A more complete and comprehensive understanding of the nature of burnout can be obtained through a biological consideration of this issue.
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The previous article discussed the importance of a biological consideration of burnout. While the healthcare context is the focus of this article mini-series, this exploration of the issue of burnout is equally applicable across other professions and within personal role aspects of burnout. As emphasized within the previous article, while the biological elements of this issue are being explored, it is by no means intended as an exclusion of the culture and environmental aspects of burnout. In fact, as will hopefully become apparent, through the discussion of this article, the environmental aspects are very much included within the consideration of the biological elements of burnout. In particular, it is the interplay between these factors which becomes most important to understand in the pursuit of a more complete framework of the issue of burnout. It is also essential to recognize that this acknowledgment of the biological aspects of burnout is not synonymous with placing blame or fault on the individual.
The previous article in this series provided the context for the importance of understanding the biological considerations of burnout. The upcoming installment of this series will explore how this recognition can be utilized to develop and implement strategies to address this important issue in a fashion that is in alignment with our biology. The purpose of this part of the discussion is to explore in greater detail the issue of burnout from the perspective of our common biology as humans.
The necessity for understanding the underlying biology of burnout emanates from consideration of two important elements. Firstly, all healthcare professionals work within the same culture and system and, yet, not all become burned out. Secondly, the responses and reactions of the same healthcare professional when encountering similar cues and situations is not necessarily consistent across time. These two important realities indicate that there is more to understanding the issue than solely analyzing the system itself or its resulting culture. If this was all there was to consider in respect to burnout, then these two experiences would not be present. The existence of these two aspects serves as a form of inconvenient truth or reality in response to the contention that burnout is solely the result of a dysfunctional and overly demanding healthcare system. As stated previously, the recognition that other factors must be considered should not be equated with either blame on the individual or an assertion that the culture and system are not important factors.
When we consider the biology of burnout, we can develop a more complete and comprehensive understanding of this issue which can then be used to inform more effective strategies to address the topic. As discussed in past articles, our nervous system is the primary influencer and determinant of our experience in response to internal, external, and relational cues and stimuli. The manner in which our nervous system functions when we encounter any, and all, of these types of situations is best explained through the principles of Polyvagal Theory, which have been the focus of prior articles. The issue of burnout, from my perspective, is a special case application of this framework.
Within the healthcare system, the various professionals involved with all aspects of the system are exposed to cues and stimuli from their environment, within themselves, and from the interactions with others within the system, including patients, colleagues, and co-workers. Each of these experiences provide potential cues of safety and connection as well as cues of uncertainty, risk, or threat. The determination of the type of cue is a subconscious and instantaneous process governed by our neuroception. On the basis of the result of this function, our biology will shift towards a grounded, ventral vagal stabilized state; a mobilized sympathetic state; or a shutdown dorsal vagal state. While these shifts are predictable, they are not the individual’s choice or intention.
It can be readily appreciated that each individual within the healthcare system is functioning within a high pressure, high demand context. As such there are numerous internal, external, and relational cues to which each person is continuously exposed. Given the large number of professionals working within the system, there are also numerous relational stimuli and the reactions of any single individual can impact many others. It is important to continue to emphasize that our neuroception and resulting shifts in biological state are not within our conscious control and do not result from intentional or deliberate choices. It is also important to realize that each healthcare professional is a human with many other roles and responsibilities which can impact their biology during their professional tasks. As such, it is entirely possible that experiences in other domains of life can have significant impact within professional roles. This can be most readily appreciated when one considers the demands upon healthcare professionals who have children at home and the distinct possibility for there to be impacts upon their biology from one domain which affect the other.
An important consideration from Polyvagal Theory which applies to this discussion is that of the intervening variable. In his description of this principle, Dr. Porges illustrates how our biological state influences our neuroception in response to the various stimuli we encounter. This can be most readily understood through a common example that we have all likely experienced. We often get stuck, frequently unexpectedly, in traffic while driving. At times, we are able to remain grounded and calm despite the inconvenience. At other times, however, we may become angry, aggravated, frustrated, or impatient. The traffic may be no different, however our response can be dramatically different. The explanation for this variation in experience lies in our biological state at the time of the event, as predicted through the principle of biological state as an intervening variable.
This principle also occurs within the healthcare context. We may encounter similar situations, such as unexpected emergencies, patients running late, supplies not being available, and other professionals behaving in high stress ways, to name but a few. Our responses to these, and other, scenarios can be quite different on the basis of our biological state at the time of the situation. This reflects the concept of the intervening variable.
This understanding is important as we consider the biological impact over time as burnout progresses. Initially, as we may have greater ventral vagal stabilization there may be instances in which we respond to these common scenarios in ways demonstrating maintenance of a grounded and connected, ventral vagal stabilized state. At other times, we may mobilize into a sympathetic state and demonstrate frustration, aggravation, anger, or even anxiety. Over time, if our biological state becomes more commonly mobilized into sympathetic states or shutdown in dorsal vagal states, our responses will become more in line with these biological states on account of the principle of the intervening variable. This results from our neuroception within each of these states.
The biological considerations discussed above lead to a greater understanding of the interplay of the internal, external, and relational cues and stimuli and their impact on development of burnout. When neuroception leads to mobilization towards sympathetic states, the resulting characteristics are consistent with earlier stages and symptoms of burnout. This can include aggravation, aggressive responses, frustration, and anxiety. As the resulting shift in biological state results in a greater degree of shutdown into dorsal vagal states, the resulting manifestations are consistent with the more advanced features of burnout. These features include shutdown, dissociation, exhaustion, loss of fulfilment, and depersonalization. This framework provides far greater understanding than does an overly simplified rubric in which only the culture and system are considered.
Through an application of the polyvagal informed framework within the issue of burnout, it becomes possible to more completely understand the issue and its nuances. From this recognition, additional strategies emerge which can address burnout in a fashion that is more in line with our biological processes. This will be the topic of the next installment of this series.
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REFERENCES
Allison, M. The Play Zone: A Neurophysiological Approach to our Highest Performance. https://theplayzone.com.
Gervais, M; Carroll, P. Compete to Create: An Approach to Living and Leading Authentically. Audible Original; 2020.
Porges, SW. Polyvagal Safety: Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company; 2021.
Porges SW, Porges S. Our Polyvagal World: How Safety and Trauma Change Us. New York: W.W. Norton & Company; 2023.
