Occupational burnout (hereinafter known as burnout) is one of the most significant modern diseases that produces a significant effect on personal and public life and professional activity. The World Health Organization (WHO) officially included burnout into edition 11 of the International Disease Classification (IDC-11) as of January 1, 2022. In accordance with this decision, it is about a clinically significant syndrome, ‘conceptualized as resulting from chronic workplace stress that has not been successfully managed’ [1].

Based on the study of Dr. Torsten Heinemann, Professor of Sociology from Hamburg University, and Linda Heinemann, clinical psychologist and psychotherapist at the Goete University in Frankfurt, burnout is ‘one of the most widely discussed mental health problems in today’s society’ [2].

In spite of numerous academic papers devoted to burnout, researches, training sessions and courses, burnout has not been overcome today and is becoming increasingly relevant. COVID-19 pandemic and related significantly restructured social and professional life contributed to this in many respects.

Burnout is especially relevant for some professions because the society places extremely high demands on them, communication with people here extends beyond functionalism, and professional activity is regulated using not only rigid legal but also soft ethical standards. Health professionals are definitely representatives of such professions.

Many modern studies [3] deal either with diagnostics of burnout or examination of burnout overcoming factors using social and mental tools (for instance, good organization management and teaching how to cope with stress). Without prejudice to the research and practices, authors believe that in the medical environment, the issues of burnout development are associated with, first, organizing the work of the healthcare system, second, need in competent training of medical personnel as far as professional knowledge and flexible creative clinical thinking, mental and emotional stability go, and, third, shortcoming of ethical and communication competencies of medical workers, inability to display empathy and respect towards a patient’s autonomy.

Thus, the purpose of the study is to detect socioexistential and ethical and communication conditions for emotional burnout among healthcare professionals to develop recommendations that prevent the examined syndrome.

MATERIALS AND METHODS

The study was based on interviewing and questioning of doctors of the Belarusian State Medical University (BSMU), Belarusian Medical Academy of Postgraduate Education (BMAPE), communication with health professionals (doctors and nurses), patients and representatives of social organizations in the field of biomedicine. Content analysis of open access questioning of doctors about burnout, analysis of chats and social networks of healthcare professionals, discussion of cases and situations with doctors during thematic debates at the BMAPE were used as well.

STUDY RESULTS

The existing problem of burnout spreading among healthcare professionals should be considered in social and personal (existential) dimensions. This allows to outline ways of obtaining recommendations and practical measures that prevent development of burnout in medical environment.

In social dimension, researchers quote the following factors typical both of healthcare workers, and representatives of other professions such as manifestations of economic and sociopolitical instability, high competitiveness, improper labor conditions, non-observance of work and rest regulations, conflicts at work, absence of job guarantees, infringement of personal ambitions, doctor-p atient communication problems and lack of satisfactory financial incentives [4]. They result in stress during a professional activity and, as a consequence, in burnout.

Objectively considering healthcare professionals as a significant resource of healthcare system (and the entire society), we can determine it as a ‘renewable in the long term’ because it takes six to fifteen (and more) years to prepare one specialist when the theoretical and practical educational components are combined. Moreover, a healthcare professional who works directly with patients should be fostered with ideas of humanism, mercy and empathy. It is difficult to do so using learning materials only. The healthcare professional should also develop communication, legal, research and other professional competencies.

We should not underestimate depletion of the resource renewable in the long term due to retraining of a healthcare professional, his switch to another professional field and possible labor migration in search for better working conditions, payment, emotional climate, etc.

Statistical data stating the exact percentage of healthcare professionals leaving the healthcare area because of emotional burnout are currently lacking. Their age, length of employment, rates, a number of patients examined per day are unknown (ranking the load related to outpatient attendance and home visits is required for doctors who work in a polyclinic). Thus, it is difficult to analyze how many healthcare professionals and of what specialties suffer from burnout to the greatest extent, how their number changed during the COVID-19 pandemic, etc. An extensive scientific and practical examination of burnout among healthcare professionals is required in the post- Soviet area during COVID-19 pandemic taking into account labor conditions, set objectives and possibilities of their implementation. The research is needed to develop relevant recommendations to prevent burnout among healthcare professionals, as it will improve social conditions, structure labor of healthcare professionals and develop the system of healthcare organization.

In the social dimension, we consider prevention of burnout among healthcare professionals in the context of functioning and improvement of Public Health, system organizing medical activity and system of society- based medical education. In the personal (existential) dimension, it’s necessary to focus mainly on psychological and emotional factors that lead to burnout of healthcare professionals and possible ways of their prevention.

As far as the existential dimension goes, considering a healthcare professional as a separate person, but not as the ‘resumed in the long term’ healthcare resource, signs of emotional burnout are manifested in the broadest sense — from personal crisis to suicide. For instance, according to US-based researches, 300–400 therapists die because of burnout (the data are approximate with no exact statistics left). The thoughts emerge in up to 7% of healthcare professionals who participated in the interrogation, whereas 35% noted that they wouldn’t ask for help in case of those thoughts [5].

According to WHO, healthcare professionals commit suicide 1.5–4 times more frequently than representatives of other professions, irrespective of gender. This is most frequently observed among those who have access to medicinal preparations used as a tool for suicide [6, 4].

Among possible preconditions leading to such a tragic scenario, the lack of ethical and communication knowledge and skills is of great importance. Ethical pluralism, collision of absolutist and utilitarian strategies, replacement of an ethical constituent with common sense, collision of ethical ideology and legal standards, political collisions, and economical factors become a heavy load for a modern healthcare professional.

The issue is that ethical (bioethical) preparation of healthcare professionals frequently remains at the level of the Hippocratic oath. It doesn’t include examination of modern developments, recommendations, provisions of international instruments and, finally, principles and rules of modern bioethical ethics and cases extracted from Russian and international medical practice. Holding discussions regarding biochemical (medical) ethics, authors repeatedly faced the issues of total ignorance by doctors (nurses) of the ВМА International Code of Medical Ethics [7], Convention on Human Rights and Biomedicine [8], etc., basic ethical recommendations, for instance, on working with children, patients with mental diseases, taking medical decisions regarding the end of life, algorithm of working with informed consent, ethical and legal issues of compliance with medical confidentiality, etc. [9].

Fostering modern ethical consciousness, ability to navigate in complex and multiple- valued situations and understanding significance of the multidisciplinary approach in healthcare professionals constitute an obligatory condition for professional medical education, including the system of advanced training among healthcare professionals. Thus, advanced training courses such as Ethical and legal activity framework of healthcare ethics committees and commissions, Ethical and legal competence of a doctor, Bioethical aspects of communication in healthcare, created to develop ethical skills among doctors based on modern ethical and legal principles and rules are very popular at the Belarusian Medical Academy of Postgraduate Education. A serious disadvantage is that the capacity of these courses is currently insignificant. That’s why they are basically visited by healthcare supervisors who are supposed to educate their employees later. It would be correct to expand the education/provide advance training to ordinary doctors and nurses using ethical (bioethical) subjects in medical universities, constant training, courses, master classes.

The activity can be carried out not by state structures only, but also by public medical associations and organizations, journals, etc. A positive example can be represented by a number of conferences in Minsk in 2016–2019 organized by the Ministry of Health of the Republic of Belarus supported by the Committee on Bioethics (DH-BIO) at the Council of Europe, on Human Rights and Biomedicine for Medical and Legal Employees; Scientific and Practical Conference ‘Ethical and Legal Issues of Ensuring Rights of Patients and Healthcare Professionals under conditions of modern healthcare’ (Jurspectr) held in 2019, constant ethics column in Head Nurse journal (Grevtsov Information Agency), organization of ‘Doctor- patient’ column on site of Center for Republican Bioethics (https://bioethics.belmapo.by/), etc.

Another significant factor that indirectly influences occupational burnout in the medical environment includes expanded patient’s autonomy. On the one hand, this is a regular process that develops self-consciousness of a modern patient; on the other hand, the process also has a negative constituent resulting in a growing number of cases of the so-called ‘patient’s extremism’ via unreasonable complaints about doctors and nurses. According to the interview held in November 2019 by Doctor at Work social network and RNC Pharma, 63% of patients asking for help display inadequate behavior, 32% of doctors have come across rudeness of patients and consider this as a typical behavior, and only 3% of them noted that during a medical interview, patients act in a polite and civil way [10].

At the same time, the growing autonomy of a patient should be taken both as a natural process of human and society development, and as the developing process of ‘separation of responsibility’, which recognizes the absolute right of a patient to take decisions about his own life and health. Unfortunately, healthcare professionals frequently refuse the right of a patient for the autonomy, assuming that they are better aware of the situation and can take a better and more informed decision [11]. On the one hand, a healthcare professional puts pressure with subsequent additional emotional burden, and, on the other hand, he/she is not ready (and is not always able) to listen to a patient. This prevents him/her from sharing responsibility and letting go of the situation.

As far as burnout prevention goes, special attention is given to the skill of empathy. In the medical environment, it is taken as a feeling that comes with experience. However, a healthcare professional needs to be taught a correct manifestation of empathy, as this developed skill is an burnout barrier. Empathy of a healthcare professional should not be taken as regular compassion, but is more like sympathy with involvement into the problems of others, joint compassion with emphasis on emotionality and own involvement into the problem [12]. Empathy, which is essential to a healthcare professional without an effect of burnout intensifying factor, means practical compassion and involvement, with emphasis on sympathy through activity, practical aid and using practical skills for its implementation.

During an anonymous interview of healthcare professionals and patients (50 medical practitioners and 50 patients) held in 2018, those surveyed were offered to enumerate and distribute by significance/positions (1–4) attributes determined by them as essential to doctors/patients and expected to be seen during attendance. While developing a table of mutual expectations, almost every patient placed empathy and communication skills first, and respect second. The same goes with priorities of healthcare professionals towards patients: first, positive mood and ability to communicate, second, respect. Moreover, emphasis on professional data in the list of patients’ expectations was made in the third line of the summary table only denoted as ‘intelligence and knowledge’ and ‘love for profession’ (table).

Thus, social skills should be obligatorily developed in every healthcare professional. They include not only knowledge and proper ethical values, but also an ability to use communication skills and technologies of communication. This can be promoted using special training courses, seminars, further education courses (for instance, such courses as ‘Culture of social relations’ or ‘Technologies of business communications’ developed at the department of public health and healthcare of the Belarusian Medical Academy of Postgraduate Education).

Basic ethical and communication principles and practical skills that promote positive doctor- patient relations and, as a consequence, prevent a healthcare professional from emotional burnout, include as follows:

• being patient- centered and human-c entered;
• display respect for a patient comprehended as respect for a patient’s dignity, his values, priorities and decisions, including when the patient consciously refuses help (a healthcare professional can explain and give an advice but has no moral right to put pressure, urge and teach);
• follow the rule of telling patients the truth (about the diagnosis, condition, perspectives, etc.): the truth should be told but this can be done gently and carefully taking into account circumstances and condition of the patient;
• respect confidentiality of patients’ data: remember that conversation regarding the diagnosis, treatment, prognosis and any other personal information should be held with the patient or his/her legal representatives (if the patient is not able take decisions) or with the persons mentioned by the patient;
• an ability to listen to and hear a patient, an ability to start and end a dialogue, prohibition to use euphemisms, uncontrolled vocabulary, slang, etc.;
• encouraging a patient’s communication with his close relatives as this can be the best medicine and the most successful therapy for the patient;
• requirement not to use urgency/occupation as a reason for disrespect or exclusion of formalities when communicating with patients (for instance, not to say hello or knock on the door of the ward, etc.);
• preserve and respect corporate culture, in particular, never display a negative attitude towards actions of other healthcare professionals;
• trying to take care of self by establishing communication borders with a patient (relatives) and communication time limits, having an ability to switch between other (including personal) problems and issues [13].

CONCLUSIONS

Considering highlighting of burnout in modern scientific literature, interviewing and interrogating doctors, patients and nurses and doctors, the authors made certain conclusions.

First, to prevent burnout among healthcare professionals, healthcare system requires restructuring and humanization based on the principles of human centricity, patient- centered practice, and specifics of continuously renewed resource of healthcare professionals. Medical professionals need to be trained in ‘self-saving’; monitoring of the current burnout-r elated situation, management of psychological counselling, building a single system of psychological support and rehabilitation of healthcare professionals affected by the crisis are required. In our opinion, the work should be based on significant country studies that enable to detect an exact percentage of healthcare workers suffering from burnout. Second, ethics and communication training programs that prevent and restrain the process of emotional burnout among healthcare professionals need to be expanded within restructuring of healthcare system. The programs should be held on a constant basis as continuing education courses, thematic conferences, public initiatives, training courses, seminars, etc.

Third, resting on the time inquiry to develop the patient’s autonomous model, it is necessary to work more with people regarding the issue of medical literacy, respect for medical profession, ethical and communication standards of behavior, on the one hand, and improve the system of legal standards that protect a healthcare professional not just from unjust ‘patient’s extremism’, but also from any illegal behavior towards medical personnel, on the other hand.