digest, June 24, 2016. http://www.hcplive.com/physicians-money-digest/practice-management/physician-burnout-affects-healthcare-facilities-too. Accessed July 24, 2016.

Byyny RL (2016). Time matters in caring for patients—twenty minutes is not enough. The Pharos 79:2–8.Find this resource:

Catalan J, Burgess A, Pergami A, Hulme N, Gazzard B, Phillips R (1996). The psychological impact on staff of caring for people with serious diseases: the case of HIV infection and oncology. J Psychosom Res 40(4):425–435.Find this resource:

Centers for Disease Control and Prevention (CDC) (2013). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. https://stacks.cdc.gov/view/cdc/20711. Accessed July 24, 2016.

Clever SL, Ford DE, Rubenstein LV, et al. (2006). Primary care patients’ involvement in decision-making is associated with improvement in depression. Med Care 44:398–405.Find this resource:

Cooke M (1992). Supporting health care workers in the treatment of HIV-infected patients. Prim Care 19(1):245–256.Find this resource:

Demmer C (2002). Stressors and rewards for workers in AIDS service organizations. AIDS Patient Care STDS 16:179–187.Find this resource:

Des Jarlais DC (1990). Stages in the response of drug abuse treatment system to AIDS epidemic in New York City. J Drug Issues 20:335–347.Find this resource:

Dyrbye LN, Power DV, Massie FS, et al. (2010). Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students. Med Educ 44(10):1016–1026.Find this resource:

Enzman D, Schaufeli W, Girault, N (1995). The validity of the Maslach Burnout Inventory in three national samples. In L Bennett, D Miller D, M Ross (eds.), Health Workers and AIDS: Research, Intervention and Current Issues in Burnout and Response (pp. 131–150). Amsterdam: Harwood Academic Publishers.Find this resource:

Felton JS (1998). Burnout as a clinical entity—its importance in health care workers. Occup Med 48; 237–250.Find this resource:

Frierson RL, Lippmann SB (1987). Stresses on physicians treating AIDS. Am Fam Physician 35:153–159.Find this resource:

Gueritault-Chalvin V, Kalichman SC, Demi A, Peterson JL (2000). Work-related stress and occupational burnout in AIDS caregivers: test of a coping model with nurses providing AIDS care. AIDS Care 12(2):149–161.Find this resource:

Halbesleben JR (2006). Patient reciprocity and physician burnout: what do patients bring to the patient–physician relationship? Health Serv Manage Res 19:215–222.Find this resource:

Halbesleben JR, Rathert C (2008). Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev 33(1):29–39.Find this resource:

Hall JA, Roter DL (2002). Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns 48(3):217–224.Find this resource:

Hall JA, Roter DL, Katz NR (1988). Meta-analysis of correlates of provider behavior in medical encounters. Med Care 26:657–675.Find this resource:

Jackson JL, Chamberlin J, Kroenke K (2001). Predictors of patient satisfaction. Soc Sci Med 52(4):609–620.Find this resource:

Kalichman SC, Gueritault-Chalvin V, and Demi A (2000). Sources of occupational stress and coping strategies among nurses working in AIDS care. J Assoc Nurses AIDS Care 11(3):31–37.Find this resource:

Kaplan SH, Greenfield S, Ware JE (1989). Assessing the effects of physician–patient interactions on the outcomes of chronic disease. Med Care 27(3 Suppl):S110–S127.Find this resource:

Karam F, Bérard A, Sheehy O, et al. (2012). Reliability and validity of the 4-item perceived stress scale among pregnant women: results from the OTIS antidepressants study. Res Nurs Health 35(4):363–375.Find this resource:

Krasner MS, Epstein RM, Beckman H, et al. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302(12):1284–1293.Find this resource:

Lazarus RS, Folkman S (1984). Stress Appraisal and Coping. New York: Springer.Find this resource:

Lee R,Ashforth B (1990). On the meaning of Maslach’s three dimensions of burnout. J Appl Psychol 75(6):743–747.Find this resource:

Lert F, Chastang JF, Castano I (2001). Psychological stress among hospital doctors caring for HIV patients in the late nineties. AIDS Care 13(6):763–778.Find this resource:

Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM (1997). Physician–patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 277(7):553–559.Find this resource:

Macks JA, Abrams DI (1992). Burnout among HIV/AIDS health care providers. Helping the people on the frontlines. AIDS Clin Rev 1992:281–299.Find this resource:

Maslach C, Jackson SE, Leiter MP (1997). Maslach Burnout Inventory, third edition. In CP Zalaquett, RJ Wood (eds.), Evaluating Stress: A Book of Resources (pp. 191–218). Lanham, MD: Scarecrow Education.Find this resource:

Miller D, Gillies P (1996). Is there life after work? Experiences of HIV and oncology health staff. AIDS Care 8:167–182.Find this resource:

Mueller KP (1997). The relationship between social support and burnout among social work caregivers of HIV/AIDS clients. Dissertation Abstracts International Section A: Humanities and Social Sciences Vol. A, p. 3683.Find this resource:

Mugavero MJ, Westfall AO, Cole SR, et al. (2014). Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis 59:1471–1479.Find this resource:

Ratanawongsa N, Roter D, Beach MC, et al. (2008). Physician burnout and patient–physician communication during primary care encounters. J Gen Intern Med 23(10):1581–1588.Find this resource:

Roter DL, Hall JA, Katz NR (1987). Relations between physicians’ behaviors and analogue patients’ satisfaction, recall, and impressions. Med Care 25(5):437–451.Find this resource:

Roter DL, Larson S (2002). The Roter Interaction Analysis System (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 46(4):243–251.Find this resource:

Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS (1997). Communication patterns of primary care physicians. JAMA 277:350–356.Find this resource:

Schneider J, Kaplan SH, Greenfield S, Li W, Wilson IB (2004). Better physician–patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med 19(11):1096–1103.Find this resource:

Shanafelt TD, Bradley KA, Wipf JE, Back AL (2002). Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 136(5):358–367.Find this resource:

Shanafelt TD, Hasan O, Dyrbye LN, et al. (2015). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings 90(12):1600-1613.Find this resource:

Shanafelt TD, Mungo M, Schmitgen J, et al. (2016). Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 91:422–431.Find this resource:

Shanafelt TD, West C, Zhao X, et al. (2005). Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 20(7):559–564.Find this resource:

Stewart MA (1995). Effective physician–patient communication and health outcomes: a review. CMAJ 152:1423–1433.Find this resource:

Testad I, Mikkelsen A, Ballard C, Aarsland D (2010). Health and well-being in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes. Int J Geriatr Psychiatry 25(8):789–797.Find this resource:

Thomas MR, Dyrbye LN, Huntington JL, et al. (2007). How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med 22(2):177–183.Find this resource:

Tiamson ML, McArdie R, Girolamer T, Horowitz HW (1998). The institutional memorial service: a strategy to prevent burnout in HIV healthcare workers. Gen Hospital Psychiatry 20(2):124–126.Find this resource:

Travado L, Grassi L, Gil F, Ventura C, Martins C; Southern European Psycho-Oncology Study Group (2005). Physician–patient communication among Southern European cancer physicians: the influence of psychosocial orientation and burnout. Psychooncology 14(8):661–670.Find this resource:

Van Servellen G, Leake B (1993). Burn-out in hospital nurses: a comparison of acquired immunodeficiency syndrome, oncology, general medical, and intensive care unit nurse samples. J Prof Nurs 9(3):169–177.Find this resource:

Visintini R, Campnini E, Fossati A, Bagnato M, Novella A, Maffei C (1996). Psychological stress in nurses’ relationships with HIV-infected patients: the risk of burnout syndrome. AIDS Care 8(2):183–194.Find this resource: