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Moral distress (MD) occurs when an individual knows the ethically correct action to take in a situation but institutional constraints prevent the individual from acting. MD is a well-documented phenomenon among nurses and occurs at a high frequency in the critical care setting. When MD is not adequately addressed and actions are not taken to mitigate precipitating factors within an organization, moral injury, moral residue, and burnout may consequentially result in nurses leaving their role or the profession. Nurse leaders are positioned to exemplify ethical leadership and provide support for their staff when MD is experienced; however, nurse leaders experience MD to a more global degree and much less is understood regarding the experience of MD among nurse leaders, as few studies have examined MD within this population. The aim of this dissertation was to explore the experience of MD among nurse leaders through qualitative methods. An initial qualitative study among unit-based critical care nurses in a single hospital in Alabama examining how unit-based critical care nurse leaders navigate MD among their staff revealed nurse leaders are likely to experience MD as a result of similar sources to staff nurses with the additional source of role-specific challenges. A qualitative systematic review revealed the known experiences, consequences, and strategies to address MD existing within the literature. A second, qualitative descriptive study conducted state-wide in Alabama among unit-based critical care nurse leaders converged with the findings of the qualitative systematic review and further added context to existing literature by revealing the experience of MD among nurse leaders may not be impacted by geographic contexts. Findings of these studies may inform the development or adaptation of MD measurement tools and interventions, conceptual and theoretical frameworks, and/or further exploration of the experience of MD among the nurse leader population.

OBJECTIVE: Pharmacy students with substantial educational debt are at risk for excessive workloads, burnout, and clinical errors. During the COVID-19 pandemic, policies addressing economic hardships for all student debt borrowers included temporary suspension of monthly payments and 0% interest during the pause. This study aimed to understand student-level factors regarding student debt from the lived experiences of current pharmacy students and aimed to understand how current pharmacy students view temporary loan relief. METHODS: We used semi-structured interviews of pharmacy students across four years of progression in their pharmacy program to better understand student experiences with debt, different factors that may influence the impact of student debt on short-term and long-term outcomes for students, and student perspectives on debt relief policies and potential solutions. Our thematic analysis was grounded in existing evidence and a conceptual framework, while also allowing codes to emerge directly from the data. RESULTS: A total of 20 pharmacy students were interviewed with a median student debt of $77,000, with debt amounts ranging from $0 to $209,000. Students described what mediating factors influenced their experiences, the influence of student debt on clinician burnout, and other outcomes impacted by student debt. Six overarching themes emerged relevant to current students: student debt influences education and career decisions, debt is risky given the saturated pharmacy market, debt is an accepted burden, debt will inhibit starting a life, the COVID-19 loan relief is revealing, and early financial education is needed. CONCLUSION: Pharmacy students burdened with debt described a variety of different experiences and attitudes towards that debt and provided their perspectives on how student debt influences short-term education and career decisions. While students accept the tradeoff of debt for their education as an inevitable burden, reported coping mechanisms and strategies shared suggest some solutions may be available to ameliorate this burden.

OBJECTIVES: To understand the relationship between stressful work environments and patient care by assessing work conditions, burnout, and elements of the diagnostic process. METHODS: Notes and transcripts of audiotaped encounters were assessed for verbal and written documentation related to psychosocial data, differential diagnosis, acknowledgement of uncertainty, and other diagnosis-relevant contextual elements using 5-point Likert scales in seven primary care physicians (PCPs) and 28 patients in urgent care settings. Encounter time spent vs time needed (time pressure) was collected from time stamps and clinician surveys. Study physicians completed surveys on stress, burnout, and work conditions using the Mini-Z survey. RESULTS: Physicians with high stress or burnout were less likely to record psychosocial information in transcripts and notes (psychosocial information noted in 0% of encounters in 4 high stress/burned-out physicians), whereas low stress physicians (n=3) recorded psychosocial information consistently in 67% of encounters. Burned-out physicians discussed a differential diagnosis in only 31% of encounters (low counts concentrated in two physicians) vs. in 73% of non-burned-out doctors’ encounters. Burned-out and non-burned-out doctors spent comparable amounts of time with patients (about 25 min). CONCLUSION: Key diagnostic elements were seen less often in encounter transcripts and notes in burned-out urgent care physicians.

First responder social workers are exposed to a stressful work environment, which puts them at risk for burnout. Burnout increases turnover rates, which negatively impacts both social workers and the clients they serve. The use of self-care practices mitigates the harmful effects of burnout. Because first responder social workers in southern California have an average turnover rate of 6 to 12 months after hire, this study explored southern California first responder social workers’ experiences with self-care practices. A basic qualitative design using semistructured interviews was applied through the purposeful sampling of eight first responder social workers. The study was grounded in Orem’s theory of self-care. The findings highlighted that first responder social workers were aware and knowledgeable about self-care. First responder social workers experienced numerous benefits, including burnout prevention, improved ability to manage stress, and increased work performance with the utilization of self-care practices. Participants also faced challenges with regularly utilizing self-care practices that resulted in impaired functioning. This study will inform positive social change as it identified the challenges faced by first responder social workers in using self-care practices and offered possible solutions.

BACKGROUND: Violence directed at healthcare workers (HCWs) is common and may be more frequent in the emergency department (ED). In addition to physical injury, other consequences of workplace violence in the ED include an increased risk of burnout, post-traumatic stress disorder, reduced job satisfaction, and feelings of avoidance and futility. Understanding behaviors underlying workplace violence is the first step to employing mitigation strategies. The objective of this descriptive study was to assess the prevalence and types of violence against HCWs in a large, urban ED. METHODS: This study took place in the ED of an urban hospital with an annual ED census of approximately 100,000. A previously existing general patient safety incident “dropbox” for HCWs was utilized to capture workplace violence reports. At the completion of the study period, all data was collated into the electronic database and each report was categorized based on the nature and severity of the abuse. Further, all events were also coded as either involving or not involving specifically racist, sexist, or homophobic content. The primary outcomes were the number of reported events over the study period, and the percentage of total events that fell into each category. The secondary outcomes were the overall prevalence and ratio of events that included racist, sexist, or homophobic language or provocation. RESULTS: Over the 5-month survey period, 130 reports of workplace violence were recorded, on average 0.85 per day. Perpetrators were mostly male, and most victims were nurses. Hospital security was involved in 26% of cases. At least 37% of incidents involved patients that were intoxicated and/or had history of psychiatric illness. Type I events (swearing provocatively, shouting, and legal threats) were the most common at 44% of encounters while 22% involved physical violence. Racist, sexist, and homophobic comments were involved in 8 (6%), 18 (14%), and 3 (2%) incidents respectively. CONCLUSION: We found that workplace violence against HCWs was common in this study, and sometimes involved a component of racist, sexist, or homophobic bias. Consistent with previous ED literature, we found that abusive events occurred almost daily and that approximately 20% of events involved physical violence. Future efforts toward policy change to address workplace violence in health care is needed at local, state, and national levels.

PURPOSE: To evaluate the association between elements of the built environment and physician well-being using a scoping review. BACKGROUND: Physicians currently report low work satisfaction, high burnout and depression. The built environment has been shown to affect well-being in the general population, but its relationship to physician well-being is not well understood. Gaining a better understanding of this relationship will allow for better evidence-based design for physician well-being. METHODS: A scoping review of the literature was conducted of Scopus and PubMed databases using key words for (1) environmental variables such as "environmental design"; (2) physician terms, such as "doctor"; and (3) outcome measures of well-being, such as "burnout." Studies were included if they had at least one measure of the built environment and one measure of physician well-being. Of 1,723 abstracts screened, 146 full-text articles were reviewed, leaving 16 articles to be included for data extraction. RESULTS: Included studies were from all around the world, except for, notably, the United States. Robust interpretation of the data was challenging because of the lack of standardization in the assessment of environmental factors and physician well-being. Excessive noise was the variable most linked to well-being. Suitable surroundings, including lighting, furniture, and art, were also linked with satisfaction, but it was unclear whether there was an association with well-being. CONCLUSION: Understanding how environmental factors affect physician well-being is paramount but considerably understudied. Standardization of research approach should be developed in order to produce more robust research to create evidence-based designs for physician well-being.

OBJECTIVE: The current studies explored associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes among frontline workers affected by the coronavirus pandemic. METHOD: We administered online self-report surveys to emergency responders (N = 473) and hospital personnel (N = 854) in the Rocky Mountain region of the United States between April and June of 2020. Surveys assessed frequency and intensity of exposure to PMIEs alongside psychological and functional outcomes. RESULTS: Between 20% and 30% of frontline workers reported exposure to PMIEs of at least moderate frequency and intensity. Exposure to more intense PMIEs was associated with greater psychological symptoms (i.e., stress, depression, and anxiety) and functional impairment (i.e., professional burnout), especially among emergency responders who reported frequent exposure but also hospital workers who reported few exposures. CONCLUSION: Efforts to facilitate and maintain the well-being of the public health workforce should specifically address critical incidents encountered by frontline workers that have embedded moral and ethical challenges.

BACKGROUND: Arts-and-humanities-based interventions are commonly implemented in medical education to promote well-being and mitigate the risk of burnout. However, mechanisms for achieving these effects remain uncertain within graduate medical education. The emerging field of the positive humanities offers a lens to examine whether and how arts-based interventions support well-being in internal medicine interns. AIM: Through program evaluation of this visual art workshop, we used a positive humanities framework to elucidate potential mechanisms by which arts-based curricula support well-being in internal medicine interns. SETTING: We launched the re-FRAME workshop at the Philadelphia Museum of Art in winter 2020. PARTICIPANTS: Fifty-six PGY-1 trainees from one internal medicine residency program. PROGRAM DESCRIPTION: The 3-h re-FRAME workshop consisted of an introductory session on emotional processing followed by two previously described arts-based interventions. PROGRAM EVALUATION: Participants completed an immediate post-workshop survey (91% response rate) assessing attitudes towards the session. Analysis of open-ended survey data demonstrated 4 categories for supporting well-being among participants: becoming emotionally aware/expressive through art, pausing for reflection, practicing nonjudgmental observation, and normalizing experiences through socialization. DISCUSSION: Our project substantiated proposed mechanisms from the positive humanities for supporting well-being-including reflectiveness, skill acquisition, socialization, and expressiveness-among medical interns.

BACKGROUND: Burnout among millennial medical students is an important health issue with a possibility of potential professional dissatisfaction. The reason for burnout is multifactorial. The gender of the medical student may play a significant role when choosing a residency specialty and making a career choice. Gender may also influence while establishing the burnout seen in students. Here we tested the association between burnout in medical students based on gender and residency specialty choice during COVID-19. METHODS: A multicentric cross-sectional study, using a questionnaire-based survey on the items related to gender, educational interest, status, residency aspiration, changes to career aspiration based on gender, and COVID-19 and an indigenous burnout assessment tool that was administered to all the medical students in the study. Reliability and validity of the tool were assessed, and the burnout was calculated for emotional exhaustion, personal achievement, and depersonalization domain. RESULTS: A total of 487 medical students (42.5% males, 57.2% females) completed the survey. A higher number of female participants felt that COVID-19 affected their energy levels (68.9%), interest in education (53.2%), and developed reservations about residency specialty of choice (46%); emotional and physical exhaustion (2.88 ± 0.69 & 2.34 ± 0.76) was higher than the male participants (3.16 ± 0.67 & 2.75 ± 0.85). CONCLUSION: More female participants experienced emotional distress, depersonalization or professional disengagement, and psychological and physical stress and exhaustion due to the COVID-19 pandemic. An important association observed in the study was between residency choice and burnout.

BACKGROUND: There has been considerable research into burnout but much less into how surgeons thrive and find joy. This study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, explored factors influencing surgeon well-being, the eventual goal being translating findings into tangible changes to help restore the joy in surgery. METHODS: This was a qualitative, descriptive study. Purposive sampling ensured representation across ages, genders, ethnicities, practice types, and geographies. Semi-structured interviews were recorded and transcribed. We coded inductively, finalized the codebook by consensus, and then constructed a thematic network. Global themes formed our conclusions; organizing themes gave additional detail. Analysis was facilitated by NVivo. RESULTS: We interviewed 17 surgeons from the US and Canada. Total interview time was 15 hours. Our global and organizing themes were: Stressors (Work–life Integration, Administration-related Concerns, Time and Productivity Pressures, Operating Room Factors, and Lack of Respect). Satisfaction (Service, Challenge, Autonomy, Leadership, and Respect and Recognition). Support (Team, Personal Life, Leaders, and Institutions). Values (Professional and Personal). Suggestions (Individual, Practice, and System level).Values, stressors, and satisfaction influenced perspectives on support. Experiences of support shaped suggestions. All participants reported stressors and satisfiers. Surgeons at all stages enjoyed operating and being of service. Supports and suggestions included compensation and infrastructure, but human resources were most critical. To experience joy, surgeons needed high-functioning clinical teams, good leaders/mentors, and supportive family/social networks. CONCLUSIONS: Our results indicated organizations could (1) better understand surgeons’ values, like autonomy; (2) provide more time for satisfiers, like patient relationship building; (3) minimize stressors, like time and financial pressures; and (4) at all levels focus on (4a) building teams and leaders and (4b) giving surgeons time and space for healthy family/social lives. Next steps include developing an assessment tool for individual institutions to build “joy improvement plans” and to inform surgical associations’ advocacy efforts.

OBJECTIVES: Describe demographic and professional factors predictive of burnout in academic otolaryngology before and during the COVID-19 pandemic. METHODS: In 2018 and 2020, cross-sectional surveys on physician wellness and burnout were distributed to faculty members of a single academic institution's otolaryngology department. Faculty were dichotomized into low and high burnout groups for 2018 (n = 8 high burnout, 19%) and 2020 (n = 11 high burnout, 37%). To identify protective factors against burnout, three semi-structured interviews were conducted with faculty that reported no burnout. RESULTS: Forty-two participants (59%) in 2018 and 30 out of 49 participants (62%) in 2020 completed the survey. In multivariate analysis of 2018 survey data, full and associate professors had significantly lower odds of high burnout (OR 0.06, 95% CI 0.00–0.53; p = .03). Female gender was associated with increased in odds of high burnout (OR 15.55, 95% CI 1.86–231.74; p = .02). However, academic rank and gender did not remain independent predictors of high burnout in the 2020 survey. We identified significant differences in drivers of burnout brought on by the pandemic, including a shift from a myriad of work-related stressors in 2018 to a focus on patientcare and family obligations in 2020. Interview analysis identified three themes in faculty who reported no burnout: (1) focus on helping others, (2) happiness over compensation as currency, and (3) gratitude for the ability to have an impact. CONCLUSION: Approximately 20% of faculty reported high burnout before the pandemic, and this proportion nearly doubled during the pandemic. The risk factors and themes identified in this study may help academic otolaryngologists prevent burnout.

[This is an excerpt.] A literature review exploring factors influencing the intent of nurse managers employed in acute care settings to leave their current positions identifies five major themes: organizational support, job satisfaction, work-life balance, personal characteristics, and burnout. [To read more, click View Resource.]

Pharmacy faculty commonly report feeling stressed, overwhelmed, exhausted, and burnt out. Women may be disproportionally impacted by personal and professional demands. The purpose of this commentary is to describe one mechanism for creating a suborganization (Circle) that establishes a supportive community to combat burnout and promote professional fulfillment. This commentary is a description of one American Academy of Colleges of Pharmacy (AACP) Women Faculty Special Interest Group (SIG) Circle. The authors describe how one Circle sought to enhance the well-being of its members through the various domains of the Stanford Model of Professional Fulfillment, including personal resilience, workplace efficiency, and creating a culture of well-being. Circles and similar frameworks may be effective tools for combatting burnout, improving fulfillment, and promoting wellness and well-being among women and other groups of faculty.

PURPOSE: Professional identity formation (PIF) is a dynamic process by which an individual internalizes the core values and beliefs of a specific profession. Within medical education, PIF begins in medical school and continues throughout training and practice. Transitions affect PIF, with a critical transition occurring between medical training and unsupervised practice. This study aims to characterize PIF during the transition from resident to early-career faculty physician and explores the relationship between PIF and burnout during this transition. METHOD: The authors conducted a qualitative study using constructivist grounded theory. They conducted semistructured interviews with early-career faculty physicians (defined as practicing for ≤ 5 years) from the Department of Medicine, Mayo Clinic. Deidentified interview transcripts were processed through open and axial coding. The authors organized themes and identified relationships between themes that were refined through discussion and constant comparison with newly collected data. During data analysis, the authors identified self-determination theory, with the concepts of autonomy, competence, and relatedness, as a framework to support the organization and analysis of the data. RESULTS: Eleven early-career faculty physicians participated in the interviews. Their PIF was characterized by the dual desires to fit in and stand out. Striving for these desires was characterized by imposter syndrome, driving physicians to question their decision making and overall competence. Participants associated imposter syndrome and academic pressures with burnout. Autonomy support by the institution to pursue opportunities important for career development helped mitigate burnout and support PIF. CONCLUSIONS: Early-career faculty physicians face identity challenges when transitioning from training to unsupervised practice, including striving to fit in and stand out. They link this tension to imposter syndrome, which they associated with burnout. Institutional awareness and support, including addressing structural and cultural contributors to imposter syndrome, are paramount as new faculty explore their identities and navigate new challenges.

[This is an excerpt.] A new bargaining chip appeared on the table as hospital employees in Iowa negotiated a new contract with the University of Iowa Hospitals and Clinics—protection from patient attacks. Iowa’s increase in non-fatal workplace injuries and illnesses among registered nurses echoed national trends with a 32.9 percent increase in violence-related workplace injury and illness in nurses from 2019 to 2020. Across the US, violent assaults in health care are rising; three nurses were killed at work in the fall of 2022. One hospital-based analysis shows two nurses are assaulted every hour. The statistics are alarming and disturbing. The COVID-19 pandemic increased patient violence toward nurses and health care workers; in one survey, 27 percent of nurses reported more incidents during the pandemic than previously. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Government: Ensuring Workers' Physical and Mental Health (Strengthen Occupational Safety and Health Policies).

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[This is an excerpt.] A mental health pandemic exists in nurses, the entire health workforce, health sciences faculty, and students as the nation and world recover from the COVID-19 pandemic. Depression, suicide rates, and burnout have skyrocketed in these populations, resulting in presenteeism, absenteeism, and high job turnover as well as substantial collegiate drop-out rates that are costing both healthcare and educational institutions huge economic losses. Findings from research also have shown strong positive associations among clinician burnout, mental health issues, and preventable medical errors (Melnyk et al., 2021). Promoting the mental health and well-being of the healthcare workforce, as well as health sciences faculty and students is not a nicety; it is a necessity as people's lives are at stake. [To read more, click View Resource.]

[This is an excerpt.] During the COVID-19 pandemic, pharmacists’ roles were expanded. Pharmacists have constantly been on the front line, administering COVID-19 vaccines and providing treatment. With these added responsibilities, there is often a trade-off—especially when adequate support isn’t provided. This can lead to burnout, a workplace phenomenon characterized by emotional exhaustion and lack of personal accomplishment at work. In May 2022, the US surgeon general issued an advisory report to address health worker burnout and resignation. The report emphasizes the importance of protecting the health, safety, and well-being of health workers. Pharmacists should have a variety of tools at their disposal to prevent, identify, and cope with burnout. [To read more, click View Resource.]

This chapter explores the evolution of a mindfulness-based program that began as a patient-focused pilot study and developed into a hospital-wide staff-focused program. Initially, a mindfulness-based program was adapted and studied to measure its impact on stress and coping in a group of adolescents with implanted cardiac devices. The positive outcomes of this study led to a larger randomized study in the same patient population. With continued positive outcomes, a larger, train-the-trainer model was designed and implemented. This program trains hospital staff in mindfulness techniques with the goal of decreasing their own stress and burnout while ultimately reaching and benefitting larger groups of patients and nonclinical staff through greater mindful awareness and education of staff. The program has had a hospital-wide impact including tremendous support from hospital administration. In addition to outlining background and specifics of the nurse-led model, this chapter describes the processes that were undertaken to develop and implement the program.

OBJECTIVES: This study explored design solutions that can help clinicians manage work-related stress, pursue mindful work, and practice relaxation and coping strategies. BACKGROUND: Clinicians are experiencing burnout at increasingly higher rates, leading to compromised patient care. While self-care and stress management strategies are shown to be effective in healthcare settings, little is known about how the design of healthcare settings can facilitate these strategies. METHODS: Using findings of a preceding study by the authors, a virtual walk-through video of a design proposal for a free-standing emergency department was built. Feedback data were collected from clinicians in 10 in-depth interviews, and emerging themes were identified using qualitative content analysis. RESULTS: Our findings suggest that work environments that reflect intentional efforts to meet clinicians? needs for stress management can enhance their feeling of being valued and sense of professional worth. Clinicians are more likely to step away from work if there are multiple spaces for bio breaks and rest breaks. Primary break rooms are preferred to be close to patient care areas, but respite/escape spaces are preferred to be distant and private from patient care areas. Participants endorsed the provision of at least one staff bathroom large enough for extra seating and one outdoor respite space. Multiple workspaces should allow the completion of various tasks with adjustable levels of privacy. CONCLUSIONS: We suggest special attention to non-institutional aesthetics, providing choice and control, increasing flexibility, promoting privacy for focused work, maximizing access to daylight and outdoors, and providing opportunities for grief support.

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