In the first installment of this two-part episode of Diabetes Care Conversations, host Dr. Paola Acevedo sits down with clinical health psychologist and diabetes researcher Dr. Mary de Groot to explore burnout among diabetes care professionals. They discuss what burnout is, why diabetes care and education specialists are especially vulnerable, and how workplace culture, organizational systems, and personal well-being influence professional fulfillment and burnout.
Visit ADCES.org for more resources on all things DCES, and join us next time for part 2 of this episode!
Dr. Paola Acevedo
For diabetes care and education specialists, the work is deeply meaningful. It involves building long-term relationships, supporting behavior change, navigating complex health systems, and helping people manage a condition that never takes a day off. But those same qualities that make the work rewarding can also make it emotionally demanding. Welcome to Diabetes Care Conversations. I'm Dr. Paola Acevedo, a primary care clinical pharmacist and certified diabetes care and education specialist.
In this episode, we'll explore what burnout really is, how it manifests among healthcare providers, and why diabetes professionals may be particularly vulnerable. We'll discuss the role of expectations from ourselves, our patients, and our health systems, the parallels between provider burnout and diabetes distress, early warning signs to watch for, and practical strategies that individuals and organizations can use to foster resilience and professional fulfillment. I'm delighted to be joined today by Dr. Mary de Groot, a clinical health psychologist and diabetes researcher whose work has helped shape our understanding of the link between diabetes and depression and the emotional and behavioral aspects of diabetes care. Dr. de Groot, thank you so much for joining us.
Dr. Mary de Groot
Thank you so much for having me. It's a pleasure to join you.
Dr. Acevedo
To set the stage for our conversation, I'd like to start by better understanding what burnout actually looks like in healthcare. We hear that term very often, but it can mean different things to different people. What are the components of work-related burnout and how do we see them manifest in healthcare providers?
Dr. de Groot
That's a wonderful question. And I love that we're talking about this topic because it's so timely and so relevant to so many of our settings and also to so many diabetes care and education specialists. So I'm just delighted to be able to talk with you about this today. When we think about burnout, the traditional definition of burnout is that it is a state of persistent exhaustion, depersonalization, and a decreased sense of personal accomplishment. And that goes back to the original constructs of burnout that was innovated by Christina Maslach and her colleagues. And while we think about burnout as an experience of individuals, our thinking and our research about burnout has evolved to a larger understanding that burnout is not a function of poor resilience or of weakness on the part of healthcare providers that are very strong and are very giving of their time and energy, but really is a characteristic of institutions that affects individuals, leadership, our patients, right? It has enormous effects. So there are different models of well-being and professional well-being and burnout. One of the models that I like to think about that I find very useful evolved from work that Tait Schanafelt and others have done at the Mayo Clinic and now at the Stanford Center for Professional Wellbeing. And the Stanford model has three components that surround personal and professional fulfillment. One component is the culture of wellness in an organization. So that's resources that are available, the values alignment that may be happening, c peer support, appreciation, flexibility. There's another component that surrounds professional fulfillment and that is efficiency of practice.
So what are the tools, what are the elements that are at the system level that either contribute to how well we're doing and how well we can do our work, or that become the pebbles in our shoes. So that can be our electronic medical record systems, that can be our workflows, that can be scheduling, that can be clerical burden, patient flow, all of those kinds of operational elements. And then the third component is personal resilience. So that tends to be located at the individual level and we interact with these other cultural and operational elements. So that's our ability to get good sleep. That's our self-care. That's how all of the other parts of our lives intersect with our professional work and identity and well-being. So I like the Stanford model because it really speaks to the complexity of what we mean by well-being and wellness at a professional level. And also speaks to many of the different elements that are both drivers and also that are solutions when our well-being is not at the level where we want it to be or worse yet, we're at the level of burnout.
Dr. Acevedo
Now that we've established what burnout is and how it manifests, let's narrow our focus to diabetes care specifically. Why does diabetes care lend itself to burnout among clinicians and educators?
Dr. de Groot
Well, there's a number of factors. So first, I mean, thinking about what's the prevalence of burnout. Well, we don't have specific numbers specifically for diabetes care and education specialists who represent a spectrum of professional guilds, right? So nursing, pharmacists, dietitians, psychologists, some like myself. We do know that when we look at individual types, we know that burnout rates have been very high. So data that's been presented by the American Nursing Association, for example, that dates back to 2020. So it is a little bit dated at this point, found that burnout rates among nurses were as high as 62%. And among young nurses, those that were 25 years of age or younger were up to 69% just five years ago. So even if our burnout rates aren't quite as high as they were in the midst of the COVID 19 pandemic, one of the things that we recognize is that people have lived with that experience and carry that experience with them. And recovery has a very long tail, up to two to five years following an epidemic. And so, of course, we had a worldwide pandemic, and we can expect that recovery tail to be even longer. And we see that among physicians as well. Why do we care about burnout? Well, we care because we care about health professionals, which health professionals are very important to our diabetes community. We know that some of the impacts of burnout include suboptimal patient care, decreased productivity, decreased job satisfaction, and high rates of turnover. There was a recent meta-analysis that was conducted by Lee and colleagues in 2024, so just a couple of years ago. There was a meta-analysis of 85 studies that included almost 300,000 nurses.
And what they found was that burnout was associated with lower patient safety climate, lower patient satisfaction ratings, lower nurse-assessed quality of care, increased infections, increased patient falls, increased medication errors. And many of these we would consider to be a function of inpatient care, and that certainly matters, but then also has implications for outpatient care, which is typically the milieu for diabetes care and education specialists.
And then we know that the drivers of burnout include excessive workload and job demands, lack of control and flexibility, difficulties with work life integration. So how do I keep all of the spinning plates spinning? Isolation of lack of social support at work, problems with organizational culture and values, and inefficiency and inadequate resources.
So we have that all as kind of a background, right? And then to your question about, well, how does this apply to diabetes care and education specialists? Well, when we think about the context of providing diabetes-related care, we are not talking about an acute model, right? Diabetes is a lifetime gig for our patients. And for many of us, we have long term relationships with our patients. On the one hand, that can be very fulfilling.
Right. So that we can see a patient grow. We can be with the patient as they go on their journey through different developmental life stages. And that can be a source of fulfillment. But it's also demanding, right? The 24-7, 365 demands that are on the patient are also the repeated kinds of challenges that our patients can bring to healthcare providers. And sometimes it can feel like we're on a treadmill and that we're just not making, we're not getting traction in having patients meet the goals that we know would be.
And that evidence tells us could be healthy for them. We also know that our patients and healthcare providers struggle with access to supplies, to medications. There are many financial constraints. Some of those financial constraints are increasing as there'll be changes at the state level to Medicaid programs, and that there's more work involved and more hassle involved for patients and also for all of us in healthcare to provide the necessary documentation, prior authorizations, all of these pieces that connect patients to the medications and the devices that we know would best serve them. We're in a unique time in the history of diabetes where we have more devices, more medications than we've ever had at any other point in the history of this disease. But they're only as good as the way our patients use them and if they have access to them. And so there's more work involved there.
We also have demands from a healthcare provider perspective on the evolution of technology. So as great as it is to have more technological devices, to have automated systems that correct blood sugars through insulin pumps and all other manner of technology, it also means that there's a steeper learning curve for all of us. So that we need to be on the front lines of teaching our patients. Again, that can be a plus, right? We're learning, we're growing, there's new innovation.
That can be very exciting, but it can also increase the cognitive demand for healthcare providers because we have more data that we need to sift through when we're meeting with a patient, but we don't necessarily have more time to meet with that patient. And then the last thing that I would add to this is the risk of unrealistic expectations. And that can come from multiple sources. So one of those can be unrealistic expectations that our patients bring to us. Here is my diabetes, please fix me, right? Or you're the diabetes expert, so your job is to manage diabetes, right?
Dr. Acevedo
Thank you for highlighting those factors that are unique to diabetes professionals, including the double-edged sword that is diabetes care as a whole. I think that is something our listeners will really relate to. And I think that's a perfect segue to this next thought. One of the things that makes diabetes care so meaningful is how invested we become in helping people succeed. But that same commitment can sometimes create pressures, both internal and external. What role do unrealistic expectations, both self-imposed and from patients, health systems or caregivers play in burnout among diabetes professionals?
Dr. de Groot
Those may be implicit or maybe even explicit statements that some of our patients may have, or that may be their theory of health about diabetes. And if we side with that, then we're really, you know, doing a disservice to helping patients understand that they're the ones on the ground doing the 24-7-365 management. And our job is to be a support person. Sometimes we can have unrealistic expectations of ourselves, right? We can put excessive pressure on ourselves. We want the best for our patients.
We want our patients to meet their A1C targets or other self-management goals. And we may have a tendency to take on more responsibility than is ours to have or ours to manage. And so that's a risk if we're piling that pressure on ourselves. Guilt is another piece, right? If we're feeling helpless, if a patient isn't making the progress that we would love for them to make, we may internalize that ourselves. We may personalize that in ways that may not be really appropriate to the situation. But we carry that with us anyway.
And then lastly, there's an institutional piece. So there are quality metrics that are built into the reimbursement processes for hospital systems, and that can have effects on how we are evaluated. For some people, that can have effects on how they're compensated. If we are held responsible for A1C levels across a clinic and our compensation is dependent on that, that can feel like a very and can be a very unfair quality metric because we can't directly change a patient's A1C. Even patients can't directly change an A1C. They can influence it with all of the tools that we can provide them and we can help to influence them. But having that kind of direct impact on us from a compensation perspective can really raise the stakes, the pressure, and also the unrealistic expectations on the part of the system. And also on the part of individuals.
Dr. Acevedo
You've highlighted that burnout isn't simply about working too hard or caring too much. There's clearly a much bigger picture involving both the individual and the systems we work in. In diabetes care, what are the biggest personal and organizational contributors to burnout? And how can providers distinguish between challenges they can address themselves versus those that require system level change?
Dr. de Groot
That's an excellent question. And one of the things that I wanted to share with you was some work that I did with Dr. Michael Craven and Dr. Zachary Simons and Dr. Elizabeth Vrany. It was work that we did back in 2018, 2019 to better understand what diabetes distress looks like for diabetes healthcare professionals. So that includes physicians, pharmacists, nurses, dietitians, psychologists, the full spectrum of providers.
And we started by conducting qualitative interviews. So we conducted twenty-two qualitative interviews with a variety of healthcare providers, so including all of those folks that I just mentioned, to better understand what their experience was of providing care in diabetes and what were some of the strains and stresses. And what made me curious about this to even start this study was just my own personal experiences and being embedded as a clinical health psychologist in an adult endocrinology practice where we have a multidisciplinary team. We have a wonderful 32 fantastic diabetes care and education specialists, another 30 endocrinologists across our statewide health system. And I could see struggle in my patients and I could also see struggles in their providers and would hear about some of those struggles in the patient sessions. And so all of that kind of became something that I became curious about. So over the course of these interviews, what we found was that we conducted an analysis of the data and identified five key themes in the data. The first one was difficulty dealing with self-care demands, barriers in non-adherence among patients. A second theme was the emotions associated with treating patients with diabetes. A third was emotional fatigue that accompanies treating diabetes. The fourth was a lack of clear role definition in diabetes care. So who's covering which aspect of diabetes care when that isn't clear? And then finally barriers and supports in the work environment. And so even in this list of themes, right, you can hear that there's both a individual side of the experience and also systems level and operational factors with that.
And that work led us to develop a measure called the Diabetes Related Emotional and Attitudinal Distress Measure, which of course is an acronym that's stands for DREAD D-R-E-A-D. But that measure, these qualitative interviews really gave us an opportunity to develop items that would help us to capture diabetes related distress among healthcare professionals. And of course, we know that we have diabetes-related distress measures for every other aspect of what I affectionately term diabetes land, that is all of us connected to diabetes. We have measures for parents, we have measures for children with type 1 diabetes, we have measures for adults with type 1, adults with type 2 diabetes. And so this seemed like the perfect companion. What we found when we validated the measure in a sample of 135 healthcare providers back in 2019, which included 99 nurses, dietitians, and pharmacists, was this subgroup of diabetes care and education specialists were in the middle of the mix across professionals in terms of diabetes distress. So one to five scale, one being mild or no distress, five meaning high levels of distress. And it can be across the 46 items, you can take an average item score. And what we found was that across nurses, across dietitians and pharmacists, they had an average score of 2.3 average item score, which kind of puts them in the middle. The highest group actually were physician assistants, followed by psychologists and endocrinologists. So that was one sample at one point in time. We expect that those kinds of scores would float and change over time and hopefully improve over time. But it does give us one kind of index. We also found with this measure that it correlated very nicely with the Maslach Burnout Inventory. So a gold standard measure of general professional burnout. So while it captured some unique items that were unique to diabetes care and education specialists, it also had some grounding in professional burnout more generally. And so really important for us to pay attention to.
Dr. Acevedo
Dr. de Groot, thank you so much for sharing your insights and expertise with us today. I feel that we could talk about this topic for hours and would actually love to have you back on another episode.
Dr. de Groot
It would be my pleasure.
Dr. Acevedo
We'll pause our conversation for now and pick up again with Dr. de Groot on our next episode of Diabetes Care Conversations. For additional resources on diabetes care and education and professional practice, visit ADCES.org. Thank you all for joining us for this episode of Diabetes Care Conversations. Until next time, take care of yourselves and each other.