Burnout in forensic medicine: prevalence, triggers, coping mechanisms, postive influencing factors and variations between different work categories

In a study by S. Oddie, L. Ousley, seventy one forensic healthcare workers were assessed for burnout using the PNOSS and MBI questionnaires. Findings revealed high levels of EE, moderate levels of DP, and low levels of personal PA. Occupational stressors such as limited resources and organizational issues had the greatest impact on EE, while organizational issues and staff conflict negatively influenced PA [36].

Two other studies explored burnout and occupational stressors in FHW, examining coping mechanisms, mindfulness, personal well-being, and job satisfaction. Kriakous et al. found that challenging patient behaviors, bureaucracy, lack of resources, low job status, and work conflict were associated with moderate levels of stress. High levels of mindfulness were linked to low-stress scores on the SSQ scale and low levels of burnout across all subscales. Prediction analysis illustrated that high levels of total occupational stress can generate high levels of DP but acting with awareness as a coping strategy can counteract DP. They also found that maladaptive coping strategies were predictive of high EE [37]. Elliott and Daley’s study involving 135 FHW, including those from forensic mental health institutions, revealed moderate levels of burnout across all three subscales of the MBI. Psychological distress, chronic stress, and negative coping strategies were associated with high levels of emotional exhaustion, which in turn reduces the overall psychological well-being of the individual. Also, higher levels of EE were observed in people consuming more alcohol. High levels of occupational stress and negative coping mechanisms predicted depersonalization, which was more prevalent in smokers. However, high levels of burnout in terms of PA were observed in only a fifth of the subjects, suggesting that the majority felt confident and rewarded in their work. Elevated occupational stress was associated with work-home conflicts, challenging patient behavior, low job status, lack of staff support, and bureaucracy [38].

Van Der Ploeg and Kleber investigated burnout syndrome and occupational stress among 132 forensic doctors using MBI, IES, QEEW, and CIS scales. They found that frequent acute stressors such as cases involving young children as victims of sexual assault, murder, suicide, aggressive detainees, or decomposed bodies were associated with a critical level of distress in 14% of subjects. There was a proportional relationship between the number of critical incidents and the level of posttraumatic response. Regarding burnout, 40.5% of subjects experienced high levels of DP, followed by EE at 25% and low PA at 20.2%. Individuals with high distress scores on the IES scale were at high risk for fatigue (33%) and burnout (44%). High emotional job demands, insufficient financial rewards, and lack of information from supervisors were identified as the most influential chronic stressors. Forensic doctors experienced more emotional distress, and received less job-related information, but were more satisfied with their financial rewards compared to a reference group. The study concluded that there is a cumulative effect of acute stressors in forensic doctors, with more exposure leading to increased symptoms of intrusion and avoidance [39].

J. Z. Goldstein and H. S. Alesbury conducted a study among FMW in a medical examiner’s office, revealing that 64% of staff felt worn out by work. Self-perceived burnout was associated with contact with human remains and next of kin of victims. Additionally, 50.7% of respondents lacked a current professional or academic community to discuss mental health concerns freely, and 73.9% felt that common mental health issues in their profession were not adequately addressed [40].

In the study involving mortuary staff, which included autopsy technicians, forensic medicine specialists, and residents, chronic stress was found to be triggered primarily by encountering pregnant women and infant victims in 64.1% of the subjects, followed by burned or fragmented corpses in 20.4% of subjects, and putrefied bodies in 15.5% of subjects. High levels of burnout were observed in terms of PA, with 76% of subjects experiencing burnout in this area. However, only 32% and 14% of subjects were diagnosed with high levels of burnout in EE and DP scales, respectively. There was no significant difference in burnout levels between male and female staff members, but autopsy technicians exhibited higher levels of EE, while forensic medicine residents showed lower levels of PA. When examining PTSD symptoms among mortuary staff, autopsy technicians were found to have higher scores for intrusive thoughts, physiological arousal, and avoidance compared to forensic medicine specialists or residents. This suggests that autopsy technicians may be at a higher risk of developing PTSD compared to other roles within the mortuary staff [41].

In the case of FSP, including both laboratory-based and field-based workers, burnout levels were moderate across all subgroups, with no significant differences observed between field-based and lab-based workers. Burnout was associated with low levels of organizational readiness concerning work-related exposures. The need to testify and work with victims families were identified as predictors of secondary traumatic stress among FSP [42].

The correlation between job satisfaction, alexithymia, and burnout was explored in three research articles by M. Iorga, all focusing on forensic pathologists and autopsy technicians [43,44,45]. In these studies, autopsy technicians exhibited lower levels of burnout across all three dimensions, with only 38.6% experiencing low PA. Additionally, only 4.5% of subjects showed definite signs of alexithymia, while 100% expressed high levels of job satisfaction. Critical job-related events and cases with high emotional impact were found to correlate strongly with alexithymia [43]. Exposure to cases involving children as victims of abuse, decomposing bodies, and inmate suicides contributed to emotional disturbance among forensic doctors. While forensic doctors generally exhibited low EE but high DP and low PA, those involved in teaching had higher levels of EE, but also higher PA. Higher job satisfaction was correlated with lower EE levels, while personality traits such as extraversion was associated with lower DP and neuroticism with higher EE [44, 45].

A comprehensive examination of burnout in relation to coping strategies was conducted by R. Sehsah et al. involving 133 forensic doctors, who completed the Brief COPE and MBI inventories. The findings revealed that 57.1% of forensic doctors experienced high levels of EE, 37.6% exhibited high levels of DP, and 66.2% reported low levels of PA. Moreover, 72.9% and 51.9% of participants demonstrated moderate to high levels of EE and DP, respectively, while 75.9% displayed moderate to low levels of PA. Factors associated with moderate to high levels of EE included stressful duties exceeding five per month, male gender, smoking habits, on-call obligations, and roles as forensic MEs. Similarly, individuals with moderate to high DP levels were predominantly young males (< 39 years), smokers, and forensic examiners with frequent stressful duties and on-call responsibilities. Notably, those with low PA were often female practitioners with less than 12 years of experience. Stressful duties reported included involvement in court proceedings, legal executions, exhumations, and cases of sexual assault and child victims. Forensic doctors with high EE tended to employ maladaptive coping mechanisms, while those with high DP levels often resorted to religion or behavioral disengagement. Conversely, individuals with low PA status were less inclined to use active coping strategies, exhibited lower levels of emotional focus, and engaged less in self distraction techniques [46].

Burnout prevalence among forensic medicine workers varies across its three dimensions. On average, 46.75% of individuals experience high levels of EE, 36.00% exhibit significant DP, and 50.23% report low PA. EE and DP levels tend to be higher in forensic doctors, autopsy technicians, and forensic science practitioners exposed to intense stressors.

Autopsy technicians exhibit higher levels of EE and intrusive thoughts, reflecting the intense psychological demands of their work. Forensic medicine residents, however, tend to report lower levels of PA, possibly due to the challenges of early career responsibilities. Field-based forensic science practitioners experience greater stress compared to their lab-based counterparts.

Stressors associated with burnout in FMW include challenging patient behavior, bureaucracy, exposure to traumatic cases such as child homicides and decomposed bodies, lack of resources, and inadequate workplace support. Coping strategies like mindfulness, social support, religion, and humor can help diminish these effects, while maladaptive strategies, such as substance abuse, are associated with poorer outcomes and heightened emotional distress.

Mindfulness has been shown to reduce EE, while acting with awareness helps decrease DP. High job satisfaction is associated with lower levels of EE, highlighting the protective role of workplace fulfillment. Additionally, resilience and personality traits like extraversion are linked to reduced DP, whereas neuroticism contributes to higher EE.

Vicarious trauma, posttraumatic stress syndrome and burnout. Is there a pattern?

In the case of FMW, approximately 13% of workers were likely to have PTSD, 21% experienced mild to moderate depression, and approximately 10% had severe depression. Additionally, 23% experienced mild to moderate anxiety, with 7% experiencing severe anxiety. The latter was more prevalent in younger female individuals, while death investigators appeared more susceptible to depression and PTSD, and administrators to depression and anxiety compared to MEs [47]. Females were observed to be more susceptible to distress intolerance, depression, and PTSD [48]. E. Brandolo and his colleagues observed an association between case exposure in forensic personnel and symptoms of depression and PTSD [49]. Chronic exposure to traumatic cases seemed to raise levels of alienation and negative cognition, leading to PTSD and depression [49]. The most disturbing type of cases for FMW included infant or child homicide, or infant and child accidental death, significantly contributing to depression [47]. Frequent exposure to trauma and distressed family members triggered symptoms of alienation, distress intolerance, and negative cognition, crucial in the development of depression and PTSD [50]. Research on forensic examiners and nurses dealing with sexual assault found VT to be present on average with TAB-S scores ranging from extremely low to very high, with participants reporting higher levels of vicarious trauma in interviews compared to questionnaires. Problem solving, high social support, and avoidance strategies were the main coping mechanisms used in dealing with chronic stress. Also, the study demonstrated that older individuals tend to use more avoidance strategies and rely less on social support [51]. Horvath and Massey evaluated coping strategies and resilience to VT among 120 members of the Faculty of Forensic and Legal Medicine, finding humor, active coping, emotional support, positive reframing, self-distraction, behavioral disengagement, venting, religious behavior, but also substance abuse as frequent coping strategies [52]. Despite lower overall resilience compared to the general population, most respondents exhibited high levels of resilience, suggesting a preference for stressful and emotionally demanding professions. Lower beliefs in a just world and less resilience were associated with higher psychological distress [52].

Forensic staff exposed to tragic events often experience VT and PTSD symptoms, such as distress intolerance and avoidance. Psychological distress and cumulative exposure to traumatic events intensify the risk of burnout and PTSD, suggesting a cyclical relationship where unresolved trauma worsens burnout, which in turn exacerbates vulnerability to PTSD. Both VT and PTSD shares overlapping stressors with burnout such as case exposure to tragic events, emotional distress, and chronic workplace stressors.

Occupational stressors in FMW

Apart from those previously outlined, occupational stress was referenced in six research articles from our database in relation to case exposure, medical or psychological conditions, as well as resilience, personal well-being, and workplace support. Two studies employed a personally designed questionnaire, while two others utilized interviews for assessing occupational stress. One article employed a theoretical narrative approach, while the final article utilized the QEEW and C19FS for measuring work-related stress, RES for resilience, and WBI for personal well-being. Results indicated that 36% of FSP experienced significant chronic stress primarily attributed to workplace scenarios, management/supervisors, or backlog pressure rather than personal life [53]. Notably, field-based workers exhibited higher stress levels than lab-based counterparts, with females reporting higher stress levels overall. Furthermore, 39% of workers believed that stress influenced their decision-making abilities [54]. In the case of FHW, S. Bogaerts et al. noted that individuals scoring low on WBI displayed heightened fear of COVID-19 during the pandemic, leading to increased psychosomatic symptoms and work-related stress. Also, individuals who had sleeping problems and who perceived their work more emotionally demanding reported a lower level of psychological well-being. Conversely, those with greater resilience reported higher psychological well-being, despite facing chronic workplace stressors such as insufficient personal resources, which often led to burnout [55]. During interviews with fourteen FMW, intense chronic workplace stress stemmed primarily from job structure, involving work scenarios related to death and various forms of violence. Workers also struggled to compartmentalize personal and professional lives, often becoming emotionally invested in cases. Inadequate building structures, secondary work overload, contamination risk from corpses, and the lack of protective equipment were identified as significant chronic stressors [56]. H. Shahnavazi’s findings from interviews with twelve forensic experts underscored that occupational stress, physical illness symptoms, depression, and psychological deterioration were predominantly linked to work and/or family conflict, interference with work duties, and the overall stressful environment within the Forensic Medicine department [57]. Additionally, employees felt their supervisors lacked concern for their physical and mental well-being, contributing to a detrimental cycle [57, 58].