Burnout in practice: A qualitative study of the impact of organizational factors on burnout and patient care among VA mental health providers

Abstract

Organizational causes of burnout among mental health providers (MHPs) are extensively documented in the literature. Additionally, several studies have established a relationship between higher burnout rates and poorer patient care. However, it remains unclear whether worse patient care results from organizational causes of burnout, MHP burnout itself, or a combination of both. Therefore, an in-depth qualitative exploration of MHPs’ experiences with organizational causes of burnout and their perceptions of how these causes may affect patient care was conducted. Fifty-four MHPs (i.e., social workers, psychologists and psychiatrists) across nine Veteran Health Administration (VA) medical centers participated in semi-structured interviews. Content analysis was used to analyze the data. Findings revealed a complex relationship between organizational factors and individual behaviors influenced by burnout, and their potential impact on patient care. MHPs’ acknowledged that their burnout could impact the quality of care provided to Veterans. The behaviors associated with burnout, such as disengagement, lack of empathy, distraction, lack of preparedness, and procrastination, may inadvertently compromise the therapeutic alliance and the overall efficacy of treatment. Findings also indicated that MHP experienced moral distress from the dissonance between the desire to provide high-quality care and the reality of institutional constraints. Additionally, MHP burnout impacted Veterans’ trust and engagement with the VA mental health care system. Therefore, addressing burnout requires a multifaceted approach including organizational reforms, support and resources for MHPs, and dedicated support for MHPs to deliver high quality care. Our findings emphasize the critical need for organizational-level interventions that prioritize clinical care over bureaucratic demands.

Background

Burnout among mental health providers (MHPs) has been widely recognized as a significant issue (Morse et al., 2012, Vivolo et al., 2022, Westwood et al., 2017), particularly within the Veterans Health Administration (VA). Within the VA, MHPs experience burnout rates second only to those of primary care physicians (Zivin et al., 2020). Despite these high burnout levels, VA MHPs continue to provide high-quality, integrated mental health services, often surpassing non-VA facilities in terms of timely and effective care (Apaydin et al., 2023, Loho and Rosenheck, 2023, Rand Corporation, 2019, Watkins et al., 2016). This indicates that, although experiencing burnout, MHPs may still be capable of delivering effective care, but it may come at a cost to their own wellbeing and personal standards.

Burnout is generally characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment (Maslach & Leiter, 2017). Numerous studies have identified systemic factors contributing to burnout, particularly organizational constraints and pressures that MHPs face in their daily work. These include high caseloads, insufficient resources, lack of autonomy, low wages, inadequate support from colleagues and supervisors, and unrealistic productivity expectations. Additionally, MHPs working with trauma-exposed clients are at heightened risk of burnout due to the emotional toll of continuous exposure to patient suffering (Eliacin et al., 2018, Garcia et al., 2014, Hallett et al., 2024, McCormack et al., 2018, Rollins et al., 2021, Villarosa-Hurlocker et al., 2019, Yang and Hayes, 2020).

One key concept that is particularly relevant to the burnout experience is moral distress. Moral distress occurs when MHPs recognize the ethically correct course of action, but feel unable to act due to organizational constraints (Jameton, 1984). This phenomenon is exacerbated by the same organizational factors contributing to burnout, creating a cycle where burnout and moral distress mutually reinforce each other (Maunder et al., 2023). Both burnout and moral distress are shaped by systemic issues such as heavy workloads, inadequate resources, and lack of supervisory support, which can impede MHPs from delivering care that aligns with their professional and ethical standards (Delfrate et al., 2018, Lamoureux et al., 2024), possibly affecting patient care.

The organizational consequences of burnout can be profound. High levels of burnout among MHPs often lead to increased staff turnover as providers leave toxic work environments in search of less demanding positions (Fukui et al., 2019, Yanchus et al., 2017). This turnover creates a ripple effect in which remaining staff members must take on heavier caseloads, leading to further burnout and exacerbating the cycle of staff departures (Fukui et al., 2019, Hallett et al., 2024). In turn, this creates a strained work environment with insufficient resources to meet patient needs. MHPs under these conditions often have less time to dedicate to each patient which can result in fewer therapy sessions, rushed appointments, and less individualized care. In addition to reduced time for patient interactions, burnout has been associated with decreased productivity, lower quality of work, and an increased likelihood of making errors (Maslach and Leiter, 2017, Salyers et al., 2017). These factors may further erode the quality of care that patients receive. Other negative consequences of burnout include diminished empathy (compassion fatigue), emotional disengagement, and depersonalization, all of which can undermine the therapeutic relationship between MHPs and their patients (Eliacin et al., 2018, McCormack et al., 2018, Salyers et al., 2017, Salyers et al., 2015a).

The impact of burnout on patient care is multifaceted. Several studies have established a link between high burnout levels among MHPs and compromised patient care. These effects include disruptions in the therapeutic relationship, reduced patient trust, and diminished engagement in the treatment process (Delgadillo et al., 2018, Salyers et al., 2017). Burnout-related staff turnover leads to increased wait times for patients and often results in inconsistent care, which further hampers the patient-provider relationship (Fukui et al., 2019, Salyers et al., 2015b, Yanchus et al., 2017). Research has also shown that MHPs' perceptions of patient care, including patient satisfaction and the therapeutic alliance, tend to decline in relation to their own increased burnout levels (Salyers et al., 2015a, Salyers et al., 2015b). However, MHPs perceptions may be influenced by the cognitive and emotional toll of burnout itself, leading them to a distorted evaluation of the care they provide (Yang & Hayes, 2020). Although burnout may affect how mental health professionals feel about their own effectiveness, studies indicate that it does not always translate into observable decreases in patient care quality, such as higher referral or hospitalization rates (Zivin et al., 2023). Thus, burnout may skew MHPs' perceptions of the care they provide, leading to a disconnect between their perceived and actual performance. While burnout may not always translate into a tangible decline in all aspects of patient care, it can still have significant effects on MHP wellbeing and the quality of the therapeutic relationship, especially in terms of building and maintaining patient trust.

Trust in healthcare providers is a critical element in the effectiveness of treatment. Studies have shown that trust is associated with better treatment adherence, improved patient satisfaction, reduced anxiety about care, and more collaborative decision-making (Pyne et al., 2023). However, for MHPs experiencing burnout, the ability to establish and maintain trust with patients may be compromised by organizational constraints such as high caseloads, insufficient appointment availability, and time pressures. These challenges may make it difficult for MHPs to engage with patients on a deeper, more personal level, thereby potentially undermining the therapeutic alliance and affecting the overall quality of care (Pyne et al., 2023). Additionally, turnover among MHPs can affect patient trust, since frequent changes in providers may disrupt continuity of care, leaving patients feeling uncertain and less confident in the therapeutic relationship.

Specifically, within the VA, burnout among mental health providers arises from both institutional and organizational influences. Institutional factors, such as system-wide policies supporting evidence-based psychotherapies can reduce burnout and improve job satisfaction (Sripada et al., 2024); however, organizational factors, including workload, staffing, administrative demands, resources etc., directly shape providers’ day-to-day experiences and have been identified as primary contributors to burnout (Zivin et al., 2023). Because this study is grounded in frontline providers’ experiences, we focused on organizational-level factors, which are most proximal to daily work and directly influence patient interactions. Burnout at this level can affect engagement, effectiveness, and the therapeutic relationship, underscoring the importance of understanding organizational contributors. Following this line of thinking, this study asks, “What are the organizational factors that contribute to mental health provider burnout, and how do these factors influence patient care?”

Methods

Setting and study design

The VA—the context for this study—is the largest integrated healthcare system in the US and treats complex mental health conditions (Apaydin et al., 2023, Watkins et al., 2016). Data used for this study were drawn from a larger mixed-methods study that aimed to characterize variation in MHP burnout across VA facilities and identify workplace characteristics that contributed to burnout (Zivin et al., 2022). Quantitative data from the larger study were used for sampling purposes (described below). For this qualitative analysis, we used an exploratory design to better understand how MHPs (social workers, psychologists, and psychiatrists) defined and experienced burnout, the organizational factors they identified as contributing to their burnout, and their opinions on how their burnout affected patient care.

In addition to frontline providers, we included mental health leadership to capture organizational perspectives on factors contributing to burnout. Many leaders also provide direct patient care, positioning them uniquely to reflect on systemic influences and clinical realities. Leadership decisions can shape practice environments through staffing, workload, and resource allocation. However, their roles as frontline providers allowed us to better understand how organizational priorities intersect with frontline experiences. Including both groups enabled a comprehensive exploration of organizational dynamics surrounding burnout and their implications for patient care.

This study took place nationally across nine VA medical centers. The VA Ann Arbor Institutional Review Board reviewed and approved this study with a waiver of signed consent (approval no. 1597568).

This study takes an interpretivist epistemological position which assumes that experiences are socially constructed and best understood through the meanings that participants attribute to them (Wells & Giacco, 2025). We approached the study with the view that organizational influences on provider burnout cannot be captured as objective facts, but rather, as situated understandings shaped by context and interaction. This standpoint informed our choice of in-depth qualitative interviews and thematic analysis, which are methods well suited to capturing the complexities of providers’ perspectives. Consistent with this orientation, the research team engaged reflexively throughout the study, acknowledging how our professional backgrounds (e.g., medical anthropology, psychology, public health, and health policy) and assumptions may have influenced data collection, interpretation, and the representation of findings.

Sampling

To guide site selection, we employed a stratified sampling strategy. A stratified sampling approach entails dividing a population into distinct subgroups (strata) based on shared characteristics and then taking a random sample from each of these subgroups to create a representative overall sample. We chose this approach to capture a diverse range of facilities with respect to MHP staffing levels and burnout rates.

We used MHP-to-patient staffing ratios for each VA medical center obtained from the VHA Office of Mental Health and Suicide Prevention. Facilities were grouped into tertiles based on these staffing ratios and categorized as having high, medium, or low staffing. Burnout among MHPs was assessed at the facility level using data from the 2018 VA All Employee Survey (AES), which includes two burnout-related items: emotional exhaustion (“I feel burned out from my work”) and depersonalization (“I worry that this job is hardening me emotionally”). Both items are rated on a one (never) to seven (every day) scale. For each facility, we calculated a Z-score which quantifies the distance between a data point (average facility burnout score) and the mean of a dataset (average burnout scores across all VA facilities) (Schober et al., 2021). Facilities were then grouped into three burnout categories, “low,” “medium,” and “high,” based on the magnitude of their Z-scores (e.g., Z < 1 = low burnout, Z < 2 = medium burnout, Z < 3 = high burnout). Each VA facility was subsequently assigned to one of nine possible strata representing combinations of staffing level and burnout (e.g., high burnout/medium staffing). From each of these nine strata, one site was randomly selected to ensure our sample reflected a range of organizational contexts.

For the MHPs, we used purposeful sampling to create lists of staff from three different job roles (social work, psychology, and psychiatry) to be contacted for recruitment from each site. These three job roles were chosen because the study was focused on burnout among MHPs that provide psychotherapy and other mental health (MH) treatment.

Recruitment

We contacted medical center directors for approval to include their facility in this study. If approval was not obtained, we contacted the next site within the same categorization until we secured participation from all nine combinations. Interviewers were not aware of participants’ burnout level during data collection; that was determined only after discussions of their experiences. Regardless of burnout level, all participants discussed the same organizational factors, allowing for a comprehensive understanding of contributors to burnout.

We emailed MHPs a description of the study, including a study information sheet and instructions on who to contact if interested in participating. We sent a follow-up email a week after the initial email if there was no response, followed by a phone call to gauge interest, describe the study, and answer any questions. If a respondent expressed interest, we scheduled an interview at a time convenient for them. If the provider did not have a phone number, instant messaging through the VA’s chat platform with the same information sent in the initial email was used for contact. If there was no response after two phone calls or an instant message, we considered it a passive decline, and no further attempts were made.

Data Collection

Between August 2021 and May 2022, we conducted semi-structured interviews with 54 MHPs (social workers [N = 19], psychologists [N = 20], psychiatrists [N = 12], and MH leadership [N = 3]) across nine VA sites representing different burnout and staffing levels as described above. At the time of the interviews, the three participants who held MH leadership positions did not serve as frontline providers. Table 1 presents site characteristics and participant roles.

Table 1.

Site and participant characteristics.

Site	Staffing Level	Burnout Level	Leadership Interviewed	Psychiatrists Interviewed	Psychologists Interviewed	Social Workers Interviewed	Total
Site 1	Low	Low	0	0	2	1	3
Site 2	Med	Low	0	2	2	2	6
Site 3	High	Low	0	2	2	2	6
Site 4	Low	Med	2	1	2	3	8
Site 5	Med	Med	0	0	4	2	6
Site 6	High	Med	0	1	3	2	6
Site 7	Low	High	0	3	1	2	6
Site 8	Med	High	1	1	2	2	6
Site 9	High	High	0	1	2	3	7
		TOTAL:	3	12	20	19	54

We conducted interviews via video conferencing, and verbal consent was obtained for the interview and audio-recording prior to beginning the interview. One participant did not want their interview audio-recorded, so handwritten notes were taken by the interviewer. Interviews lasted on average just over an hour. Since participants were VA employees, and interviews were conducted during their work hours; they could not receive payment for their participation.

Open-ended questions focused on better understanding MHPs’ experiences with burnout (e.g., “Can you tell us about a time when you felt particularly burnt out from your job?”), organizational factors that contributed to their burnout (e.g., “What job tasks do you do that contribute most to feelings of burnout?”), effects on professional (including patient care) and personal lives (e.g., “Have you ever felt like burnout affected your ability to care for patients?”), current resources available at their facility to address burnout (e.g., “Are there any current interventions that we haven’t discussed that specifically address burnout?”), and suggestions for how to address MHP burnout. Questions were informed by existing published literature (Eliacin et al., 2018, Fukui et al., 2019, Garcia et al., 2014, McCormack et al., 2018, Morse et al., 2012, Salyers et al., 2015b), AES survey questions, and study team members’ expertise on burnout (Appendix A).

Two team members with experience in qualitative methods conducted interviews. After conducting four interviews, the interviewers met to discuss what they heard and to revise the interview guide. Interviews were audio-recorded and transcribed for analysis. A third study team member, who did not participate in the interviews, listened to the audio recordings and reviewed the transcripts for accuracy and removed all identifiable information.

Data analysis

A multi-step content analysis process was used to analyze the data (Elo & Kyngäs, 2008). First, two team members (MH, LT), who conducted the interviews, began by identifying deductive codes from the interview guide and created a preliminary codebook that included definitions. Second, they independently coded the same transcript to apply deductive codes and identify new inductive codes grounded in the data. Third, the two team members met to review, line-by-line, the applied codes. Agreed-upon inductive codes and their definitions were added to the codebook (Appendix B). Three additional transcripts were coded using this process to ensure consistent application of codes and identification of any new codes. Fourth, once consistency was reached, the remaining transcripts were divided equally between the two team members. If new codes emerged, they were added to the codebook, and previously coded transcripts were reviewed for code applicability. The two team members met weekly to discuss the coding, the coding process, and preliminary findings. Additionally, preliminary findings were presented in larger team meetings throughout the coding process for feedback and discussion.

Once all transcripts were coded, a third qualitative team member uploaded the transcripts into NVivo 12 (QSR International, 2017) and reviewed the coding for accuracy. Code reports aggregating all instances of a given code from all participants were generated and reviewed. Review of code reports allowed for comparison of coded data to ensure accuracy of code application and to identify patterns and themes within and across codes. Memos with supporting quotations were created, summarizing the major findings for each code report. Memos were then grouped based on findings to identify overall emergent themes. For example, the codes “disengagement” and “decreased empathy” were grouped together under the theme “interactions with patients.” Organizational factors that impacted these interactions and contributed to MHP burnout were also identified.

Themes were presented in larger team meetings for discussion and refinement. We ensured the trustworthiness (Shenton, 2004) of the interpretation of findings by involving the larger team, which included researchers and clinicians from diverse training backgrounds and content expertise.

Data saturation often occurs between nine and seventeen interviews (Guest et al., 2006, Hennink and Kaiser, 2022). For this study, we confirmed data saturation during both the data collection and analysis phase. Preliminary review of the transcripts of the first three sites (N = 20 interviews) indicated that data saturation was reached due to no new information being collected. However, given the sampling plan, interviews with MHPs continued until all 54 interviews were completed to ensure no differences between sites were present based on burnout and staffing levels. Data saturation was also confirmed during the analysis process, regardless of burnout or staffing level when no new codes or themes emerged.

Results

Findings revealed a complex relationship between organizational factors and individual behaviors influenced by burnout and their potential impact on patient care. Importantly, when MHPs spoke about their burnout and how they thought it affected their ability to provide care, they identified the organizational factors that caused their burnout and, thus, influenced their behaviors. Themes representing MHPs' experiences with organizational factors contributing to their burnout and how these factors influenced patient care were 1) superficial and routinized interactions with patients, 2) increased distraction, 3) lack of preparedness, 4) procrastination, 5) moral distress, 6) MHPs’ perspectives on patient reactions to their burnout, and 7) mitigating burnout. Each theme is presented below, accompanied by a detailed exploration of the key factors that shape and define each theme. These details provide a deeper understanding of the nuances and variations within each theme, offering a comprehensive understanding of MHPs' burnout and its potential impact on patient care.

Theme 1: Superficial and routinized interactions with patients

MHPs stated they were often not fully present when conducting therapy sessions. They felt pressure to get through the appointment and move on to the next which affected their ability to fully engage with patients. The pressure to see patients consecutively was the result of needing to meet their individualized productivity targets which are metrics specifically calculated for providers based upon assigned work and coding expectations (Department of Veterans Affairs, 2020). MHPs also felt pressured to help meet access metrics. Within the VA, access performance measures assess “average wait times, number of patients waiting for a scheduled appointment and number of patients that cannot be scheduled for an appointment in 90 days or less” (Department of Veterans Affairs, 2021).

MHPs felt the need to meet these measures, but it resulted in them not fully engaging with patients because they were often rushing through an appointment in an attempt to see all their scheduled patients. This lack of engagement meant that they were missing opportunities where psychotherapy could be more beneficial for the patient. The MHPs did not want to “go deeper” (ID 1018, Psychologist) with the patient because they knew that they could not schedule their patient again for another 1–3 months:

The agent of change is to be present with what's happening and emotionally. And I know that is what creates so much movement in them is if I’m really tuned in enough to catch their moments of feeling something and go deeper with them. And with that and be that kind of holding presence, while they identify what that feeling is or what it means to them and what their thoughts. But I’m just kind of numb, and it's not happening. (ID 1018, Psychologist)

MHPs thus attributed this need to get through appointments and not “go deeper” to organizational factors of meeting or exceeding productivity/performance measures, having too many patients on their caseload, the inability to see patients according to evidence-based guidelines (i.e., “therapy dosing”), and having to cover for chronic MHP understaffing. They also had to contend with scheduling constraints and the expectation from their leadership to see more patients. These pressures resulted in MHPs disengaging from moments they knew would benefit patients in order to manage their own burnout.

MHPs also stated that their therapy sessions with patients had become more “routine” and not as “creative.” Their questioning of the patient became more structured and rote, and they did not dig deeper into what the patient was saying, for example:

[T]here's not enough time to do all the administrative tasks in addition to high quality. The thing that we all care about the most is high quality clinical care, but the whole. The thing is that you've got to do all the admin stuff to keep it all moving. (ID 1278, Psychologist)

Several organizational factors attributed to approaching psychotherapy in a more routine way including oversized caseloads, lack of opportunity or support to attend professional development training to learn new skills, lack of time to talk with colleagues about engaging and treating patients, and pressures to complete documentation on time. MHPs stated that given the administrative tasks they have to complete (e.g., scheduling one’s own patients, placing consults, coordinating care, etc.), they did not have the energy or the time to engage in high quality clinical care.

MHPs described struggling to maintain empathy or counterbalance the depressed mood of their patients because of their burnout. In the past, they could manage their lack of empathy by talking with and receiving support from their colleagues; however, due to their need to see one patient after the next, often during their protected time (e.g., lunch or administration time), they could not connect with colleagues where they often found understanding and support. Lack of time, high case and workload, and productivity/performance expectations of seeing patients one after the other contributed to their lack of empathy during interactions with patients. As one participant explained:

I distinctly remember several times, like vets coming in and being like, “[name of provider], I just, I don't want to do, like I'm so depressed…,” and I’m, like (heavy sigh), “I am too, like what do you think I'm going to do about this?” But I did my best to compartmentalize it, but I did feel like I just wasn't on my A-game. (ID 1156, Psychologist)

MHPs thus referred to their lack of empathy as “compassion fatigue” and often felt guilty for not being able to convey empathy or even act empathetic toward their patients. While they identified with their patients’ feelings, they often felt like they could not help.

A few MHPs mentioned that during periods of burnout, they tended to rely on self-management mobile apps such as those for mindfulness or stress reduction exercises during treatment sessions, for instance:

[T]he VA has really promoted smart phone apps and their use of them. And I’ll teach veterans on using them, but in sessions where I’m really burned out, I’ll be like, “Okay, let’s do this breathing exercise on the app.” And I just let the app do the work so I don’t have to engage as much. It does have its utility, but that’s not how I want to be as a clinician. (ID 1380, Social Worker)

In this quote, we can see that although apps helped provide therapeutic content during sessions and MHPs recognized the utility of self-management and educational tools provided by the apps, participants also would have liked to engage in a more interactive exchange during the session which, they felt, would have been more beneficial to the patients, acknowledging that this was a workaround rather than an ideal approach.

Theme 2: Increased distraction

MHPs also stated that they had become more distracted during therapy sessions with patients or while trying to complete documentation requirements. MHPs said that their mind would often wander and that they would “go through the motions” of providing care. A few providers stated that during patient therapy sessions or trying to complete other patient-related care tasks, their computer messaging system would often “ping,” letting them know new requests were coming in. Although their schedule indicated that they were in a session or on administration time (dedicated time set aside to complete documentation requirements and other work-related tasks), easy electronic access to MHPs meant that they were regularly interrupted which elevated their anxiety. These interruptions also reminded them of all the other work (e.g., documentation, administrative tasks, and workload) they needed to complete, distracting from the patient in front of them. For one psychiatrist, having to multi-task to get all their work completed on time with continuous interruptions led to a potentially dangerous patient safety issue:

[T]here was one patient where I accidentally sent him the wrong dose of medication, and fortunately, his wife caught it. And afterwards, I was like, “I don't know how I made that mistake.” And, was it a day where I was getting messages while I was trying to write the prescription, and I just got distracted and I wrote the wrong prescription? And, I don't know what happened. I think that, for me, the biggest issue is, I was just, I'm spending so much time getting pinged to all these other kinds of messages and trying to multi-task while I'm seeing a patient, and am I going to miss something or put something in wrong like this prescription? (ID 1250, Psychiatrist)

Although lapses in patient safety were rarely mentioned by our participants, here, we can see that MHPs were concerned that their distraction during sessions could inadvertently affect the provider-patient therapeutic relationship. They feared that being mentally preoccupied with administrative tasks could hinder their ability to fully engage with patients, resulting in a less empathetic or attentive presence. For many, the ongoing pressure to balance clinical responsibilities with administrative tasks created a sense of cognitive overload, making it more difficult to maintain the level of focus and emotional investment they believed was necessary for effective treatment.

Theme 3: Lack of preparedness

MHPs also stated they felt unprepared for therapy sessions. They stated that their burnout resulted from organizational factors of having too many patients on their panels, not seeing patients as often as they should, and not having time to review patients’ history before seeing them:

I'd say that the hardest session was not the first one, but the second one, because in the first session, you're getting all this information. Second session, you're supposed to remember it, and I wouldn't, don't recognize the person in the waiting area, don’t recognize their name. It usually takes me at least six to eight months of seeing someone before I recognize their name. Would not put their name with them for months, and so it makes it a lot harder to be connected clinically, know what was going on with them. (ID 1232, Psychologist)

In this quote, we can see that MHPs felt like their lack of preparedness impacted their ability to know the patient and develop individualized treatment plans. They stated that although it is important to “clinically connect” with a patient, they could not do so, often due to a lack of energy, time, and attention and feeling overwhelmed. The constant pressure to see a high volume of patients without sufficient time to review patient histories or engage deeply with their cases led to feelings of inadequacy and frustration. Many expressed that they could not provide the level of personalized care they felt their patients deserved, leading to a sense of professional dissatisfaction.

Theme 4: Procrastination

Several providers acknowledged that they put off doing certain tasks because they did not have the energy to complete them. For example, MHPs stated that they often delayed completing documentation requirements, making follow-up phone calls, or requesting referrals for patients due to fatigue, lack of energy, and feeling overwhelmed. They saw documentation requirements as onerous in terms of volume, lack of ease to complete, and unreasonable deadlines, so they tended to avoid these tasks for as long as possible. Several also stated that these tasks (e.g., making follow-up phone calls) were not included in their performance evaluations, even though they represented important, routine aspects of patient care and take time to complete. As one participant explained:

I think what contributed to my fatigue is me constantly guilting myself into saying, “I know I’m not giving 100 % today. I know I'm not making this call to request the service for this person today. I know I'm not touching base with this person today when I should.” I do think it affected my ability to care for my clients on a bunch of levels. (ID 1163, Social Worker)

MHPs recognized that these delays could potentially impact patient care, as missed follow-ups or incomplete documentation could lead to disruptions in treatment plans or delays in necessary referrals. They expressed concern that by postponing certain tasks, they were inadvertently compromising the quality of care they provided. This cycle of delay, fueled by burnout, further exacerbated feelings of guilt and self-criticism, which in turn contributed to the overall emotional toll of their work.

Theme 5: Moral distress

Although moral distress was beyond the scope of this study to fully investigate, a few MHPs identified organizational factors that, for them, resulted in burnout stemming from feelings of delivering “good enough” care (ID 1379, Psychologist). Participants discussed this sentiment within the context of moral distress.

They also identified organizational factors that contributed to their moral distress, consisting of unmanageable work demands that took away from one-on-one treatment, oversized caseloads which resulted in their inability to see patients as often or for as long as they should, the pressure to see as many patients as they could to meet productivity, and performance measures. These factors often left them feeling sad, frustrated, disappointed, and guilty over not being able to provide the care they felt patients needed and deserved.

When asked how they thought burnout affected their and their colleagues’ ability to care for veterans, most MHPs said that they had talked with their colleagues who had also expressed frustration and felt that they were not delivering the care that they felt veterans needed. Because burnout was present throughout the sites interviewed, some MHPs felt that their colleagues’ burnout exacerbated their own; they often had to cover for absent colleagues or for those who refused to take on any additional patients or work because their work and caseloads were already unmanageable, for example:

I think we've seen people [colleagues] very tired, very reticent to take new people. They’re like, “I just can't take another person. I just can't do it right now.” [Sick] days where people start looking for jobs more regularly. (ID 1379, Psychologist)

A few of the participants stated that they also had to deal with feelings of guilt, disappointment and sadness. They felt guilty and disappointed in themselves because they knew they were not giving 100 % of their attention and energy to their patients because of other work demands. They knowingly let tasks slip that could affect patient care. They knew they did not meet their own and their patients’ expectations:

I felt pretty disappointed with how I’m performing when I was doing the best I can, and I felt sad when I couldn't quite meet everything. There would be times where I'd call a person back two weeks after I got alerted to the note, and they were mad at me for not getting back to them sooner. And I could relate, and I understood. And I felt bad about that. And sometimes, I'd eat too much of that pie of guilt and not being enough. (ID 1197, Psychologist)

Notably, despite experiencing guilt, disappointment, and sadness, participants said that they could provide the care veterans needed, but not to level MHPs would prefer.

I feel like I'm giving somebody like 50 % of what I can really give them, and that may be good enough, but for you, intrinsically, it doesn't feel good enough. And you feel like you're just kind of, you’re in slow motion. (ID 1379, Psychologist)

Moral distress, therefore, derived from having to treat patients in a way that went against their personal ethics to meet organizational expectations:

If you want to put like a star next to something, it’s the wait time that people have to access mental health treatment. And that is, creates moral injury in psychotherapists, and then we feel rotten about it. So, not only do we feel bad that people have to wait for treatment, but we also feel bad that we have to rush people through treatment and that we can't give someone an indefinite length of treatment, that we basically have to refer them out if they need more ongoing treatment. It's like Lucille Ball with the [chocolates]. She's learning, and people keep on coming and coming. And you're, like, “What do I do with these people?” (ID 1278, Psychologist)

Having to treat patients as if they were on an assembly line violated MHPs training and personal moral code.

On the other hand, pressure to meet productivity and performance measures often took precedence over the type of treatment MHPs wanted to provide. Oversized caseloads and time pressures along with documentation requirements meant that MHPs were not able to see patients as often or as long as they deemed necessary. One MHP (ID 1032, Social Worker) described the therapy they delivered as “supportive therapy” or “check-ins,” just trying to keep the patient stable rather than engaging in more effective evidence-based therapy that they knew would be more beneficial to the patient. While discussing moral distress, another MHP stated that MHPs are prevented from treating patients in a clinically appropriate way because of all their other work tasks:

[C]linicians experience a sense of moral injury because they can't do for the patient what they want because there's all this stuff in front of them that's getting in the way, whether it's a computer or it's checklists, or it's whatever it is. You're not just addressing a schedule. This isn't just about a scheduling issue or documentation issue. This is about…. This is going against who I am, I was called to do this, and it's being squashed. (ID 1134, Psychiatrist)

Experiencing moral distress may result from the cumulative effects of ineffective processes that MHPs feel they cannot change or have no control over.

One participant (ID 1018, Psychologist) described how performance measures, applied across VA facilities, can lead MHPs having to offer services they do not have training in or feel competent enough to offer:

I would say that when it comes to the performance measures, management will do whatever they have to do to pass them, but I’m not willing to be unethical in that equation. And that is a real burnout kind of situation.

Mismatch between available resources and performance expectations create a sense of moral distress, as providers were asked to offer services outside of their expertise or scope of practice. As such, MHPs expressed frustration with being forced to operate in ways that they felt compromised the ethical standards they valued, particularly when it came to patient care. This conflict between their personal values and organizational demands intensified burnout, leading to feelings of moral distress.

Theme 6: MHP Perspectives on patient reactions to their burnout

Many of the MHPs spoke about how turnover within the MH service affected their burnout and impacted veteran care. Providers talked about how their workload increased as they tried to cover for the understaffing, which increased their stress levels, and because of this, they had even thought about quitting or changing jobs. They heard from veterans who expressed frustration, dissatisfaction, and feelings of abandonment when their MHP left the VA. MHPs stated that many veterans had become reluctant to open themselves up to a new provider for fear of becoming abandoned again. They also felt that the chronic turnover of MHPs reduced the trust veterans had in the VA. Frontline providers attempted to assuage veterans’ frustrations while simultaneously coping with their own, as described by a participant:

I've seen patients decompensate when their therapist left. It also gives patients pause to accept another therapist. We [MHPs] have to deal with them being left there and the fallout. There's a lot of negative rhetoric from patients about the VA, frustrations that they voice all the time, being dissatisfied with VA care, and it's just another thing that sort of reinforces their negative beliefs about the VA. “Well, their therapists just leave. They don't stick around,” or “The VA can't, isn't hiring anybody. And why aren't they doing this? Don't they care about Veterans?” (ID 1297, Psychiatrist)

Participants also told us that veterans knew that MHPs were burned out. They stated that veterans often overheard MHPs talking with colleagues and that the conversations included comments such as, “I’m here,” or, “I’m hanging in there.” Also, veterans grew frustrated because MHPs often arrived late to their appointments, and the VA did not have enough therapists to care for everyone or provide the frequency of needed appointments. MHPs stated that they must often field complaints from veterans and that veterans have left therapy stating that they were dissatisfied with their care:

[A]ctually, I’ve had a couple [patients], not mine personally, leave because they’re like, “I wanted more from this, and I’m not getting it.” So, you do get some people that get angry and have had some valid points, I mean. (ID 1089, Social Worker)

Evident frustration not only reflected veterans' unmet needs, but also highlighted the tension between MHPs' professional commitment to care and the systemic limitations MHPs were facing. Providers felt torn between wanting to offer more support and the reality of being stretched thin, exacerbating feelings of guilt and burnout among MHPs.

Theme 7:Caring for veterans helps mitigate burnout

For almost all participants, caring for veterans was a primary motivator for joining the VA and why they remain. They enjoy caring for veterans and feel a sense of responsibility for them. MHPs stated that when they are providing care for a veteran, they felt “energized,” “connected,” and “recharged:”

[T]he least thing that burns me out is sitting with a veteran. That's the reason I'm here. I like sitting with veterans I love, like, that's the thing that recharges me. (ID 1042, Social Worker)

Notably, providers did not attribute patient care to their burnout, but rather, to the administrative and organizational demands that came along with providing patient care, for example:

I do try to be as focused as possible because I am of the belief that, and again, like I said, I like working with my veterans. I don't feel burnout when it comes to necessarily doing what I'm supposed to be doing for them. I think my burnout comes more with the processes of, “Oh here's another, you know, checkbox that you have to do. Here's another something else.” (ID 1032 Social Worker)

This distinction underscores the complexity of burnout in healthcare settings. While direct interaction with veterans remains a source of motivation and personal fulfillment, the systemic pressures, including administrative burdens and organizational inefficiencies, and the sheer volume of people who need to be seen contribute significantly to the emotional and mental exhaustion that providers experience. Many MHPs expressed a deep commitment to their work, but the disconnect between their passion for patient care and the overwhelming demands of the system left them feeling increasingly burned out. The challenge, they suggested, was not in the act of caregiving, but in navigating the structures that hindered their ability to provide that care effectively.

Discussion

Understanding the experiences of MHPs reveals the complex relationship between organizational factors, MHP burnout, and patient care. MHPs acknowledged that their burnout could impact the quality of care provided to veterans, but they also highlighted the organizational factors that directly affected both their burnout and patient care. Behaviors associated with burnout, such as disengagement, lack of empathy, distraction, lack of preparedness, and procrastination, align with previous research highlighting the adverse effects of burnout on clinical practice (Eliacin et al., 2018, McCormack et al., 2018, Salyers et al., 2017, Salyers et al., 2015a). Although these behaviors may inadvertently compromise the therapeutic alliance and the overall efficacy of treatment, they emerged in response to organizational factors such as strict productivity/performance measures, oversized caseloads, high workload, and time-consuming documentation requirements.

Indeed, a significant portion of participants’ discussions revolved around organizational factors causing or contributing to burnout and their perceived effect on patient care. Participants consistently identified high caseloads, understaffing, administrative burdens such as scheduling their own patients, excessive documentation requirements, and performance pressures as primary contributors and confirm what other studies have found (Eliacin et al., 2018, Garcia et al., 2014, Hallett et al., 2024, McCormack et al., 2018, Rollins et al., 2021, Villarosa-Hurlocker et al., 2019, Yang and Hayes, 2020). These systemic issues resulted in some MHPs in this study feeling they had to prioritize quantity over quality, leading to what they defined as routine and superficial patient interactions. The pressure to meet administrative requirements often detracted from the time available for patient care, exacerbating feelings of burnout and frustration among MHPs.

Moral distress is an important finding to emphasize because studies have found that moral distress is associated with decreased job satisfaction and intention to quit (Lamiani et al., 2017, Maunder et al., 2023). Providers often attribute moral distress to working in environments with institutional constraints that conflict with their personal or moral ethics (Lamiani et al., 2017, Morley et al., 2019). These environments, defined by conflicting priorities, expect providers to deliver high-quality care to increasing numbers of patients without adequate resources or support (Lamiani et al., 2017). Such conditions can result in distress, including feelings of guilt, helplessness, and sadness (Delfrate et al., 2018, Lamiani et al., 2017, Lamoureux et al., 2024, Morley et al., 2019). Some of our participants felt resigned to providing what they considered suboptimal care; however, organizational pressures drove them to provide this type of care, reflecting a conflict between personal values and systemic constraints. For the participants, moral distress arose from the dissonance between the desire to provide high-quality care and the reality of institutional constraints, emphasizing the need for organizational changes to mitigate these stressors.

Another important finding includes the impact of MHP perceptions of veterans’ trust and engagement with the VA mental health care system. A recent study by Pyne and colleagues found a “correlation between Veterans’ lack of trust in VA mental healthcare providers and in the VA healthcare system” (Pyne, et al., 2023, p. 7), possibly indicating that if patients do not trust their providers, they will not trust the system overall. Although establishing relationships is a main component of trust, from MHPs’ perspectives in our study, veterans were reluctant to engage in patient-provider relationships. Frustration and dissatisfaction with staff turnover, perceived lack of care continuity, and fear of abandonment led to disengagement from treatment. Frontline MHPs found themselves having to assuage veterans’ concerns regarding care, mainly due to chronic understaffing. MHPs also felt the responsibility to see more patients to ensure that veterans received care, even though they felt the care they provided represented more “supportive therapy” rather than evidence-based treatment. On the other hand, they felt providing some type of care was better than not providing care at all. This finding underscores the importance of addressing MHP burnout, not only for providers, but also for veteran patients. Thus, organizational-level efforts to reduce burnout should focus on administrative and systemic reforms and on fostering and supporting the therapeutic relationship between MHPs and patients so that MHPs can provide care that aligns with their personal ethics. Hiring additional mental health staff will enable patients to be seen more efficiently and help redistribute the caseload and workload of current MHPs, allowing them more time to focus on patient care. Ensuring that MHPs have the time and resources to engage meaningfully with patients could help mitigate the effects of burnout and build trust between patients, MHPs, and the overall VA healthcare system.

Interestingly, our study found that direct patient care could serve as a mitigating factor for burnout. The sense of connection and purpose derived from helping veterans remained a source of resilience for many MHPs. It is critical to appreciate our findings in the context of prior studies (Rand Corporation, 2019, Watkins et al., 2016), confirming that VA mental health care and services offered are as good or better than care provided outside the VA, yet MHPs in this study still felt like they were failing as clinicians. VA MHPs, and MHPs, in general, may negatively assess their ability to provide quality mental health care more because of their burnout. Thus, providing MHPs with data demonstrating the positive aspects of care may confirm that they are delivering high-quality care and could help alleviate some of their feelings of guilt and disappointment. Empowering and supporting MHPs to deliver high-quality care could also help address burnout. For example, hiring administrative support staff can relieve MHPs from administrative duties, enabling them to concentrate on providing care.

The VA has made efforts to address high rates of employee burnout. In September of 2022, the VA formed the Reduce Employee Burnout and Optimize Organizational Thriving (REBOOT) initiative (VA Health Systems Research, 2024). This initiative is focused on seven key priority areas: implementing chief clinician wellbeing officers, optimizing meeting practices (frequency and length), optimizing training and education (streamlining requirements), strengthening mental health support for employees, addressing clinical team inefficiencies, maximizing use of human resources policies and flexibilities, and strengthening a culture of servant leadership. Additionally, since 2012, the VA aimed to hire more MHPs including staff with more diverse training (e.g., licensed professional counselors) and retaining current staff (United States Government Accountability Office, 2022), although the extent to which the VA will be able to increase hiring to a point that it can mitigate MHP burnout remains unclear. In addition to these efforts, our findings suggest there are remaining provider-identified causes that must be addressed to alleviate MHP burnout.

Although institutional policies establish the conditions for practice, the organizational environment shapes how these policies are enacted and experienced by frontline providers. The concept of structurational divergence (SD) (Nicotera et al., 2015) may explain why certain organizational stressors persist; there is a misalignment between formal institutional structures (e.g., policies, standardized metrics) and the actual work practices that MHPs use. This misalignment may force MHPs to constantly adapt, creating inefficiencies, moral distress, and extra cognitive burden. Over time, these stresses contribute to burnout by increasing emotional exhaustion, reducing job satisfaction, and eroding a sense of control (Nicotera et al., 2015). In the VA, performance metrics are often at odds with the realities of MHPs’ caseload and do not reflect or consider all the work they do. Eventually, these misalignments contribute to persistent stress and burnout, even when supportive organizational policies exist. Framing findings through SD emphasizes that burnout reflects systemic institutional and organizational dynamics, not just individual factors. Therefore, interventions should target both institutional support and local organizational processes such as workload, staffing, administrative requirements, and collaborative opportunities to reduce burnout and support patient care.

While this study was conducted within VA, the organizational drivers of burnout identified (e.g., workload, staffing, and resource availability) are relevant to mental health providers in non-VA clinical settings as well. As of August 2024, more than one-third of the U.S. population resides in a mental healthcare professional shortage area, where access to care is limited due to insufficient numbers of qualified providers (Health Resources and Services Administration, 2024). This shortage exacerbates the challenges faced by MHPs, intensifying workload pressures and potentially diminishing the quality of care provided. Understanding these organizational factors is crucial for developing interventions to reduce burnout and enhance patient care across healthcare systems.

This study has limitations. Although 54 MHPs across nine VA sites were interviewed for variability, only those who responded first to the study invitation were interviewed. MHPs experiencing burnout may have had a higher likelihood of responding and, therefore, may be overrepresented in the sample. However, some participants did state that they were not experiencing burnout at the time of their interviews and were included for their thoughts, perspectives, and opinions in the analysis. Since sampling was based only on staffing and burnout levels, VA facilities that planned or had already implemented organizational-level interventions to address burnout may have been inadvertently excluded. Additionally, some participants may have hesitated to admit how their burnout affected patient care given the potential risks. Therefore, all organizational factors that could contribute to reduced patient care may not have been captured.

Conclusion

This study provides a comprehensive examination of MHPs' perceptions of how burnout affects their ability to care for veterans, highlighting the complex interplay between individual behaviors and organizational factors. Addressing burnout requires a multifaceted approach that includes organizational reforms, support, and resources for MHPs, and dedicated support for MHPs to deliver high quality care that meets their professional standards. By prioritizing both the well-being of providers and the quality of patient care, the VA, and other healthcare systems can better fulfill its mission to serve veterans and other patients. Thus, future research should explore targeted organizational-level interventions to reduce burnout and investigate their impact on both provider wellbeing and patient care.

CRediT authorship contribution statement

Molly Harrod: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Linda Takamine: Writing – review & editing, Writing – original draft, Formal analysis, Data curation. Kristen Abraham: Writing – review & editing, Writing – original draft, Methodology, Investigation. Veronica Ortolan: Writing – review & editing, Writing – original draft, Formal analysis, Data curation. Jennifer Burgess: Writing – review & editing, Writing – original draft, Resources, Project administration, Data curation. Peter P. Grau: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Rebecca Sripada: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Kara Zivin: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization.

Ethical approval

The project was approved by the Ann Arbor VA Healthcare System Institutional Review Board (approval no. 1597568). A waiver of documented informed consent was obtained to protect participants’ confidentiality. Participants were emailed a project summary document that gave information on the scope of the interviews as well as risk and confidentiality safeguards. Prior to each interview, the interviewers explained the study, participants’ rights, including the right to withdraw from the study. Verbal informed consent was then obtained along with explicit permission to record the interview before beginning.

Funding

VA Health Systems Research (IIR 17–262 and RCS 21–138) provided financial support of this work through funding awarded to KZ. The funders did not have a role in conceptualization of the study, study design, data collection and analysis, preparation of the manuscript, or decision to publish.

Declaration of Competing Interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. : Interview Guide

Introduction

Thank you for agreeing to speak with us about your experiences with burnout as a mental health provider. We want to remind you that this a research study and that all research studies are completely voluntary. You can stop participating at any time, or you can decline to answer any question. Your responses will be confidential and any account of the interview, including notes or transcripts will be de-identified. The sound files will be kept on a secure VA server. Do we have your permission to continue to audio-record this interview?

Interviewee Background

We would like to first get to know you a little bit better. Can you tell us:

FRONTLINE PROVIDER

LEADERSHIP

1.What is your role? 2.How long have you worked here? 3. What is your patient load like? a. How many patients do you see on a typical day? b. Can you describe the patient population you treat? c. How do you deliver treatment? i. Face-to-face? ii. Telehealth? iii. Other? d. Do you provide group and/or individual sessions?

1.What is your role? 2.How long have you worked here? 3. What types of clinics are in your service? a. What services do your clinics provide? b. How many providers are in your service? 4. What is your service staff make-up like? (i.e., number and types of providers, support staff, management) a. How many current open positions are there in your service? b. Types of positions? [If there are other leadership positions, let Jen and Roni know] 5. What is the patient load like? a. How many patients does your service see on a typical day? b. How would you describe the patients’ complexity? c. How does your service deliver treatment? i. Face-to-face? ii. Telehealth? iii. Other?

Burnout Experience

As you know, we’re interested in hearing about your experiences with burnout opinions about possible interventions that may help address burnout. We know from previous research that providers define and experience burnout differently.

FRONTLINE PROVIDER

LEADERSHIP

4.How would you describe burnout? 5. Can you tell us about a time when you felt particularly burnt out from your job? a. What led to that situation? b. What did you do to cope with those feelings? c. What job tasks do you do that contribute most to feelings of burnout? d. Are there tasks that you do that you think other staff could be doing? 6. Have you ever felt like burnout affected your ability to care for patients? a. If yes, how so? (ask for a particular example) b. If no, how do you maintain the care of your patients? 7. Do you feel like burnout has affected your colleagues’ ability to care for their patients? a. If yes, what impact, if any, did this have on your practice? 8. Do you ever talk with co-workers or management about burnout? a. If yes, what were those conversations about? b. If no, why not?

6.How would you describe burnout? 7. Can you tell us about a time when you felt burned out? a. What led to that situation? b. What did you do to cope with those feelings? c. What job tasks do you do that contribute most to feelings of burnout? d. Are there tasks that you do that you think other staff could be doing? Service Staff Burnout Experience Next, we’d like to talk specifically about frontline provider burnout. 8. Please describe your staffs’ experiences with burnout. a. What do you think contributes to their burnout? b. How do you address staff burnout in your service? 9. Do you ever talk with your staff about burnout? a. If yes, what were those conversations about? b. If no, why not? 10.How would you describe your relationship with your staff? 11. What role do you think burnout has in providers’ abilities to care for their patients? a. Provide specific examples of when burnout contributed to suboptimal patient care

Provider Practice

Next, we’d like to learn more about your practice [OR SERVICE] and what your work week looks like.

FRONTLINE PROVIDER

LEADERSHIP

9.Can you describe, in general terms, what you do on a day-to-day basis? 10. How do you feel about your current practice? a. Do you feel like you have time to see the amount of patients in the time you have? b. Do you have a say in your schedule? c. To what degree do you feel like you have the freedom to make clinical decisions that meet your patients’ needs? i. Do you have a say in medication decisions? d. Is there anything you would change about your practice? i. If yes, do you feel like management supports you in those changes? ii. Do you feel like you have too much or too little supervision? 11. Are there any performance measures you feel contribute to burnout? a. If you could change how your performance is measured, what do you think is the most important aspect to measure?

12.Can you describe, in general terms, what you do on a day-to-day basis? 13. How do you feel about your service’s ability to practice? a. Do you feel like you have enough providers to meet demand? b. Do the providers have adequate time to see patients? i. How would you describe the patients’ complexity? c. What about support staff? d. Do you feel like you have control over how your service practices? (Why or why not?) 14.How do you think patient care measures impact burnout? 15.Do you think how providers are evaluated impact burnout?

Workplace Environment

Next, we’d like to talk about your work environment.

FRONTLINE PROVIDER	LEADERSHIP
12. Can you tell us about any staff turnover that has happened within the last year? a. How did that affect your practice? b. How did that affect staff morale? 13. Have you ever thought about quitting or changing jobs? a. Have you ever felt like your job was at risk?	16. Can you tell us about any staff turnover that has happened within the last year? a. How did that affect your service? b. How did that affect staff morale? c. What impact did it have on you/your job? 17. Have you ever thought about quitting or changing jobs? a. Have you ever felt like your job was at risk?

Suggestions for Interventions

And finally, we would like to hear any ideas or suggestions that you may have that would help address burnout among mental health providers.

FRONTLINE PROVIDER AND LEADERSHIP

1.Is there anything that you (or your staff) do on a consistent basis to deal with burnout or even just the day-to-day stress? 2. Are there any current interventions that we haven’t discussed that specifically address burnout? a. If yes, please describe. 3.Are there any interventions you would like to see implemented at your facility to help address burnout? 4.What types of additional resources could the VA provide that you think would be helpful in coping with job stress and/or burnout? 5.What other suggestions do you have to address burnout among MHPs?

Appendix B. : Codebook

Theme/Code	Definition	Contributing Organizational Factors (Mentioned as causing burnout and effecting patient care)
Interactions with Patients	How burnout effects interactions with patients	•Productivity/Performance measures •Oversize caseload •Workload •“Therapy dosing” •Staffing •Lack of professional development •Documentation •Administrative tasks •Lack of connections with coworkers
Disengagement	Trying to make it through the appointment, not present during therapy sessions, not engaging with client, keeping therapy “superficial”, routine approach to therapy, wishing they could engage more
Decreased empathy	Lack of empathy or “compassion fatigue”, cannot convey empathy, identify with clients feelings of depression
Distraction	Wandering mind, going through the motions of providing care, thinking about other work	•Technology interruptions •Administrative tasks •Documentation •Workload
Lack of Preparedness	Feelings of being unprepared for therapy sessions, not knowing the clients history or remembering them	•Oversize caseload •Workload
Procrastination	Putting off tasks that could affect patient care, e.g., referrals, care coordination etc. Task that do not count toward productivity/performance measures are easier to put off.	•Documentation •Administrative tasks •Productivity/performance measures
Moral Distress	Feeling like they were working against their own “moral code”	•Workload •Oversize caseload •Therapy dosing •Productivity/performance measures •Staffing •Administrative tasks •Documentation •Lack of resources
“Good enough care”	Delivering care that is “supportive” or “checking in” rather than care MHPs feel clients need. Not be able to see clients according to evidence-based guidelines
Feelings of sadness, frustration, disappointment, guilt	Feeling sad, frustrated, disappointed and guilty for not delivering the care their clients need and/or they want to be delivering, resigned to providing “good enough care”
Unqualified for services	Offering services MHPs felt they were unqualified or untrained to offer
MHPs Perceptions of Patient Reactions		•Staffing •Workload
Veteran frustration, dissatisfaction	MHPs experiences with Veteran frustration over not being able to get an appointment when needed, their MHP’s constantly leaving, etc.
Veterans feeling abandon- reluctant to engage in treatment	MHP’s knowledge of Veterans’ feelings of abandonment; reluctance to engage in treatment; not wanting to retell their story to a new MHP
Veteran knowledge of MHP burnout	MHPs stating that they are aware that Veterans know about their burnout
Mitigating Burnout
Caring for Veterans	Caring for Veterans primary motivator for joining VA, helps MHPs feel connected, recharged, energized etc., caring for Veterans is what keeps them at the VA
Organizational Contributors to Burnout
Administrative tasks	Any tasks that they are doing that other staff could/should do. Scheduling own patients, placing consults, coordinating care, etc.
Staffing	Issues with staffing/being understaffed that interviewee states/implies contributes to burnout. Employees who are on leave or daily call-ins that effect staffing. Open positions within their service. Any issues with recruitment including offering virtual positions
Workload	Any mention of having too much work due to understaffing or amount of documentation (double code with caseload and/or documentation). Include having to work past tour, during administrative time or on weekends to complete work
Productivity/Performance measures	VA’s collection and analysis of data including access measures. Punitive measures. Measures that do not reflect quality of care or capture relevant aspects of care
Documentation	Amount of documentation; redundant documentation, documentation deadlines
Oversize caseloads	Having more patients than they should/are able to care for. INCLUDES mention of workload. More patients=more work
Therapy dosing	Not having the time in schedule to be able to provide the right/recommended amount of therapy.
Lack of professional development	Little to no opportunity to obtain additional training or attend professional conferences.
Lack of connections with coworkers	Not having time to connect or talk with coworkers due to work demands
Technology interruptions	Any mention of technology (e.g., Instant messages, emails) that interrupt their work
Lack of resources	Any resources that are mentioned that are needed to perform their job better, more efficiently. (CODE Understaffing with “Staffing”)

Data availability

The data for this study consists of in-depth interviews with mental health providers regarding sensitive workplace issues. To protect participants from possible negative consequences, the datasets generated and/or analyzed for the study are not available due to participant confidentially and privacy but may be available from the corresponding author upon reasonable request.