An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice

Best Practices for Technology in Clinical Social Work and Mental Health Professions to Promote Well-being and Prevent Fatigue

The shift to communication technologies during the pandemic has had positive and negative effects on clinical social worker practice. Best practices are identified for clinical social workers to maintain emotional well-being, prevent fatigue, and avoid burnout when using technology. A scoping review from 2000 to 21 of 15 databases focused on communication technologies for mental health care within four areas: (1) behavioral, cognitive, emotional, and physical impact; (2) individual, clinic, hospital, and system/organizational levels; (3) well-being, burnout, and stress; and (4) clinician technology perceptions. Out of 4795 potential literature references, full text review of 201 papers revealed 37 were related to technology impact on engagement, therapeutic alliance, fatigue and well-being. Studies assessed behavioral (67.5%), emotional (43.2%), cognitive (57.8%), and physical (10.8%) impact at the individual (78.4%), clinic (54.1%), hospital (37.8%) and system/organizational (45.9%) levels. Participants were clinicians, social workers, psychologists, and other providers. Clinicians can build a therapeutic alliance via video, but this requires additional skill, effort, and monitoring. Use of video and electronic health records were associated with clinician physical and emotional problems due to barriers, effort, cognitive demands, and additional workflow steps. Studies also found high user ratings on data quality, accuracy, and processing, but low satisfaction with clerical tasks, effort required and interruptions. Studies have overlooked the impact of justice, equity, diversity and inclusion related to technology, fatigue and well-being, for the populations served and the clinicians providing care. Clinical social workers and health care systems must evaluate the impact of technology in order to support well-being and prevent workload burden, fatigue, and burnout. Multi-level evaluation and clinical, human factor, training/professional development and administrative best practices are suggested.

How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study

PURPOSE

This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement.

DESIGN/METHODOLOGY/APPROACH

Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method.

FINDINGS

The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus.

PRACTICAL IMPLICATIONS

For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed.

ORIGINALITY/VALUE

Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.

Prevalence of burnout among healthcare professionals in Singapore

INTRODUCTION

The aim was to study the prevalence of burnout among various groups of healthcare professionals in Singapore.

METHODS

An anonymous online survey questionnaire was conducted using the Maslach Burnout Inventory - Human Services to measure three categories of burnout: emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA) from July 2019 to January 2020 in a healthcare cluster in Singapore.

RESULTS

The survey was completed by 6,048 healthcare professionals out of a target survey population of 15,000 (response rate 40.3%). The study revealed 37.8% of respondents had high EE score ≥27, 29.7% of respondents had high DP score ≥10, and 55.3% of respondents had low PA score ≤33. Respondents with either high EE score or high DP score constituted 43.9% (n=2,654). The Allied Health group had the highest mean EE score, which was significantly higher than those of Medical, Nursing and Non-clinical groups (P<0.05). The Medical group had the highest mean DP score and this was significantly higher than the Nursing, Allied Health and Non-clinical groups (P<0.05). The Non-clinical group had the lowest PA, which was significantly lower than the Medical, Nursing and Allied Health groups (P<0.005).

CONCLUSION

There was high prevalence of burnout among healthcare professionals in Singapore, especially the allied health professionals. There were significant differences in the 3 categories of burnout (EE, DP and PA) among the different groups of healthcare professionals. There is an urgent need to address the high burnout rate.

The perceived work environment and well-being: A survey of emergency health care workers during the COVID-19 pandemic

Background

During the COVID‐19 pandemic, health care provider well‐being was affected by various challenges in the work environment. The purpose of this study was to evaluate the relationship between the perceived work environment and mental well‐being of a sample of emergency physicians (EPs), emergency medicine (EM) nurses, and emergency medical services (EMS) providers during the pandemic.

Methods

We surveyed attending EPs, resident EPs, EM nurses, and EMS providers from 10 academic sites across the United States. We used latent class analysis (LCA) to estimate the effect of the perceived work environment on screening positive for depression/anxiety and burnout controlling for respondent characteristics. We tested possible predictors in the multivariate regression models and included the predictors that were significant in the final model.

Results

Our final sample included 701 emergency health care workers. Almost 23% of respondents screened positive for depression/anxiety and 39.7% for burnout. Nurses were significantly more likely to screen positive for depression/anxiety (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.11–3.86) and burnout (aOR 2.05, 95% CI 1.22–3.49) compared to attendings. The LCA analysis identified four subgroups of our respondents that differed in their responses to the work environment questions. These groups were identified as Work Environment Risk Group 1, an overall good work environment; Risk Group 2, inadequate resources; Risk Group 3, lack of perceived organizational support; and Risk Group 4, an overall poor work environment. Participants in the two groups who perceived their work conditions as most adverse were significantly more likely to screen positive for depression/anxiety (aOR 1.89, 95% CI 1.05–3.42; and aOR 2.04, 95% CI 1.14–3.66) compared to participants working in environments perceived as less adverse.

Conclusions

We found a strong association between a perceived adverse working environment and poor mental health, particularly when organizational support was deemed inadequate. Targeted strategies to promote better perceptions of the workplace are needed.

PROVIDER TECHNOLOGY, FATIGUE AND WELL-BEING: A SCOPING REVIEW (Preprint)

Background

Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement.

Objective

This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers.

Methods

A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout.

Results

Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts.

Conclusions

Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.

[Is this the parallel pandemic? : Measures to improve working conditions and stress levels among health care personnel]

Employee health and ability to perform is essential to a functioning health care system. Even before the coronavirus disease 2019 (COVID-19) pandemic, a substantial proportion of employees reported impaired mental health at work. This paper outlines the state of knowledge and evidence on interventions to promote mental health in the workplace, with particular focus on the organization of work and activities. In addition to an initial review of approaches, the factors facilitating successful and effective approaches are addressed.

Transition to Independent Surgical Practice and Burnout Among Early Career General Surgeons

Background: The transition from surgical residency to independent practice is a challenging period that has not been well studied. Methods: An email invitation to complete a 55-item survey and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was sent to early career general surgeons across Canada. The chi-square test or Fisher's exact test was used to compare demographic and survey characteristics with burnout. Multivariable logistic regression was performed. Results: Of the 586 surgeons contacted, 88 responded (15%); 51/88 surgeons (58.0%) were classified as burnt out according to the MBI-HSS. Most surgeons (68.2%) were not confident in their abilities to handle the business aspect of practice. The majority (60.2%) believed that a transition to independent practice program would be beneficial to recent surgical graduates. Conclusions: Our data showed high prevalence of burnout among recently graduated general surgeons across Canada. Further, respondents were not confident in their managerial and administrative skills required to run a successful independent practice.

Effect of interventions for the well-being, satisfaction and flourishing of general practitioners-a systematic review

OBJECTIVES

Clinician well-being has been recognised as an important pillar of healthcare. However, research mainly addresses mitigating the negative aspects of stress or burnout, rather than enabling positive aspects. With the added strain of a pandemic, identifying how best to maintain and support the well-being, satisfaction and flourishing of general practitioners (GPs) is now more important than ever.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, PsycINFO, Embase, CINAHL and Scopus from 2000 to 2020.

STUDY SELECTION

Intervention studies with more than 50% GPs in the sample evaluating self-reported well-being, satisfaction and related positive outcomes were included. The Cochrane Risk of Bias 2 tool was applied.

RESULTS

We retrieved 14 792 records, 94 studies underwent full-text review. We included 19 studies in total. Six randomised controlled trials, three non-randomised, controlled trials, eight non-controlled studies of individual or organisational interventions with a total of 1141 participants. There were two quasi-experimental articles evaluating health system policy change. Quantitative and qualitative positive outcomes were extracted and analysed. Individual mindfulness interventions were the most common (k=9) with medium to large within-group (0.37-1.05) and between-group (0.5-1.5) effect sizes for mindfulness outcomes, and small-to-medium effect sizes for other positive outcomes including resilience, compassion and empathy. Studies assessing other intervention foci or other positive outcomes (including well-being, satisfaction) were of limited size and quality.

CONCLUSIONS

There is remarkably little evidence on how to improve GPs well-being beyond using mindfulness interventions, particularly for interventions addressing organisational or system factors. This was further undermined by inconsistent reporting, and overall high risk of bias. We need to conduct research in this space with the same rigour with which we approach clinical intervention studies in patients.

PROSPERO REGISTRATION NUMBER

CRD42020164699.

FUNDING SOURCE

Dr Diana Naehrig is funded through the Raymond Seidler PhD scholarship.

The Role of Burnout in the Association between Work-Related Factors and Perceived Errors in Clinical Practice among Spanish Residents

This study aimed to evaluate the prevalence of burnout syndrome in a sample of residents from different specialties, to determine the influence of work-related factors on the development of burnout, and to examine the mediating role of burnout in the relation between such work factors and perceived errors in clinical practice. A total of 237 Spanish residents participated (M_age = 28.87, SD = 3.84; 73.8% females). The Maslach Burnout Inventory and an ad hoc questionnaire were administered to assess burnout and work-related factors. Comparison analyses and mediational models were conducted. Half of the residents reported high levels of burnout (48.9%). Burnout was significantly associated with perceived errors in clinical practice. Significant differences were found between residents with lower and higher burnout levels, showing that those with higher burnout were less satisfied with the working conditions. Burnout mediated the associations between adjustment of responsibility, support among residents, satisfaction with teaching and rotations, general satisfaction, and perceived errors in the clinical practice. Adjusted levels of responsibility and workload, enhanced supervision, and more social support from colleagues predict lower levels of burnout, which may result in fewer errors in clinical practice. Consequently, such work-related factors should be taken into account as a preventive strategy for burnout and errors in the clinical practice so adequate patient care, good mental health of future specialists, and, therefore, higher quality of public health care can be ensured.

Does academic practice protect emergency physicians against burnout?

Burnout is a complex syndrome thought to result from long-term exposure to career-related stressors. Physicians are at higher risk for burnout than the general United States (US) working population, and emergency medicine has some of the highest burnout rates of any medical specialty. Burnout impacts physicians' quality of life, but it can also increase medical errors and negatively affect patient safety. Several studies have reported lower burnout rates and higher job satisfaction in academic medicine as compared with private practice. However, researchers have only begun to explore the factors that underlie this protective effect. This paper aims to review existing literature to identify specific aspects of academic practice in emergency medicine that may be associated with lower physician burnout rates and greater career satisfaction. Broadly, it appears that spending time in the area of emergency medicine one finds most meaningful has been associated with reduced physician burnout. Certain non-clinical academic work, including involvement in research, leadership, teaching, and mentorship, have been identified as specific activities that may protect against burnout and contribute to higher job satisfaction. Given the epidemic of physician burnout, hospitals and practice groups have a responsibility to address burnout, both by prevention and by early recognition and support. We discuss methods by which organizations can actively foster physician well-being and provide examples of 2 leading academic institutions that have developed comprehensive programs to promote physician wellness and prevent burnout.

A 2-Question Summative Score Correlates with the Maslach Burnout Inventory

Introduction

There is a high prevalence of burnout among emergency medicine (EM) residents. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a widely used tool to measure burnout. The objective of this study was to compare the MBI-HSS and a two-question tool to determine burnout in the EM resident population.

Methods

Based on data from the 2017 National Emergency Medicine Resident Wellness Survey study, we determined the correlation between two single-item questions with their respective MBI subscales and the full MBI-HSS. We then compared a 2-Question Summative Score to the full MBI-HSS with respect to primary, more restrictive, and more inclusive definitions of burnout previously reported in the literature.

Results

Of 1,522 residents who completed the survey 37.0% reported “I feel burned out from my work,” and 47.1% reported “I have become more callous toward people since I took this job” once a week or more (each item >3 on a scale of 0–6). A 2-Question Summative Score totaling >3 correlated most closely with the primary definition of burnout (Spearman’s rho 0.65 [95% confidence interval 0.62–0.68]). Using the summative score, 77.7% of residents were identified as burned out, compared to 76.1% using the full MBI-HSS, with a sensitivity and specificity of 93.6% and 73.0%, respectively.

Conclusion

An abbreviated 2-Question Summative Score correlates well with the full MBI-HSS tool in assessing EM resident physician burnout and could be considered a rapid screening tool to identify at-risk residents experiencing burnout.

Ensuring Mentorship of New Physicians in Their First Year: Constructs for New Mentoring Processes

INTRODUCTION

The importance of mentoring new physicians is well established.

OBJECTIVES

To evaluate and improve use of a competencies-based mentoring checklist to help new physicians understand the basic work environment and resources in their daily jobs as well as achieve needed competencies.

METHODS

Literature searches, process improvements, and a review of curricula and mentoring from both inside and outside our large Medical Group were conducted to understand the workflow for new physician orientation, onboarding, and mentoring processes. We aimed to achieve a structured framework for mentor training, evaluation of the mentor-mentee relationship, and development of a bridge for the knowledge gaps and needs of the individual physicians in their departments. Finally, we surveyed new physician hires/mentees in 2017 about their competencies using the new checklist.

RESULTS

The new mentoring process was improved compared with the current mentoring process. Polling of physician mentees after implementation of the checklist showed a 75% completion rate of checklist competencies from January 2017 to April 2018, compared with a baseline of 0%.

CONCLUSION

Review of performance data and addressing deficiencies in a mentoring relationship can lead to active participation and meaningful change in competencies among new physicians.

Physician stress and burnout: the impact of health information technology

Objective

To quantify how stress related to use of health information technology (HIT) predicts burnout among physicians.

Methods

All 4197 practicing physicians in Rhode Island were surveyed in 2017 on their HIT use. Our main outcome was self-reported burnout. The presence of HIT-related stress was defined by report of at least 1 of the following: poor/marginal time for documentation, moderately high/excessive time spent on the electronic health record (EHR) at home, and agreement that using an EHR adds to daily frustration. We used logistic regression to assess the association between each HIT-related stress measure and burnout, adjusting for respondent demographics, practice characteristics, and the other stress measures.

Results

Of the 1792 physician respondents (43% response rate), 26% reported burnout. Among EHR users (91%), 70% reported HIT-related stress, with the highest prevalence in primary care-oriented specialties. After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% CI: 2.0-4.1; P < .0001), compared to those reporting sufficient time. Physicians reporting moderately high/excessive time on EHRs at home had 1.9 times the odds of burnout (95% CI: 1.4-2.8; P < .0001), compared to those with minimal/no EHR use at home. Those who agreed that EHRs add to their daily frustration had 2.4 times the odds of burnout (95% CI: 1.6-3.7; P < .0001), compared to those who disagreed.

Conclusion

HIT-related stress is measurable, common (about 70% among respondents), specialty-related, and independently predictive of burnout symptoms. Identifying HIT-specific factors associated with burnout may guide healthcare organizations seeking to measure and remediate burnout among their physicians and staff.

Developing institutional infrastructure for physician wellness: qualitative Insights from VA physicians

BACKGROUND

The prevalence and detrimental effect of physician burnout requires new strategies for supporting physicians. In this project, we describe the development, and assessment, of a "Balint-like" physician support group that provided social cohesion and delivered novel didactic curricula for building resilience.

METHODS

The project began with a nine-month facilitated peer-support group for physicians that met every other week. Based on input from the first group, tailored content was developed to address physician wellness needs. These curricula were delivered to participants in the second nine-month Balint-like group. We then conducted semi-structured interviews with 7 hospitalists and 2 outpatient primary care physicians who participated in the Balint-like groups to explore the intervention's value and to identify remaining unmet physician wellness needs. Using an inductive thematic analysis approach, we identified a set of institutional-, community- and individual-level factors affecting physician wellness and corresponding intervention opportunities.

RESULTS

Physicians spoke of systems-level factors that contributed to distress, and proposed infrastructure, both physical and procedural, that they felt could better support physician wellness. They highlighted the emotional challenges of daily work, and the need for a forum by which to process these interactions in order to maintain their own wellness. Participants reported that participation in Balint-like groups provided this forum and served to help the physicians normalize struggles, reduce isolation and provide new strategies for navigating challenging interactions.

CONCLUSIONS

Institutional infrastructure, in the form of regular, psychologically-safe forums for processing with peers and learning relational strategies for preserving wellness, may mitigate physician distress. This project provides a model for how to develop and deliver a low-cost physician wellness program that can be tailored to the needs of individual clinical units.

Pediatric Career Choice: Insights From a Novel, Medical School Pathway Program

OBJECTIVE

Research on how medical students choose a career in pediatrics is either dated or conflated with primary care career choice. Capitalizing on student participation in an innovative, time-variable, competency based pathway program, Education in Pediatrics Across the Continuum (EPAC), the authors explored the process of career decision-making in students at 5 medical schools (including 4 EPAC sites) who begin medical school with an interest in pediatrics.

METHODS

Individual, semistructured interviews were conducted with students in 5 groups: Group 1: accepted into EPAC, n = 8; Group 2: accepted into EPAC, opted-out, n = 4; Group 3 applied to EPAC, not accepted, pursued pediatrics, n = 4; Group 4: applied to EPAC, not accepted, did not pursue pediatrics, n = 3; Group 5: pursued pediatrics at a non-EPAC site, n = 6. Data collection and analysis occurred iteratively, with inductive coding of data revealing patterns in data explored in subsequent interviews and refined in the final analysis.

RESULTS

All students described intrinsic guiding principles, that is, "doing what you love," that attracted them to pediatrics. They described extrinsic, phase-specific experiences before medical school, before clerkship, and in clerkship that shaped their perceptions of a career in pediatrics and shed light on collective values of different specialties. Student's assessment of how their guiding principles aligned with the collective values of pediatrics, which students encountered in the clerkship phase, was a key to making career decisions.

CONCLUSIONS

Intrinsic and extrinsic factors do not act alone but interact in clerkships, and influence career choice of students who enter medical school with an interest in pediatrics.

Capacity to Address Social Needs Affects Primary Care Clinician Burnout

PURPOSE

Primary care clinicians disproportionately report symptoms of burnout, threatening workforce sustainability and quality of care. Recent surveys report that these symptoms are greater when clinicians perceive fewer clinic resources to address patients' social needs. We undertook this study to better understand the relationship between burnout and clinic capacity to address social needs.

METHODS

We completed semistructured, in-person interviews and brief surveys with 29 primary care clinicians serving low-income populations. Interview and survey topics included burnout and clinic capacity to address social needs. We analyzed interviews using a modified grounded theory approach to qualitative research and used survey responses to contextualize our qualitative findings.

RESULTS

Four key themes emerged from the interview analyses: (1) burnout can affect how clinicians evaluate their clinic's resources to address social needs, with clinicians reporting high emotional exhaustion perceiving low efficacy even in when such resources are available; (2) unmet social needs affect practice by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians' medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients' social needs as a necessary but insufficient strategy to address burnout.

CONCLUSIONS

Primary care clinicians described multiple pathways whereby increased clinic capacity to address patients' social needs mitigates burnout symptoms. These findings may inform burnout prevention strategies that strengthen the capacity to address patients' social needs in primary care clinical settings.

From Burnout to Well-Being: A Focus on Resilience

Burnout is a widespread problem in health care. Factors that contribute to enhancing engagement and building resiliency are widely discussed, but the data supporting these practices are not well understood. Interventions aimed at increasing engagement and promoting resiliency are targeted toward individual practitioners, health care institutions, and national organizations. Knowledge of the data supporting various kinds of interventions is vital to implementing change meaningfully. Prevention of burnout should start early in training with appropriate modeling and input from mentors and should incorporate stress management strategies. The most compelling data for building resilience requires institutions, physicians, and their support staff to align their values to create a mutual culture of wellness and engagement. It is imperative that institutional and national reform allows us as physicians to preserve our relationships with patients and colleagues, while also prioritizing time to reflect and pursue outside interests that recharge and restore.

Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields

BACKGROUND

While barriers to physician wellness have been well detailed, concrete solutions are lacking.

OBJECTIVE

We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.

DESIGN

We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.

PARTICIPANTS

Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).

APPROACH

Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.

KEY RESULTS

Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.

LIMITATIONS

In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.

CONCLUSION

Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

How do doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care? A qualitative study in a Norwegian hospital

OBJECTIVES

Doctors increasingly experience high levels of burnout and loss of engagement. To address this, there is a need to better understand doctors' work situation. This study explores how doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care.

DESIGN

An exploratory qualitative study design with semistructured individual interviews was chosen. Interviews were transcribed verbatim and analysed by a transdisciplinary research group.

SETTING

The study focused on a surgical department of a mid-sized hospital in Norway.

PARTICIPANTS

Seven doctors were interviewed. A purposeful sampling was used with gender and seniority as selection criteria. Three senior doctors (two female, one male) and four in training (three male, one female) were interviewed.

RESULTS

We found that in order to provide quality care to the patients, individual doctors described 'stretching themselves', that is, handling the tensions between quantity and quality, to overcome organisational shortcomings. Experiencing a workplace emphasis on production numbers and budget concerns led to feelings of estrangement among the doctors. Participants reported a shift from serving as trustworthy, autonomous professionals to becoming production workers, where professional identity was threatened. They felt less aligned with workplace values, in addition to experiencing limited management recognition for quality of patient care. Management initiatives to include doctors in development of organisational policies, processes and systems were sparse.

CONCLUSION

The interviewed doctors described their struggle to balance the inherent tension among professional fulfilment, organisational factors and quality of patient care in their everyday work. They communicated how 'stretching themselves', to overcome organisational shortcomings, is no longer a feasible strategy without compromising both professional fulfilment and quality of patient care. Managers need to ensure that doctors are involved when developing organisational policies, processes and systems. This is likely to be beneficial for both professional fulfilment and quality of patient care.

Addressing Burnout in Radiologists

Burnout is a global health problem affecting physicians across all medical specialties. Radiologists, in particular, experience high rates of burn out, and this trend has only continued to worsen. The "Promoting Health and Wellness for Radiologists Task Force of the Association of University Radiologists-Radiology Research Alliance" presents a review of the prevalence, causes, and impact of burnout among radiology faculty and trainees, and a discussion on strategies for overcoming burnout and promoting overall health and well-being among radiologists.

Does Implementation of a Corporate Wellness Initiative Improve Burnout?

Introduction

Burnout affects over 50% of all physicians. Nearly 70% of emergency physicians are affected, and it has been found to be as high as 76% in resident physicians overall. Previous wellness initiatives have yielded variable results; therefore, we looked for interventions that could potentially be effective at reversing this trend. We explored effective wellness programs originating from other industries. Our objective was to implement a corporate wellness program with previous evidence of success in other healthcare provider populations. We aimed to investigate whether this program would be effective in decreasing burnout in emergency medicine (EM) residents.

Methods

This program was conducted during required EM resident conference hours from 2016–2017. The Maslach Burnout Inventory was completed before and after the series of sessions, and we collected reactions-level data following completion of the six sessions.

Results

Post-intervention scores revealed a small trend toward increased emotional exhaustion and depersonalization scores, and with increased personal accomplishment scores. The overall satisfaction rating for this program was low, at 1.5 on a 5-point scale. Forty-three percent of residents stated that this intervention subjectively worsened their overall burnout, with another 39% stating it did not improve their burnout at all. A similar trend was seen for effects on wellness.

Conclusion

We found that a corporate wellness intervention that had previously been shown to be successful with other types of healthcare providers did not objectively improve burnout and was subjectively perceived as paradoxically worsening burnout for many residents. This result may be related to the type of intervention chosen (individual vs. systems-focused), the design of the intervention itself, or the unique stressors faced by the resident population. [West J Emerg Med.2019;20(1)138–144.]

Staffing and workforce issues in the pediatric intensive care unit

The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs

Introduction

Difficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described.

Materials and methods

We used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents’ experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results.

Results

These survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as “fair” or “good” (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters.

Discussion

We found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors.

Conclusions

Next steps include creating a “Difficult Encounters” communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

Focus on the Quadruple Aim: Development of a Resiliency Center to Promote Faculty and Staff Wellness Initiatives

DEFINING THE PROBLEM

A growing body of evidence highlights the need for wellness programs to support health care professionals. Although much of the existing literature centers on practicing physicians and physician trainees, there is growing awareness that these challenges are not unique to physicians and affect all members of the health care team. Traumatic and stressful events will always be a part of health care; how these events are addressed on a personal and team level is essential to the success of a health care system. A Resiliency Center was developed on the basis of the specific concerns and strengths of local stakeholders to support the well-being of employees at University of Utah Health.

INITIAL APPROACH

The initial approach to evaluating and supporting faculty wellness began concurrent with planning for the Resiliency Center in 2016. Stakeholders were brought together by leaders in Health Sciences to propose a Resiliency Center. Initial data gathering was performed with several survey tools, including the American Medical Association's Mini Z.

PLANNED INITIATIVES

The Resiliency Center, which is housed in the Office of Wellness and Integrative Health, is intended to serve as an overarching structure to help coordinate the faculty and staff wellness initiatives currently in existence and fill identified gaps. The four pillars of the Center are wellness initiatives, communication skills training, peer support, and an on-site Employee Assistance Program.

NEXT STEPS

The current focus is on program development and outreach, with plans to measure the impact of the Center.

Burnout, Moral Distress, Work-Life Balance, and Career Satisfaction among Hematopoietic Cell Transplantation Professionals

A projected shortage of hematopoietic cell transplantation (HCT) health professionals was identified as a major issue during the National Marrow Donor Program/Be The Match System Capacity Initiative. Work-related distress and work-life balance were noted to be potential barriers to recruitment/retention. This study examined these barriers and their association with career satisfaction across HCT disciplines. A cross-sectional, 90-item, web-based survey was administered to advanced practice providers, nurses, physicians, pharmacists, and social workers in 2015. Participants were recruited from membership lists of 6 professional groups. Burnout (measured with the Maslach Burnout Inventory subscales of emotional exhaustion and depersonalization) and moral distress (measured by Moral Distress Scale-Revised) were examined to identify work-related distress. Additional questions addressed demographics, work-life balance, and career satisfaction. Of 5759 HCT providers who received an individualized invitation to participate, 914 (16%) responded; 627 additional participants responded to an open link survey. Significant differences in demographic and practice characteristics existed across disciplines (P < .05). The prevalence of burnout differed across disciplines (P < .05) with an overall prevalence of 40%. Over one-half of pharmacists had burnout, whereas social workers had the lowest prevalence at less than one-third. Moral distress scores ranged from 0 to 336 and varied by discipline (P < .05); pharmacists had the highest mean score (62.9 ± 34.8) and social workers the lowest (42.7 ± 24.4). In multivariate and univariate analyses, variables contributing to burnout varied by discipline; however, moral distress was a significant contributing factor for all providers. Those with burnout were more likely to report inadequate work-life balance and a low level of career satisfaction; however, overall there was a high level of career satisfaction across disciplines. Burnout, moral distress, and inadequate work-life balance existed at a variable rate in all HCT disciplines, yet career satisfaction was high. These results suggest specific areas to address in the work environment for HCT health professionals, especially the need for relief of moral distress and a greater degree of personal time. As the creation of healthy work environments is increasingly emphasized to improve quality care and decrease costs, these findings should be used by HCT leadership to develop interventions that mitigate work-related distress and in turn foster recruitment and retention of HCT providers.

Developing a framework for evaluating the impact of Healthcare Improvement Science Education across Europe: a qualitative study

PURPOSE

Frontline healthcare professionals are well positioned to improve the systems in which they work. Educational curricula, however, have not always equipped healthcare professionals with the skills or knowledge to implement and evaluate improvements. It is important to have a robust and standardized framework in order to evaluate the impact of such education in terms of improvement, both within and across European countries. The results of such evaluations will enhance the further development and delivery of healthcare improvement science (HIS) education. We aimed to describe the development and piloting of a framework for prospectively evaluating the impact of HIS education and learning.

METHODS

The evaluation framework was designed collaboratively and piloted in 7 European countries following a qualitative methodology. The present study used mixed methods to gather data from students and educators. The framework took the Kirkpatrick model of evaluation as a theoretical reference.

RESULTS

The framework was found to be feasible and acceptable for use across differing European higher education contexts according to the pilot study and the participants' consensus. It can be used effectively to evaluate and develop HIS education across European higher education institutions.

CONCLUSION

We offer a new evaluation framework to capture the impact of HIS education. The implementation of this tool has the potential to facilitate the continuous development of HIS education.

The work-related stressors and coping strategies of group-employed rural health care practitioners: A qualitative study

BACKGROUND

Escalating demands on practitioners, stagnating/dwindling resources, and diminishing autonomy have heightened patient-care work-related stress. Using qualitative content/thematic analysis of responses to open-ended survey questions, plus spontaneous comments, we sought to identify rural clinicians' subjective perceptions of their workplace stressors and typical adaptive/coping strategies.

METHODS

Within a hybrid inductive-deductive approach, we framed empirical themes (derived by consensus, corroborated with text segments, and extant literature) into theory-based coding templates by which we analyzed the data.

RESULTS

Of 308 (65.1% of) recipients completing questionnaires, 290 (94%) answered open-ended questions and/or provided comments. Categorizing stressors by socio-ecology, they cited four themes: Organizational, practitioner/staff-related, patient-related, and third party-induced stressors. Organizational stressors were referenced most conspicuously. How respondents described their coping fitted the Stress, Appraisal and Coping. [Lazarus and Folkman (1984): New York, NY: Springer Publishing Company, Inc] model. Emotion-focused were referenced more than problem-focused approaches. Themes scarcely differed by demographics, except for marital status.

CONCLUSIONS

Findings highlight needs for resilience coaching, rekindling work meaningfulness, mentorship in work-home balance/limit-setting, supportive peer networks, and deeper teamwork.