1. Burnout is a multifactorial workplace phenomenon 

There is no clear consensus on how to define burnout (Tomczak & Kulikowski 2023). 

It is not a medical or mental health condition. 

The World Health Organization (2019) describes it as an occupational phenomenon resulting from ‘chronic workplace stress that has not been successfully managed’. 

This definition of burnout references three dimensions: exhaustion; detachment, hopelessness and cynicism related to one’s job; and a diminished sense of professional accomplishment. 

It is well accepted that physiotherapists experience symptoms of burnout (Brooke et al 2020, Burri et al 2022). 

Practitioners who spend more time in direct patient care are more significantly impacted (Patel & Bartholomew 2021). 

Risk factors have been identified as unavoidable (age, gender, professional experience and years of employment) and avoidable (Burri et al 2022). 

Avoidable factors may be organisational (relentless workloads, financial dissatisfaction and lack of control), psycho-emotional (stress, mental health, unsatisfactory workplace relationships, substance misuse and perfectionism), environmental (workplace settings, ethical demands and conflicts) and/or personal (general health, social networks, relationships). 

Neurodivergence and burnout is an emerging field of research. 

It is important to distinguish between the terms ‘autistic burnout’— experienced by people with neurodivergence in response to the demands of daily life— and ‘occupational burnout in people who identify as neurodivergent’. 

Features include mismatched expectations and reduced tolerance to stimulus (Tomczak & Kulikowski 2023). 

2. Burnout has impacts and consequences 

Burnout affects patients, physiotherapists and organisations (Biggs et al 2025). 

Patients report higher levels of dissatisfaction and reduced functional outcomes (Salyers et al 2017, Rogan et al 2019), which in turn discourage future help seeking due to lack of trust and impaired belief in treatment efficacy (McLaren et al 2023). 

Organisational impacts include decreased productivity and reduced patient retention (Salyers et al 2017). 

Increases in medical errors affect patient safety and organisational liability and generate psychological distress for the practitioner (Rogan et al 2019). 

Distress and lack of job satisfaction are associated with absenteeism and job leaving (Burri et al 2022). 

Attrition and workforce shortages then increase workload demands for those who remain. 

The personal toll on physiotherapists is significant—decreased job satisfaction, empathic fatigue, cynicism towards patients, difficulty concentrating, irritation, disordered eating, sleep disturbance, low motivation and increases in headaches and other bodily pains (Kim et al 2020). 

There is increased risk of developing cardiovascular, respiratory and gastrointestinal conditions (Salvagioni et al 2017). 

While burnout is not depression, burnout has been shown to have a significant relationship with both depression and anxiety (Koutsimani et al 2019) and relationships exist between burnout and moral injury (Biggs et al 2025). 

3 Moral injury is different from burnout and fatigue 

Moral injury was originally discussed in relation to military personnel. 

The concept has since been expanded to include healthcare workers (Koenig & Zaben 2021). 

Moral injury describes the strong cognitive and emotional responses that may follow involvement in or witnessing of events that violate a person’s moral or ethical code (Williamson et al 2021). 

It usually involves perceived moral betrayal by someone of higher authority (Biggs et al 2025). 

Healthcare workers are at risk of experiencing moral distress on a frequent basis, resulting in cumulative harm (Rabin et al 2023). 

Physiotherapists hold strong ethical values and have high expectations of standards of care. 

Moral conflicts can occur when facing chronic understaffing, lack of resources, funding concerns, lack of involvement in policymaking and decisionmaking and perceived lack of support (Rabin et al 2023, Biggs et al 2025). 

The perception of being coerced to deliver suboptimal care can trigger feelings of inflicting harm or withholding benefit and generate psychological distress. 

Moral injury is not a diagnosable mental health disorder. Essential features are shame and guilt and maladaptive coping strategies such as substance misuse, social withdrawal and self-destructive behaviours. 

There is heightened risk for post-traumatic stress disorder, depression and suicidality (Williamson et al 2021). 

4. Compassion fatigue does not mean caring too much 

Physiotherapists, like many healthcare professionals, are susceptible to compassion fatigue (McGrath et al 2024b). 

While compassion fatigue shares certain conceptual similarities with moral injury and burnout, its primary characteristic is emotional exhaustion resulting from empathetically engaging with patients who are experiencing significant distress (Hofmeyer et al 2020). 

Some researchers have suggested that compassion fatigue could be more accurately described as ‘empathetic distress fatigue’ (Hofmeyer et al 2020). 

Repeated exposure to patients’ trauma, pain or distress can have cumulative effects on a physiotherapist’s mental health and professional wellbeing (McGrath et al 2024b). 

These effects may manifest as emotional detachment, diminished empathy or emotional numbness and, in some cases, may contribute to decisions to reduce clinical work, change clinical settings or leave the profession altogether (McGrath et al 2024b). 

Physiotherapists working in settings where clients experience high levels of psychological distress are particularly vulnerable to compassion fatigue (McGrath et al 2024b, McGrath et al 2024a, McGrath et al 2024c). 

However, factors such as organisational support, effective self-care strategies and individual differences like personality and the tendency to engage (or not engage) empathetically with patients can influence whether compassion fatigue occurs (Rivera-Kloeppel & Mendenhall 2023). 

5. Strategies should be tailored to the physiotherapist and the workplace 

Identifying risk factors within organisations is crucial for developing targeted prevention and intervention strategies (Burri et al 2022). 

Strategies to prevent burnout, moral injury and compassion fatigue work best when they reflect practitioner needs and specific workplace stressors. 

Interventions such as clinical supervision, boundary setting, workload adjustment, access to employee assistance programs and downtime outside of work are universally beneficial (Currie & Dafny 2025). 

Assessment tools can help. The Maslach Burnout Inventory-General Survey 9 assesses burnout based on three dimensions (Wang et al 2024). 

The 30-item Professional Quality of Life Scale 5 measures compassion fatigue, work satisfaction and burnout. 

Recent studies suggest that an adjusted 21-item scale has greater stability (Singh et al 2024). 

Moral injury will not be adequately captured without relevant measures such as the Moral Injury Outcome Scale (Litz et al 2022). 

Another way to approach workplace stress in physiotherapy is the job demands– resources model (Patel & Bartholomew 2021). 

An imbalance between demands and resources generates job stress and contributes to burnout (Bakker & Demerouti 2017). 

A study investigating this model within physiotherapy identified job demands of secondary trauma and physical load and found that autonomy, competency, relatedness, impact and respect had a buffering effect (Patel & Bartholomew 2021).

>>>Ellen Lake APAM is the current national chair of the APA Mental Health group and vice-president of the International Organization of Physical Therapy in Mental Health. She works as a clinician in a community private practice and as a senior physiotherapist with Active Rehabilitation Physiotherapy. Ellen is a registered counsellor and cognitive behaviour therapist. 

>>>Dr Ryan McGrath APAM is a discipline lead and senior lecturer in physiotherapy at La Trobe Rural Health School, La Trobe University. Ryan is passionate about bridging the divide between physical and mental healthcare by upskilling physiotherapists in mental health. He is a member of the Mental Health group. 

>>>Irene Ais APAM is an integrative physiotherapist, somatic facilitator and educator. Irene is interested in mind–body connections and in the intersection of yoga, meditation and clinical physiotherapy for people living with stress, pain and chronic illness. She is a committee member of the Victorian branch of the Mental Health group.

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