CONTEXT: Burnout remains prevalent among surgical residents. Self-compassion training may serve to improve their well-being. OBJECTIVE: To evaluate the impact on well-being of a self-compassion program modified for surgical residents. DESIGN: This is a 3-year, mixed-methods study using pre-post surveys and focus groups to identify areas for programmatic improvement and the subsequent impact of the modifications. SETTING: A single academic institution. PARTICIPANTS: Surgical residents participating in a self-compassion program. Interventions A self-compassion program adapted from a larger course to fit the needs of surgical residents. MAIN OUTCOME MEASURES: Themes relating to the program's strengths and weaknesses were identified through participant focus groups. Well-being was assessed through validated measurement tools, including The Maslach Burnout Inventory (MBI), Patient Health Questionnaire-9, Perceived Stress Scale, and Spielberger State-Trait Anxiety Inventory-6. RESULTS: 95 residents participated in the self-compassion program, of which 40 residents completed both surveys (total response rate: 42%). All participants demonstrated severe burnout pre-program, based on scores of at least one of the MBI subscales. Emotional exhaustion scores improved post-program, with larger improvements seen after program modifications (2018: 58% vs 2020: 71%). Focus group findings demonstrated that residents need a safe and distraction-free space to practice self-compassion, and program engagement improved following modifications.
Self-Compassion Training to Improve Well-Being for Surgical Residents
OBJECTIVES: Combined pediatrics-anesthesiology programs uniquely prepare residents to care for critically ill children, but trainees in these combined programs face challenges as residents within 2 specialties. Social belonging predicts motivation and achievement and protects against burnout. The objective of our study was to evaluate sense of belonging and self-identified professional identity of current combined pediatrics-anesthesiology residents. METHODS: All current residents in combined pediatrics-anesthesiology programs were invited to participate in an anonymous survey assessing sense of belonging and professional identity. Open-ended responses were qualitatively analyzed using an inductive coding process and thematic analysis. Likert questions were analyzed using paired t-tests. RESULTS: Thirty-two of 36 residents completed the survey (89% response rate). A total of 92% of respondents had a lower sense of belonging in pediatrics than anesthesiology (3.32 vs 3.94) and more self-identified as anesthesiologists than pediatricians. Thematic analysis yielded 5 themes 1) the team-based nature of pediatrics results in strong initial bonds, but feelings of isolation as training pathways diverge; 2) the individual nature of anesthesiology results in less social interaction within daily work, but easier transitions in and out of anesthesiology; 3) divergent training timelines result in feeling left behind socially and academically; 4) residents identify different professional and personal characteristics of pediatricians and anesthesiologists that impact their sense of belonging; and 5) the structure of the combined program results in experiences unique to combined residents. CONCLUSIONS: Most residents in combined pediatrics-anesthesiology programs had a higher sense of belonging and self-identification in anesthesiology than pediatrics. Program structure and autonomy had significant impacts.
Sense of Belonging and Professional Identity Among Combined Pediatrics-Anesthesiology Residents
BACKGROUND: There is little existing research investigating SH/SA specifically from patients to students. This study aims to assess the prevalence and impact of SH and SA from patient to medical student. METHODS: A cross-sectional survey study was administered via electronic email list to all current medical students at the University of Washington School of Medicine (n =?1183) over a two-week period in 2019. The survey questions addressed respondents' experiences with SH/SA from patients, frequency of reporting, and impact on feelings of burnout. RESULTS: Three hundred eleven responses were received for a response rate of 26%; 268 complete responses were included in the final analysis. Overall, 56% of respondents reported ever experiencing SH from a patient. SH from a patient was reported by significantly more of those who identify as female compared to male (66% vs 31%; p
Sexual Harassment from Patient to Medical Student: A Cross-Sectional Survey
STUDY OBJECTIVES: The shame reaction is a highly negative emotional reaction shown to have long-term deleterious effects on the mental health of clinicians. Prior studies have focused on in-hospital personnel, but very little is known about what drives shame reactions in emergency medical services (EMS), a field with very high rates of post-traumatic stress disorder, burnout, anxiety, and depression. The objective of this study was to describe emotions, processes, and resilience associated with self-identified adverse events in the work of prehospital clinicians.METHODS: We conducted a qualitative study using a modified critical incident technique. Participants were recruited from two EMS agencies in North Carolina: one urban and one rural. They provided an open-ended, written reflection in which they were asked to self-identify particular events in their EMS careers that felt emotionally difficult. In-person or video indepth interviews about these events were then conducted in a semi-structured fashion using an iterative interview guide. The codebook was developed through a mix of inductive and deductive analysis strategies and discussed within the research team and a content expert for validation. Interviews were transcribed and data were analyzed following a thematic content analysis approach for types of cases identified as emotionally difficult, common emotional responses and coping mechanisms, and the lingering effects of these experiences on study subjects. RESULTS: Eight interviews were conducted with EMS personnel: five from an urban agency and three from a rural agency. Participants commonly identified complex medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS clinicians committed self-perceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed “inevitable” despite any intervention. Common themes related to coping mechanisms included both personal mechanisms, which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the “old school” where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being “not good enough” were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these clinicians. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, along with personal introspection on root causes for the sentinel event. CONCLUSION: EMS clinicians often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their coworkers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to use these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.
Shame and Guilt in EMS: A Qualitative Analysis of Culture and Attitudes in Prehospital Emergency Care
AIM: To assess differences in social group memberships and burnout levels by work tenure among new nurses and identify factors associated with their subjective well-being. DESIGN: A cross-sectional study. METHODS: Participants were 356 registered nurses who had fewer than 3 years of work tenure. Data were collected from February–March 2021. Participants' social identity, burnout, and subjective well-being were assessed using validated questionnaires. STROBE checklist was applied. RESULTS: Multiple group membership was positively associated with life satisfaction and positive affect and negatively with burnout. Burnout influenced new nurses' negative effect in their life transition period. To improve new nurses' subjective well-being, it is essential to focus on their social group membership, encourage participation in group activities, and improve access to sociopsychological resources that can help them take their first steps as professional staff and develop as healthy members of society, which will foster sustainable healthcare systems.
Social Group Membership, Burnout, and Subjective Well-Being in New Nurses in the Life Transition Period: A Cross-Sectional Study
PURPOSE: To examine associations of social support and social isolation with burnout, program satisfaction, and organization satisfaction among a large population of U.S. residents and fellows and to identify correlates of social support and social isolation. METHOD: All residents and fellows enrolled in graduate medical education programs at Mayo Clinic sites were surveyed in February 2019. Survey items measured social support (emotional and tangible), social isolation, burnout, program satisfaction, and organization satisfaction. Factors of potential relevance to social support were collected (via the survey, institutional administrative records, and interviews with program coordinators and/or program directors) and categorized as individual, interpersonal, program, or work-related factors (duty hours, call burden, elective time, vacation days used before survey administration, required away rotations, etc.). Multivariable regression analyses were conducted to examine relationships between variables. RESULTS: Of 1,146 residents surveyed, 762 (66%) from 58 programs responded. In adjusted models, higher emotional and tangible support were associated with lower odds of burnout and higher odds of program and organization satisfaction, while higher social isolation scores were associated with higher odds of burnout and lower odds of program satisfaction and organization satisfaction. Independent predictors of social support and/or social isolation included age, gender, relationship status, parental status, postgraduate year, site, ratings of the program leadership team, ratings of faculty relationships and faculty professional behaviors, satisfaction with autonomy, and vacation days used before survey administration. CONCLUSIONS: This study demonstrates that social support and social isolation are strongly related to burnout and satisfaction among residents and fellows. Personal and professional relationships, satisfaction with autonomy, and vacation days are independently associated with social support and/or social isolation, whereas most program and work-related factors are not. Additional studies are needed to determine if social support interventions targeting these factors can improve well-being and enhance satisfaction with training.
Social Support, Social Isolation, and Burnout: Cross-Sectional Study of U.S. Residents Exploring Associations With Individual, Interpersonal, Program, and Work-Related Factors
BACKGROUND AND OBJECTIVES: Burnout impacts medical students, residents, and practicing physicians. Existing research oversimplifies characteristics associated with burnout. Our study examined relationships between burnout, depressive symptoms, and evidence-based risk factors. METHODS: Our study questions were part of a larger survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA), from May 9-23, 2020. Three emails were used to recruit a national sample of family medicine residents (n=283; questions completed via Survey Monkey). We determined descriptive statistics (frequency, means) for demographic and work environment characteristics, UCLA Loneliness Scale items, health behaviors, burnout (emotional exhaustion, depersonalization), and depressive symptoms. Multivariate data analysis included developing three logistic regression (LR) equations (emotional exhaustion, depersonalization, depressive symptoms) based on four blocks of potential risk factors (demographics, work environment characteristics, UCLA Loneliness items, and health behaviors). RESULTS: Rates of psychological distress included 33.1% emotional exhaustion, 31.1% depersonalization, and 53.0% depressive symptoms. We determined stepwise forward-entry LR models for emotional exhaustion (feel isolated OR=6.89, low quality of wellness program OR=5.91, and low companionship OR=4.82); depersonalization (feel isolated OR=5.59, low quality of wellness program OR=15.11, graduate US osteopathic medical school OR=0.329, and African American OR=7.55); and depressive symptoms (feel isolated OR=5.31, inadequate time for restful sleep OR=0.383, and no dependent children OR=2.14). CONCLUSIONS: Current findings document substantial social disconnection, substandard residency wellness programs, inadequate time for exercise, sleep, and other forms of self-care in addition to substantial levels of emotional exhaustion, depersonalization, and depressive symptoms. We explore implications for the design of future burnout prevention efforts and research.
Social, Individual, and Environmental Characteristics of Family Medicine Resident Burnout: A CERA Study
Burnout among clinicians is common and can undermine quality of care, patient outcomes, and workforce preservation, but sources of burnout or protective factors unique to clinicians working in safety-net settings are less well understood. Understanding these clinician experiences may inform interventions to reduce burnout.
Sources of Clinician Burnout in Providing Care for Underserved Patients in a Safety-Net Healthcare System
The word staffing never fails to conjure up deep feelings in every nurse and nurse leader. It can make or break a shift, a unit, a hospital, or the practice of the entire profession. Staffing has been at the core of nursing for as long as I can remember, and it's interdependent with patient care and nurse satisfaction.
Staffing: Fundamental to Nurse and Patient Experience
Nurse practitioner (NP) scope of practice (SOP) policies are different across the United States. Little is known about their impact on NP work environment in healthcare organizations. We investigated the association between SOP policies and organizational-level work environment of NPs. Through a cross-sectional survey design, data were collected from 1244 NPs in six states with variable SOP regulations (Arizona, New Jersey, Washington, Pennsylvania, Texas, and California) in 2018–2019. Arizona and Washington had full SOP—NPs had full authority to deliver care. New Jersey and Pennsylvania had reduced SOP with physician collaboration requirement; California and Texas had restricted SOP with physician supervision requirement. NPs completed mail or online surveys containing the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has these subscales: NP-Administration Relations (NP-AR), NP-Physician Relations (NP-PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models assessed the relationship between state-level SOP and practice-level NP work environment. NP-AR scores were higher in full SOP states compared to reduced (β = 0.22, p< 0.01) and restricted (β = 0.15, p< 0.01) SOP states. Similarly, IPS scores were higher in full SOP states. The PV scores were also higher in full SOP states compared to reduced (β = 0.16, p< 0.001) and restricted (β = 0.12, p< 0.05) SOP states. There was no relationship between SOP and NP-PR score. State-level policies affect NP work environment. In states with more favorable policies, NPs have better relationships with administration and report more role visibility and support. Efforts should be made to remove unnecessary SOP restrictions.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).
State-level Scope of Practice Regulations for Nurse Practitioners Impact Work Environments: Six State Investigation
[This is an excerpt.] States face extensive barriers overseeing and enforcing the Mental Health Parity and Addiction Equality Act (MHPAEA) amid a growing behavioral health care crisis in the United States. The Mental Health Parity and Addiction Equality Act (MHPAEA) requires insurers to cover mental health and substance use disorder services in a manner equal to physical health services; however, enforcing the law has proven challenging. Access to behavioral health services is critical, as the United States faces a growing mental health crisis exacerbated by the COVID-19 pandemic. However, it is clear states need more support. Researchers offer recommendations to policymakers to ensure the promise of MHPAEA is realized for patients across the country, including conducting targeted benefits reviews, providing additional federal resources, and clarifying federal guidance around protections. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Ensuring Workers' Physical and Mental Health (Support Workers' and Learners' Mental Health & Well-Being).
States Struggle to Ensure Equal Access to Behavioral Health Services Amid Mental Health Crisis
The US Medical Licensing Examination (USMLE) Step 1 exam has proven a difficult stressor for medical students during their training, even with the advent of pass-fail scoring. The preparation period before the exam places students at high risk for burnout and depression, leading to impaired exam performance and other serious consequences including suicide. Many medical schools already provide academic support for students during USMLE Step 1 preparation, yet to date, there are no published programs specifically geared towards mental health support during this time.
Step Siblings: a Novel Peer-Mentorship Program for Medical Student Wellness During USMLE Step 1 Preparation
Frontline healthcare workers are exposed to significant suffering and loss. Recent studies have shown increased rates of depression and suicide among nurses and physicians when compared to the general population. Few clinician well-being interventions focus on increasing the awareness and expression of clinician’s emotions to improve psychosocial well-being. In particular, nurses are at the forefront of cancer care, and studies indicate that they cope with work-related emotions in isolation. Storytelling Through Music is a 6-week intervention that combines storytelling, reflective writing, songwriting, and stress management skills. The parent study was a quasi-experimental design, with 43 oncology nurses in either the intervention group or a non-randomized comparison group. This study evaluates the post-intervention qualitative data from participants in the intervention group (n=22). Content analysis was used for analysis, which revealed the following themes: belonging, finding meaning, and emotional transformation. Participants reported learning they were not alone in the emotional experience, that they were reminded of why they work in oncology, and that hearing their story in song transformed their feelings from sadness to something beautiful. Further, they described that hearing their story reflected back to them in song was deeply moving and provided them with emotional insight.
Storytelling Through Music to Facilitate Meaning Reconstruction and Address Psychosocial Stress in Oncology Nurses
Strategies for enriching the resident, fellow, and faculty physician experience: a system-based approach to physician well-being
Strategies for Enriching the Resident, Fellow, and Faculty Physician Experience: A System-Based Approach to Physician Well-Being
BACKGROUND: It is critical for intensive care unit (ICU) nurses to develop resilient coping strategies to cope with workplace adversities. The coping strategies will mitigate the development of maladaptive psychological disorders prone to working in a stressful environment. OBJECTIVES: The aim of this study is to analyse previous literature conducted on strategies that enhance resilience in ICU nurses to cope with workplace adversities beyond the coronavirus disease 2019 (COVID-19) pandemic. The study was conducted by examining all available global literature in the context of the aim of the study. METHOD: An integrative literature review was chosen for the study. Purposive sampling method was used to select the relevant databases to answer the review question, namely Google Scholar, EBSCOhost, Medline and Nursing/Academic Edition. The search terms used were ‘strategies’, ‘resilience’, ‘intensive care unit nurses’, ‘coping’, ‘workplace adversities’, ‘beyond COVID-19’ and post ‘COVID-19’. RESULTS: Three themes emerged from the study, namely promoting personal attributes, effective relational support and active psychological support. CONCLUSION: Enhancing resilience among ICU nurses requires both intentional individualised care from the ICU nurses and a systematic approach by nursing management that will meet the psychological needs of ICU nurses when working in a stressful ICU environment.
Strategies to Enhance Resilience to Cope with Workplace Adversities Post-COVID-19 Among ICU Nurses
The AHA recognizes the urgency, severity and national scope of the health care workforce challenges facing the field — they are a national emergency that demand immediate attention from all levels of government, as well as workable solutions. We expect the Task Force’s work will uncover new areas in which financial support, regulatory flexibility and other policy solutions will advance workforce efforts, and we welcome ideas on those strategies. In the interim, the AHA has accelerated its existing calls for federal policymakers to support the health care workforce (see the Workforce Fact Sheet for an overview of many of our current priorities). We have urged policymakers and the Federal Trade Commission to address short-term challenges such as potential price gouging and other anti-competitive behavior on the part of nurse staffing agencies. We continue to advocate for short-term financial support to hospitals — such as adding additional money to the Provider Relief Fund, suspending the Medicare sequester, and providing repayment flexibility for accelerated and advance Medicare payments. These policies would help offset higher staffing and other costs attributable to the pandemic. We also have urged the Biden administration to extend the Public Health Emergency (PHE) and make permanent regulatory flexibilities granted during the pandemic that enable hospitals to more easily bring in practitioners from out-of-state, deliver services via telehealth and enable more innovative and flexible models of care (e.g., Hospitals at Home). Finally, we have been successful in urging the Administration to expedite visas to allow highly-trained foreign health care workers to come to the U.S. to help alleviate current shortages. With respect to the behavioral health of physicians, nurses and others, which is necessary so they can deliver safe and high-quality care, we were pleased to support passage of and funding for the Dr. Lorna Breen Health Care Provider Protection Act. We have asked Congress to increase funding for the Health Resources and Services Administration’s Title VII and VIII programs, including the health professions program, the National Health Service Corps, and nursing workforce development programs, which includes loan programs for nursing faculty. Finally, we have urged policymakers to invest in the longer-term pathway of health care professionals by lifting the cap on Medicare-funded physician residencies, boosting funding to nursing schools and faculty, and funding federal loan forgiveness and scholarship programs. We have stressed that making these investments now is vital since their full benefit will take time to realize.
Strengthening the Healthcare Workforce: Strategies for Now, Near and Far
[This is an excerpt.] The Strengthening the Workforce Pipeline: Recommendations for Public Health & Healthcare in Missouri report presents recommendations to address the future of the public health and healthcare workforce in Missouri. The stakeholder task force recognizes there is no short-term fix to this workforce issue. Thus, it is important to note that a key recommendation is the formation of a Public Health & Healthcare Workforce Commission under the authority and oversight of the Office of Workforce Development within the Missouri Department of Higher Education and Workforce Development. As this recommendation is implemented, the commission will continue developing and implementing solutions to address this workforce situation. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Advancing Measurement & Accountability (Establish Health & Public Safety Workforce Analysis and Planning Bodies).
Strengthening the Workforce Pipeline: Recommendations for Public Health and Healthcare in Missouri
INTRODUCTION: Contemporary healthcare faces new challenges and expectations from society. The profession of a nurse, as well as a paramedic, is essential for the efficient functioning of healthcare. It has its importance not only in promoting and preserving health but also in prevention. With the increasing importance of providing medical care at the highest level, it is expected of these two professional groups to have more knowledge and skills than a few years earlier. The daily contact with patients and their families, the low level of control of the environment, the hierarchical system of professional dependence, and the dissatisfaction with remuneration are becoming extremely burdensome aspects of the nursing and paramedic professions. Long-term exposure to stressors associated with these medical professions may, in the long term, lead to the emergence of occupational burnout syndrome. The aim of this study is an attempt to answer the question of whether and how stress factors affect the occurrence of occupational burnout in the work of nurses and paramedics working in various medical entities. MATERIAL AND METHODS: The study covered a group of 434 respondents, including 220 nurses and 214 paramedics, working professionally in hospital departments and care and treatment facilities as well as in hospital emergency departments and ambulance services. The study was carried out using a diagnostic survey based on the questionnaire technique using the authors’ questionnaire and the standardized MBI Ch. Maslach. Two statistical values were used to statistically analyze the research results and verify the adopted hypotheses: the chi-square test and the Student’s t-test. RESULTS AND CONCLUSIONS: The current study showed that the phenomenon of occupational burnout among the studied group affects only nurses, while this problem does not apply to the studied paramedics. The main stressor among the nurses and paramedics is, above all, a very high level of responsibility. Nurses are overburdened by excessive demands and shift work, while paramedics are mostly burdened by an excess of duties. Both nurses and paramedics claim that their work is often stressful, which leads to physical and mental exhaustion.
Stress-Inducing Factors vs. the Risk of Occupational Burnout in the Work of Nurses and Paramedics
COVID-19 has exposed the grim underbelly of a fragmented, regionalized, costly, and inefficient approach to health service that is an engine for health workforce burnout. A matrix framework that defines the nature of system-level structural determinants of burnout and their relationship to service-level wellness can serve as a useful tool to understand workforce burnout causality, and guide meaningful intervention. This could inform a constructive system-level approach to health workforce burnout through the establishment of harmonized principle-based interventions across health sector jurisdictions and stakeholders.
Structural Determinants of Health Workforce Burnout
The objective of this study was to describe how structural racism and sexism shape the employment trajectories of Black women in the US health care system. Using data from the American Community Survey, we found that Black women are more overrepresented than any other demographic group in health care and are heavily concentrated in some of its lowest-wage and most hazardous jobs. More than one in five Black women in the labor force (23 percent) are employed in the health care sector, and among this group, Black women have the highest probability of working in the long-term-care sector (37 percent) and in licensed practical nurse or aide occupations (42 percent). Our findings link Black women’s position in the labor force to the historical legacies of sexism and racism, dating back to the division of care work in slavery and domestic service. Our policy recommendations include raising wages across the low-wage end of the sector, providing accessible career ladders to allow workers in low-wage health care to advance, and addressing racism in the pipeline of health care professions.
