In brief
In this exploratory Canadian study, 11 frontline staff on a pediatric eating disorders unit reported moderate (not high) burnout on the Copenhagen Burnout Inventory a year after DBT training, and all felt DBT had potential to ease burnout, though most also flagged real implementation challenges and no pre-training...
What this article is about
Quick Answer
In this exploratory Canadian study, 11 frontline staff on a pediatric eating disorders unit reported moderate (not high) burnout on the Copenhagen Burnout Inventory a year after DBT training, and all felt DBT had potential to ease burnout, though most also flagged real implementation challenges and no pre-training baseline exists to confirm cause and effect.
Student takeaways
Key Takeaways
- Among 11 frontline staff (9 nurses, 1 child life specialist, 1 child and youth worker) on a pediatric eating disorders unit, mean Copenhagen Burnout Inventory scores were moderate: personal burnout ~35.2, work-related burnout ~31.5, and client-related burnout ~26.5 (all on a 0-100 scale).
- Only one staff member scored in the high-burnout range (≥50) for personal burnout, and only one scored high for client-related burnout; no participant scored high across all three CBI subscales.
- All 11 participants expressed in qualitative interviews that DBT skills training had the potential to reduce burnout, describing benefits across personal, work-related, and client-related domains.
- Staff reported that DBT gave them clearer, more specific tools that increased their sense of effectiveness, reduced feelings of helplessness, and improved unit consistency, while validation skills strengthened staff-to-staff support.
- Nine of the 11 participants also raised concerns about the added burden of learning and delivering DBT, and staff noted DBT was not effective for all patients, particularly those who were medically unstable or unwilling to engage.
Student summary
Why This Research Matters
Eating disorders like anorexia nervosa are life-threatening illnesses that mostly affect adolescents, and anorexia carries one of the highest death rates of any psychiatric condition. Treating young patients with eating disorders is hard on staff: progress is often slow, patients can have several co-occurring conditions such as depression, anxiety, OCD, or self-harm behaviours, and relapse is common. These pressures put frontline workers, especially nurses who have the most direct patient contact, at real risk of burnout, which researchers define as emotional exhaustion, depersonalization, and a reduced sense of accomplishment.
Dialectical behavior therapy (DBT) combines mindfulness and acceptance-based strategies with behavioural skills training. It already has some evidence for reducing burnout among staff in other mental health settings, so this Canadian study asked whether training frontline staff in DBT skills could also ease burnout on a combined inpatient and day hospital unit for pediatric eating disorders, based out of a McMaster-affiliated children's hospital in Hamilton, Ontario.
The unit mainly uses Family-Based Treatment, but staff added DBT skills to help patients manage distress during the difficult re-nourishment process. Over six months, staff went through DBT training led by an expert, including training days, manuals, videos, and online modules, then practiced the skills in group sessions, during meals, and at the bedside. Twelve months after this training began, researchers asked staff to complete the Copenhagen Burnout Inventory (CBI), a well-established 19-item questionnaire that scores personal, work-related, and client-related burnout on a 0-100 scale, and to take part in a semi-structured qualitative interview about their experiences.
Of 26 eligible employees, 11 frontline staff volunteered: nine nurses, one child life specialist, and one child and youth worker, all women aged 25 to 55, and most (91%) with more than four years of experience caring for pediatric patients with eating disorders. On the CBI, average scores were moderate rather than high: personal burnout averaged about 35 out of 100, work-related burnout about 32, and client-related burnout about 27. Only one staff member scored in the "high burnout" range (50 or above) for personal burnout, and only one scored high for client-related burnout; nobody scored high on all subscales at once.
The interviews told a more detailed story. For personal burnout, staff described using DBT skills such as mindfulness, self-soothing, distraction, and interpersonal effectiveness not just at work but in their own lives, for example using mindful driving to de-stress on the commute home. For work-related burnout, staff felt DBT gave them clearer, more specific tools for helping patients, which made them feel more effective and less helpless, and it made the unit's approach more consistent and predictable, since everyone was using a shared skill language. Staff also said DBT's validation techniques helped them support one another better as a team. However, they also flagged real tensions: fitting DBT skill-teaching around medical safety checks and limited bedside time added pressure of its own. For client-related burnout, staff felt DBT skills helped calm patient anxiety and de-escalate tense family situations, but they were frank that DBT does not work for every patient. Some patients were too medically unstable or unwilling to engage, with one staff member noting that a severely malnourished patient's "brain is too starved to register what you're talking about," which could be frustrating.
Overall, all 11 staff felt DBT had real potential to reduce burnout, even though most also raised concerns about the extra demands of learning and delivering it. The researchers describe this as an exploratory, hypothesis-generating study rather than proof that DBT reduces burnout. As a nursing student, this is a useful example of how a small qualitative and descriptive quantitative study can surface promising ideas for supporting frontline mental health staff, while also showing why larger, controlled research with before-and-after burnout measurements is still needed before conclusions can be drawn with confidence.
Source abstract
Study Overview
Abstract Background Eating disorders are life-threatening illnesses that commonly affect adolescents. The treatment of individuals with eating disorders can involve slow treatment progression and addressing comorbidities which can contribute to staff burnout. Dialectical behavior therapy (DBT) has emerged as a viable treatment option and has reduced staff burnout in several other settings. Our aim was to describe frontline staff burnout using mixed methodology on a DBT-trained combined inpatient/day hospital unit for pediatric eating disorders. Method Frontline staff were trained to provide DBT skills for adolescents with eating disorders. Twelve months following the training and implementation, they completed the Copenhagen Burnout Inventory (CBI) and a qualitative interview. Directed and summative content analyses were used. Results Eleven frontline staff including nurses, child life specialists and child and youth workers participated. The CBI revealed that only one staff member experienced high personal burnout, while another experienced high client-related burnout. Qualitative data indicated that all frontline staff felt DBT had the potential to reduce burnout. Conclusion Qualitative data indicate that staff believe that DBT may hold promise in reducing burnout for pediatric frontline staff who treat children and adolescents with eating disorders. Further study is needed. Plain English summary Understanding burnout is particularly important for nursing staff in inpatient and day hospital settings for eating disorders, as nursing staff generally have the most frequent patient contact; thought to be a risk factor for burnout. The reduction of burnout can prevent detrimental effects on job performance, personal well-being, and patient outcomes. Our exploratory study shows that frontline staff believe that DBT may have the potential to reduce burnout in staff treating children and adolescents with eating disorders in a combined inpatient/day hospital setting. Further study is needed in this area.
Evidence appraisal
Main Findings
- Among 11 frontline staff (9 nurses, 1 child life specialist, 1 child and youth worker) on a pediatric eating disorders unit, mean Copenhagen Burnout Inventory scores were moderate: personal burnout ~35.2, work-related burnout ~31.5, and client-related burnout ~26.5 (all on a 0-100 scale).
- Only one staff member scored in the high-burnout range (≥50) for personal burnout, and only one scored high for client-related burnout; no participant scored high across all three CBI subscales.
- All 11 participants expressed in qualitative interviews that DBT skills training had the potential to reduce burnout, describing benefits across personal, work-related, and client-related domains.
- Staff reported that DBT gave them clearer, more specific tools that increased their sense of effectiveness, reduced feelings of helplessness, and improved unit consistency, while validation skills strengthened staff-to-staff support.
- Nine of the 11 participants also raised concerns about the added burden of learning and delivering DBT, and staff noted DBT was not effective for all patients, particularly those who were medically unstable or unwilling to engage.
Practice transfer
Clinical Relevance
- Nurses and other frontline staff on eating disorder units may find personal value in applying DBT skills such as mindfulness, self-soothing, and interpersonal effectiveness in their own lives, not only in patient care, as a form of self-care.
- Providing frontline staff with a specific, shared skill set (like DBT) may increase their sense of effectiveness with patients and create more predictable, consistent unit routines, which staff associated with lower perceived work-related burnout.
- Teams considering DBT rollout should plan realistically for competing demands, since staff in this study described tension between delivering DBT skills, maintaining medical safety monitoring, and providing adequate bedside care time.
- Clinicians should not expect DBT skills to be equally effective for all patients; staff observed that severely malnourished or unwilling patients may be unable to engage meaningfully with skills training, which can itself be a source of provider frustration.
- Given the exploratory design, any decision to adopt DBT skills training as a burnout-reduction strategy should be paired with ongoing monitoring and should not be treated as established, generalizable practice without further study.
Faculty notes
Educational Relevance
This exploratory mixed-methods study (Couturier et al., 2021, Journal of Eating Disorders) examined whether training frontline staff in dialectical behavior therapy (DBT) skills was associated with lower burnout on a combined 6-bed inpatient and 4-patient day hospital unit for pediatric eating disorders, based at a McMaster University-affiliated children's hospital in Hamilton, Ontario. The unit's primary modality remains Family-Based Treatment; DBT skills were layered in to help manage patient distress during re-nourishment. Staff underwent six months of formal DBT training (expert-led sessions, manuals, videos, online modules) and applied skills through group co-facilitation, meal support, and bedside care; consultation groups were not feasible given shift-work constraints, so daily medical rounds incorporated a DBT focus instead.
Of 26 eligible frontline employees, 11 volunteered via purposeful sampling (9 nurses, 1 child life specialist, 1 child and youth worker; all female, ages 25-55; 91% with more than four years caring for pediatric patients with eating disorders). Twelve months post-training, participants completed the Copenhagen Burnout Inventory (CBI), a validated 19-item, 0-100-scored measure with personal, work-related, and client-related subscales (high-burnout threshold ≥50), and a semi-structured qualitative interview. Directed and summative content analysis were used on the interview data.
Quantitatively, mean scores were moderate: personal burnout ~35.2 (SD 11.8), work-related ~31.5 (SD 10.6), client-related ~26.5 (SD 15.6). Only one participant scored high on personal burnout and one on client-related burnout; none scored high across all domains. Qualitatively, all 11 participants felt DBT held potential to reduce burnout. For personal burnout, staff described transferring skills like mindfulness, self-soothing, and interpersonal effectiveness into their own lives outside work. For work-related burnout, staff reported feeling more effective and less helpless with a shared, specific skill set, improved unit consistency and predictability, and stronger peer support through validation techniques - tempered by the real burden of balancing DBT delivery against medical-safety duties and limited bedside time. For client-related burnout, staff felt DBT skills reduced patient anxiety and de-escalated family conflict, but also candidly noted DBT is not suitable for all patients (e.g., medically unstable or unwilling patients), which could itself be a source of frustration. Nine of the eleven participants also raised implementation concerns, indicating the qualitative picture is more nuanced than "DBT reduces burnout" alone.
For teaching, this is a strong case study in the limits of small exploratory service-evaluation designs: there was no pre-training burnout baseline, so causal or even pre-post comparative claims cannot be supported; the 11/26 (42%) participation rate raises real potential for volunteer or engagement bias, since staff who agreed to be interviewed may be systematically different from non-participants; and DBT experience varied across the sample without power to compare burnout by dose or tenure. The single-unit, single-institution design and small, all-female sample also limit generalizability to other eating-disorder programs, adult units, or male frontline staff.
Useful discussion angles for faculty: how qualitative content analysis can surface mechanism-level insight (e.g., which specific DBT skills staff found useful and why) that a burnout score alone cannot; how to critically weigh self-selected samples in workplace wellness research; and how findings might inform practical staffing and training decisions (e.g., protecting time for skill practice, pairing DBT rollout with realistic workload planning) while stopping short of over-claiming efficacy. The authors themselves frame this as hypothesis-generating, recommending larger studies with baseline measurement and inclusion of administrator/team perspectives on implementation barriers.
Critical appraisal
Limitations
- Only 11 of 26 eligible staff (about 42%) volunteered to participate, raising the possibility that those who agreed were less burned out, more engaged, or more favourably disposed toward DBT than non-participants.
- The study had no pre-DBT-training burnout measurement, so it cannot establish whether burnout actually changed after DBT implementation or compare staff to their own baseline.
- The sample was small (n=11), all-female, and drawn from a single inpatient/day hospital unit at one institution, limiting generalizability to other eating disorder programs, adult settings, or more gender-diverse staff teams.
Classroom use
Discussion Questions
- Why might a study report both quantitative burnout scores and qualitative interview themes rather than relying on either method alone, and what did each method contribute here that the other could not?
- Given that only 11 of 26 eligible staff volunteered, how might self-selection bias have shaped the CBI scores and the largely positive qualitative impressions of DBT?
- What does the absence of a pre-training burnout measurement mean for how confidently we can attribute the moderate (not high) burnout scores to DBT implementation?
- How should nurse leaders interpret staff comments about DBT being unsuitable for medically unstable or unwilling patients when planning skills-based interventions on an eating disorders unit?
- In what ways did DBT skills reportedly extend beyond patient care into staff members' personal lives, and what might this suggest about how frontline mental health training affects the whole person, not just job performance?
- The authors describe competing demands between DBT skill delivery, medical safety monitoring, and bedside care time. How might a unit redesign staffing or scheduling to reduce this tension?
- Nine of 11 participants raised implementation concerns even while endorsing DBT's potential. Why is it important for researchers and readers to report ambivalence like this rather than only positive findings?
- How might findings differ if the study had included perspectives from unit administrators or non-participating staff, as the authors recommend for future research?
- What specific design changes (e.g., baseline measurement, larger sample, multiple sites) would be needed to move from this exploratory, hypothesis-generating study toward stronger causal evidence that DBT reduces burnout?
- How can nurses critically appraise a small qualitative/descriptive study like this one so that its promising findings inform, but do not overstate, practice change on their own unit?
Knowledge check
Quiz
1. What was the primary aim of this study?
- To compare DBT with Family-Based Treatment for treating adolescent eating disorders
- To describe frontline staff burnout using mixed methodology on a DBT-trained pediatric eating disorders unit
- To measure patient outcomes after DBT skills training
- To determine the cost-effectiveness of DBT training programs
Rationale: The abstract states: 'Our aim was to describe frontline staff burnout using mixed methodology on a DBT-trained combined inpatient/day hospital unit for pediatric eating disorders.'
2. Which instrument was used to quantitatively measure staff burnout in this study?
- Maslach Burnout Inventory
- Copenhagen Burnout Inventory (CBI)
- Professional Quality of Life Scale
- Perceived Stress Scale
Rationale: The abstract and full text specify staff completed the Copenhagen Burnout Inventory (CBI), a 19-item measure with personal, work-related, and client-related subscales.
3. How many frontline staff participated in this study, and what roles did they hold?
- 26 staff, all nurses
- 11 staff, including nurses, child life specialists, and child and youth workers
- 5 staff, all physicians
- 20 staff from multiple hospital units
Rationale: The abstract states: 'Eleven frontline staff including nurses, child life specialists and child and youth workers participated.'
4. According to the CBI results, how many staff members experienced high personal burnout?
- None
- Only one staff member
- About half the sample
- All eleven staff members
Rationale: The abstract states: 'The CBI revealed that only one staff member experienced high personal burnout, while another experienced high client-related burnout.'
5. What did the qualitative interview data indicate about staff views on DBT?
- All frontline staff felt DBT had the potential to reduce burnout
- Most staff felt DBT increased their burnout
- Staff were divided evenly on whether DBT was helpful
- Staff felt DBT had no effect on burnout
Rationale: The abstract states: 'Qualitative data indicated that all frontline staff felt DBT had the potential to reduce burnout.'
6. Approximately how many of the 26 eligible employees on the unit volunteered to participate in the study?
- 26 (100%)
- 11 (about 42%)
- 20 (about 77%)
- 3 (about 12%)
Rationale: The full text reports that 11 of 26 eligible employees volunteered via purposeful sampling, a participation rate of roughly 42%.
7. Why did staff report tension in delivering DBT skills, according to the qualitative findings?
- DBT was too easy to learn and left staff bored
- Balancing DBT skill teaching against medical safety monitoring and limited bedside care time created competing demands
- Patients refused all forms of therapy on the unit
- The hospital did not allow any DBT training
Rationale: The full text describes staff citing competing demands: balancing medical safety, DBT skill teaching, and limited bedside care time.
8. Which limitation most directly affects whether this study can claim DBT training caused a reduction in burnout?
- The study used only qualitative methods
- There was no pre-DBT-training burnout measurement for comparison
- The CBI has not been validated in any population
- The study included only physicians
Rationale: Without a baseline burnout measurement before DBT training, the study cannot establish change over time or causal effect, only describe burnout levels 12 months post-training alongside staff perceptions.
9. What did staff describe as a barrier to DBT's effectiveness for certain patients?
- Patients who were medically unstable or unwilling to engage struggled to use DBT skills
- DBT skills required expensive equipment unavailable on the unit
- Parents refused to allow any DBT-related content
- DBT skills could only be taught to adult patients
Rationale: The full text notes staff observed DBT was not suitable for all patients, especially those who were medically unstable or unwilling, with one staff member noting a malnourished patient's brain was 'too starved to register' the skills content.
10. How do the study authors characterize the nature of their findings?
- As definitive proof that DBT reduces burnout in all mental health settings
- As exploratory, with further study needed
- As a randomized controlled trial with strong causal evidence
- As irrelevant to nursing practice
Rationale: The abstract concludes: 'Qualitative data indicate that staff believe that DBT may hold promise in reducing burnout... Further study is needed.'
Study cards
Flashcards
What is the primary aim of this study?
To describe frontline staff burnout using mixed methodology on a DBT-trained combined inpatient/day hospital unit for pediatric eating disorders.
What instrument measured burnout quantitatively?
The Copenhagen Burnout Inventory (CBI), a 19-item questionnaire with personal, work-related, and client-related subscales scored 0-100.
What is the CBI's threshold for 'high burnout' on a subscale?
A score of 50 or above on a given subscale.
How many staff participated, and in what roles?
Eleven staff: nine nurses, one child life specialist, and one child and youth worker.
What was the study's participation rate?
11 of 26 eligible employees volunteered, about 42%.
What were the approximate mean CBI subscale scores?
Personal burnout ~35.2, work-related burnout ~31.5, client-related burnout ~26.5 (out of 100).
How many staff scored in the high-burnout range?
One staff member scored high on personal burnout and one scored high on client-related burnout; none scored high on all subscales.
What treatment approach does the unit primarily use, with DBT added?
Family-Based Treatment (FBT), with DBT skills layered in to help manage distress during re-nourishment.
How long was the formal DBT training staff underwent?
Six months of expert-led training including training days, manuals, videos, and online modules.
How did staff practice DBT skills day-to-day?
Through group co-facilitation, meal support, and bedside patient care.
Why were formal DBT consultation groups not used?
Because shift-work scheduling made regular consultation groups impractical; daily medical rounds incorporated a DBT focus instead.
What did all 11 participants agree on regarding DBT?
All 11 felt DBT had the potential to reduce burnout.
What proportion of participants also raised implementation concerns about DBT?
Nine of the eleven participants raised concerns about the added burden of delivering DBT.
Which DBT skills did staff mention using in their personal lives, not just at work?
Mindfulness, self-soothing, distraction, and interpersonal effectiveness skills.
What patient factor limited DBT's usefulness according to staff?
Patients who were medically unstable or unwilling to engage struggled to benefit from DBT skills training.
What is a key methodological limitation regarding causality in this study?
There was no pre-DBT-training burnout measurement, so the study cannot show whether burnout changed because of DBT.
What analytic approach was used for the qualitative interview data?
Directed and summative content analysis.
At what institution/setting was this study conducted?
A combined inpatient (6-bed) and day hospital (4-patient) pediatric eating disorders unit affiliated with McMaster University in Hamilton, Ontario.
How do the authors describe the overall strength of their conclusions?
As exploratory and hypothesis-generating, stating further study is needed before firmer conclusions can be drawn.
What is 'burnout' defined as in this study's framing?
Emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.
Search-ready answers
Frequently asked questions
What did this study find about DBT and nurse burnout on a pediatric eating disorders unit?
It found that CBI burnout scores were moderate rather than high 12 months after DBT training began, and that all 11 participating staff felt DBT had potential to reduce burnout, though most also noted real implementation challenges.
How many nurses and staff were included in this DBT burnout study?
Eleven frontline staff participated: nine nurses, one child life specialist, and one child and youth worker, out of 26 eligible employees on the unit.
What tool was used to measure burnout in this research?
The Copenhagen Burnout Inventory (CBI), a validated 19-item questionnaire measuring personal, work-related, and client-related burnout on a 0-100 scale.
Does this study prove that DBT reduces staff burnout?
No. The authors describe it as an exploratory study without a pre-training burnout baseline, so it cannot establish that DBT caused any change in burnout; it only describes burnout levels and staff perceptions after training.
What is dialectical behavior therapy (DBT) and why was it added to this unit's treatment approach?
DBT combines mindfulness and acceptance strategies with behavioural skills training. It was added alongside the unit's primary Family-Based Treatment approach to help adolescent patients manage distress during difficult re-nourishment.
What were the average burnout scores reported in the study?
Mean scores were approximately 35.2 for personal burnout, 31.5 for work-related burnout, and 26.5 for client-related burnout, all on the CBI's 0-100 scale, indicating moderate rather than high burnout overall.
Did staff have any concerns about using DBT on the unit?
Yes. Nine of the eleven participants raised concerns about the added workload of delivering DBT, and staff noted DBT skills were not effective for all patients, especially those who were medically unstable or unwilling to engage.
What are the main limitations of this study?
Key limitations include a low participation rate (42%) with possible selection bias, no baseline burnout measurement before DBT training, a small all-female single-site sample, and variability in staff DBT experience that the study could not statistically account for.
Where was this study conducted?
On a combined inpatient and day hospital unit for pediatric eating disorders affiliated with McMaster University in Hamilton, Ontario, Canada.
What do the authors recommend for future research on DBT and staff burnout?
They recommend further study with larger samples, baseline burnout measurement, and inclusion of unit administrators' and broader care team perspectives on implementation facilitators and barriers.