BACKGROUND: Repeated exposure to death and dying increases health care professionals' risk for burnout and secondary traumatic stress. Pediatric critical care providers are at particularly high risk because the death and dying of children are associated with even greater psychological impact. LOCAL PROBLEM: A charge nurse in the pediatric intensive care unit identified a need for additional staff support after critical patient events. METHODS: The aim of this quality improvement project was to design and implement a debriefing process, the Rapid Review of Resuscitation, in a 40-bed, high-acuity pediatric intensive care unit at an urban children's hospital in the midwestern United States. A preintervention-postintervention survey used the Professional Quality of Life Scale, version 5, to evaluate staff members' compassion satisfaction, burnout, and secondary traumatic stress before and 1 year after implementation. The debriefing process was designed and implemented on the basis of interview data and literature review. RESULTS: Preimplementation (104 of 222 staff members [47%]) and postimplementation (72 of 184 staff members [39%]) survey responses were compared. Compassion satisfaction scores (mean [SD] T scores: preimplementation, 54.10 [7.52]; postimplementation, 56.71 [6.62]) were significantly higher (P = .02) 1 year after implementation. Burnout (P = .69) and secondary traumatic stress (P = .06) scores were not significantly different. After implementation, 74% of respondents reported that the debriefing process was "very helpful" or "somewhat helpful" after critical patient events. CONCLUSIONS: Compassion satisfaction improved and burnout and secondary traumatic stress did not change with implementation of the debriefing process after critical patient events.
Debriefing After Critical Events Is Feasible and Associated With Increased Compassion Satisfaction in the Pediatric Intensive Care Unit
PURPOSE: Oncology teams are challenged by BO, which may be alleviated by meaningful recognition. In this study, firgun—altruistic acknowledgment—was implemented on a pediatric hematopoietic cell transplant unit to evaluate its impact on staff and work environment. METHODS: In this longitudinal, mixed-methods pilot study, interdisciplinary inpatient hematopoietic cell transplant providers received web-based firgun education. Electronic administration of validated surveys occurred at baseline and 8 weeks, including Perceived Stress Scale, Professional Quality of Life Scale, Maslach Burnout Inventory, Workplace Civility Index, Areas of Work Life Survey, and WHO-5. Weekly e-mails reminded participants to practice and log firgun. Wilcoxon signed test for paired data compared pre/post results. Interviews conducted at project completion were coded using MaxQDA software. RESULTS: Forty-two participants enrolled; 25 completed pre/post surveys; eight were interviewed. At study end, participants reported feeling less nervous and stressed ( P = .008), and less difficulty coping ( P = .01; Perceived Stress Scale), while noting increased acknowledgment of others' work ( P = .04) and seeking constructive feedback ( P = .04; Workplace Civility Index). Marked BO was not evident overall on the Maslach Burnout Inventory; however, emotional exhaustion subscale mean (SD) scores improved from pre (19.4 [8.6]) to post (16 [6.3; P = .02]) and individual items illustrated decreased fatigue ( P = .008), frustration ( P = .04), and feeling “at the end of my rope” ( P = .001). Postintervention participants noted increased receipt of recognition ( P = .02; Areas of Work Life Survey), decreased feeling “bogged down” ( P = .02), decreased affective stress ( P = .04), and negative pre-occupations ( P = .04; Professional Quality of Life Scale). Qualitative analysis revealed themes of improved confidence at work and enhanced feelings of trust and teamwork. CONCLUSION: Firgun is a tool that can potentially reduce BO and stress in interdisciplinary providers, facilitate teamwork, and promote positive work environments in clinical oncology and beyond.
Decreasing Burnout and Improving Work Environment: The Impact of Firgun on a Pediatric Hematopoietic Cell Transplant Team
Harsh realities in pandemic fatigue, burnout, inequities, and isolation are impacting academic pharmacy. Mentoring programs, especially inter-institutional programs such as those provided within the Sections and Special Interest Groups (SIGs) of the American Association of Colleges of Pharmacy (AACP), may combat some of these issues. Unfortunately, year after year, Academy members continue to request information from these groups on mentoring, whether it be the opportunity to pair up, for advice on how to be better mentors, or for guidance on how to develop a program on mentoring for the Sections and SIGs without an existing program. The need for authentic mentoring is vital to the success and retention of faculty and staff within the Academy. Therefore, it may be appropriate to take a closer look at why, despite ongoing mentoring programs scattered within AACP Sections and SIGs, these programs are unable to fulfill the needs of participants.
Developing Authentic Mentorship Through Professional Organizations
Despite the known benefits of supportive work environments for promoting patient quality and safety and healthcare worker retention, there is no clear mandate for improving work environments within Learning Health Systems (LHS) nor an LHS wellness competency. Striking rises in burnout levels among healthcare workers provide urgency for this topic. METHODS: We brought three experts on moral injury, burnout prevention, and ethics to a recurring, interactive LHS training program “Design Shop” session, harnessing scholars’ ideas prior to the meeting. Generally following SQUIRE 2.0 guidelines, we evaluated the prework and discussion via informal content analysis to develop a set of pathways for developing moral injury and burnout prevention programs. Along these lines, we developed a new competency for moral injury and burnout prevention within LHS training programs. RESULTS: In preparation for the session, scholars differentiated moral injury from burnout, highlighted the profound impact of COVID-19 on moral injury, and proposed testable interventions to reduce injury. Scholar and expert input was then merged into developing the new competency in moral injury and burnout prevention. In particular, the competency focuses on preparing scholars to (1) demonstrate knowledge of moral injury and burnout, (2) measure burnout, moral injury, and their remediable predictors, (3) use methods for improving burnout, (4) structure training programs with supportive work environments, and (5) embed burnout and moral injury prevention into LHS structures. CONCLUSIONS: Burnout and moral injury prevention have been largely omitted in LHS training. A competency related to burnout and moral injury reduction can potentially bring sustainable work lives for scholars and their colleagues, better incorporation of their science into clinical practice, and better outcomes for patients.
Developing LHS Scholars’ Competency Around Reducing Burnout and Moral Injury
BACKGROUND: The present study aimed to develop a model for predicting the safety performance of nurses based on psychosocial safety climate (PSC) and the role of job demands and resources, job satisfaction, and emotional exhaustion as mediators. METHODS: A cross-sectional study using structural equation modeling (SEM) was carried out among nurses in Iran. Data were collected using the Psychosocial Safety Climate questionnaire, Neal and Griffin's Safety Performance Scale, the Management Standards Indicator Tool, the Effort-Reward Imbalance questionnaire, the Michigan Organizational Assessment Job Satisfaction subscale and the Maslach Burnout Inventory. RESULTS: Surveys were distributed to 340 nurses provided informed consent. After removing incplete surveys, data from 280 partipants were analysed. The completion rate was 82.35%. The SEM results indicated that PSC can directly and indirectly predict nurses' safety performance. The final model showed an acceptable goodness of fit (p = 0.023). It indicated that PSC, job demands, and job satisfaction were directly related to safety performance, and also that PSC, emotional exhaustion, job resources, and job demands were all indirectly related to safety performance. Also, PSC had a significant relationship with all mediator variables, and job demands had direct effect on emotional exhaustion. CONCLUSIONS: The current study presented a new model for predicting safety performance in nurses in which PSC, both directly and indirectly, plays an important role. In addition to paying attention to the physical aspects of the workplace, healthcare organizations should also take into account PSC to improve safety. Next steps in reducing safety issues in nursing is to develop intervention studies using this new evidence-based model as a framework.
Developing a Model for Predicting Safety Performance of Nurses Based on Psychosocial Safety Climate and Role of Job Demands and Resources, Job Satisfaction, and Emotional Exhaustion as Mediators
Public safety personnel (PSP) are required to make decisions that can violate their moral standards, and they and are also disproportionately exposed to other morally challenging events that may increase their vulnerability to experiencing moral injury (MI). Yet, there is little research exploring moral pain in PSP and no existing instruments to identify MI in PSP. Here, the Moral Injury Assessment for PSP was developed and piloted with 270 Canadian and American PSP. Factor analytic results revealed 3 distinct factors related to the experience of MI for PSP: Perpetrations, Betrayals, and Emotional sequelae. The emergence of these factors replicates the perpetration and betrayal dimensions of MI established in other populations and adds to the emerging body of literature seeking to identify a consistent symptom profile of MI. Our results preliminarily suggest strong reliability (i.e., internal consistency and item–total correlation) and excellent construct validity when compared with other measures of psychological stress. This work advances our understanding of MI and the unique challenges experienced by PSP and highlights the need for future work aimed at assessing and treating MI in PSP populations.
Development and Preliminary Evaluation of the Moral Injury Assessment for Public Safety Personnel
OBJECTIVE: To decrease the electronic health record (EHR) clerical burden and improve patient/clinician satisfaction, allied health staff were trained as visit facilitators (VFs) to assist the physician in clinical and administrative tasks. PATIENTS AND METHODS: From December 7, 2020, to October 11, 2021, patients with complex medical conditions were evaluated by an internal medicine physician in an outpatient general internal medicine (GIM) consultative practice at a tertiary care institution. A VF assisted with specific tasks before, during, and after the clinical visit. Presurvey and postsurvey assessments were performed to understand the effect of the VF on clinical tasks as perceived by the physician. RESULTS: A total of 57 GIM physicians used a VF, and 41 (82%) physicians and 39 (79%) physicians completed the pre-VF and post-VF surveys, respectively. Physicians reported a significant reduction in time reviewing outside materials, updating pertinent information, and creating/modifying EHR orders (P<.05). Clinicians reported improved interactions with patients and on-time completion of clinical documentation. In the pre-VF survey, “too much time spent” was the most common response for reviewing outside material, placing/modifying orders, completing documentation/clinical notes, resolving in-baskets, completing dismissal letters, and completing tasks outside of work hours. In the post-VF survey, “too much time spent” was not the most common answer to any question. Satisfaction improved in all areas (P<.05). CONCLUSION: VFs significantly reduced the EHR clinical burden and improved GIM physician practice satisfaction. This model can potentially be used in a wide range of medical practices.
Development of a Visit Facilitator Role to Assist Physicians in an Ambulatory Consultative Medical Practice
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023
PURPOSE: Burnout has been well examined among physicians and other high-wage, high-autonomy healthcare positions. However, lower-wage healthcare workers with less workplace autonomy (e.g., medical assistants, nurses’ aides) represent a substantial proportion of the workforce, but remain understudied. We aimed to examine the effects of burnout on psychotropic medication use and misuse and whether these effects differed by occupational level. METHODS: In March 2022, we collected data from a diverse sample of US healthcare workers (N = 200) and examined the cross-sectional relationship between burnout and changes in prescribed psychotropic medication (i.e., starting, stopping, and/ or having a change in the dose/frequency) during the COVID-19 pandemic. We also separately examined the relationship between burnout and psychotropic medication misuse (i.e., without a prescription, in greater amounts, more often, longer than prescribed, and/or for a reason other than prescribed). We stratified models by occupational level (prescribers/healthcare administrators vs. other healthcare workers). RESULTS: Greater burnout was associated with higher odds of changes in prescribed psychotropic medication among prescribers/healthcare administrators (aOR = 1.23, 95% CI 1.01, 1.48), but not among other healthcare workers (aOR = 1.04, 95% CI 0.98, 1.10). Greater burnout was not associated with psychotropic medication misuse among prescribers/healthcare administrators (aOR = 0.96, 95% CI 0.82, 1.12) but was associated with increased odds of psychotropic medication misuse among other healthcare workers (aOR = 1.07, 95% CI 1.01, 1.14). CONCLUSIONS: Potential disparities in help-seeking and healthcare access might manifest in non-medical use of prescription drugs among some healthcare workers, which has implications for worker safety and well-being.
Differential Effects of Healthcare Worker Burnout on Psychotropic Medication Use and Misuse by Occupational Level
Digital tools play a big part in making the experience of being a clinician overwhelming. Digital minimalism may offer a remedy.
Digital Minimalism — An Rx for Clinician Burnout
Victim support entails one of the most intense stress- and trauma-laden interactions faced by law enforcement professionals, and this function or role frequently triggers long-lasting negative effects on officers’ psychological health and wellbeing. As police officers interact daily with victims, but also with other officers, social services, and institutions, the limits between tasks and needs may directly affect how they manage stress, trauma, and notions of individual and organisational responsibility. As such, boundary work may be a useful framework to understand and even improve how victim support police officers interact with other individuals and organisations. Drawing from a ground-breaking qualitative, in-depth research with police officers that provide support to victims of gender-based and domestic violence, this paper analyses conscious and unconscious boundaries as key elements in the officers’ wellbeing. Informed by the empirical findings of a case study of Catalonia's Mossos d’Esquadra police corps, this paper explores how victim support officers negotiate their individual and organisational boundaries as they interact with other agents and institutions, and how these negotiations affect them. This paper argues for the relevance of an officer's agency and discretion for distinguishing between conscious and unconscious boundaries, as their limits may be blurred throughout the wide range of interactions.
Drawing a Line: Boundary Work in Victim Support Police Work
BACKGROUND: The aim was to determine what factors drive and enhance compassionate care behaviors in the ICU setting and which factors drain and negate such caring attitudes and behaviors. METHODS: Qualitative, focus group discussions using video vignettes. 20 participants agreed to be part of 3 separate focus groups facilitated by the authors. RESULTS: Thematic analysis revealed emphasis on behavior and nonverbal cues, clinical decision making, communication and sensitivity, and building humane relations. The results show that physicians feel driven by the humanity and sensitivity felt in ICU work, however, there exists structural incompetence, as well as the stress and personal -systemic imbalances of ICU work, which leads to burnout and erosion of such motivations, draining compassion. CONCLUSIONS: Regulatory and scheduling practices must be examined to foster the growth of compassionate behaviors and attitudes in healthcare, and these should be treated as essential patient centered metrics.
Drivers and Drainers of Compassion in Intensive Care Medicine: An Empirical Study Using Video Vignettes
BACKGROUND: With more than 50% of anesthesiology residents reporting burnout, many residency programs have begun creating wellness programs to address burnout and promote well-being. However, to date, many wellness initiatives have focused on individual strategies rather than systems approaches to improve the learning environment. Individual-focused interventions in the absence of systematic efforts can lead to resentment, resistance, and worsening burnout and precipitate a loss of trust in leadership and the organization. Here, we describe a process to engage anesthesiology residents, who are key stakeholders, by exploring their perspectives on burnout and well-being to better inform systematic interventions to improve the clinical work and learning environments. METHODS: We conducted semistructured interviews with second- and third-year clinical anesthesia residents at the University of California, San Francisco, using the areas of worklife model as sensitizing concepts. We conducted a thematic analysis on transcribed interviews grounded in constructivist orientation. RESULTS: We identified the following 3 major categories of themes based on interviews with 10 residents: (1) definition of well-being, (2) challenges to well-being, and (3) strategies for coping with challenges and burnout. Challenges described by anesthesiology residents align with the areas of the worklife model, with the coronavirus disease 2019 pandemic precipitating additional threats in the domains of workload and community. CONCLUSIONS: Anesthesiology residents’ definition of well-being includes both individual (resilience) and systemic (meaning in work, job autonomy, and control) factors, reaffirming that positive work and learning environments are critical to professional well-being.
Drivers of Well-Being and Burnout in Anesthesiology Residents
In response to a high turnover rate and staggering orientation costs for new nurses in the cardiothoracic ICU, leaders at one organization developed a dual-role initiative that decreased overall turnover and nurses' desire to leave and increased overall job satisfaction.
Dueling Burnout: The Dual-Role Nurse
BACKGROUND: As the practice of cardiothoracic surgery continues to evolve, the optimal training model represents an area of uncertainty. We sought to describe and to compare the early career experiences of cardiothoracic surgery graduates from the 3 training models. METHODS: An anonymous survey with questions pertaining to an individual's demographic characteristics, training model, first employment experience, experience as junior faculty, career satisfaction, and personal reflection was sent to graduates from US cardiothoracic surgery training programs between 2012 and 2020. Respondents completed a traditional fellowship (2-3 years), a 4+3 model, or an integrated 6-year (I-6) residency. RESULTS: Of the 670 graduates who received the survey, there were 267 (40%) respondents. Of these, 209 (78%) respondents graduated from a traditional fellowship, 27 (10%) respondents graduated from a 4+3 pathway, and 31 (12%) respondents graduated from an I-6 residency. There was no difference in overall satisfaction, major case volume, operative autonomy, burnout, and lifestyle satisfaction between the models (P>.05). When respondents were asked about the ideal model, the 4+3 and I-6 models were favored by its graduates, regardless of the surgeons’ field of practice. CONCLUSIONS: Important early career outcomes were not different between graduates of traditional, 4+3, or I-6 models. Most graduates of the 4+3 and I-6 models believe these are the ideal training models, regardless of their field of practice.
Early Career Experiences of Cardiothoracic Surgery Graduates by Training Model: A National Survey
PURPOSE: A successful surgical residency program prepares graduates not only in technical skills and patient care, but also in teamwork and communication. The daily demands on faculty and residents create challenges in making time for discussion and reflection, to enhance and improve residency training and work culture. Organized departmental retreats provide a forum to address different facets of training. METHODS: To provide time to cultivate discussion and longitudinally improve the surgery residency experience, the authors’ program created an annual half-day education retreat for surgical residents and faculty. Clinical activities were limited during this time to allow for attendance. Each retreat focused on a particular topic and consisted of a guest speaker lecture, breakout discussion sessions, and final debriefing as a department. Surgical education retreat objectives and content focus on core pillars of professional development including but not limited to technical skills, building knowledge base, feedback, and teamwork. RESULTS: Since 2003, annual surgical education retreats have been organized at the authors’ institution. In particular, the retreat focusing on wellness in 2016 resulted in the establishment of a formal wellness program consisting of a variety of departmental efforts to mitigate resident burnout and promote wellness. CONCLUSION: Structured retreats support discussions within the department to promote education and collaboration. The positive impact of these events can provide long-term improvements in surgery residency programs, and can be applied to any training specialty.
Education Retreats: A Structured Format to Improve the Professional Development of Surgery Residents and Faculty
BACKGROUND: Physician burnout impacts all levels of medical education and has a relatively unknown impact on those responsible for medical student education, particularly in paediatrics. This study examines the prevalence of burnout among paediatric undergraduate medical educators and explores the impact of roles in medical education on medical educator burnout. METHODS: This cross-sectional mixed-methods study utilised a binational survey of paediatricians involved in undergraduate medical education. Respondents answered demographics, standardised questions about burnout and attitudes towards students, and an open-ended probe about interactions between medical student education and wellness. FINDINGS: Of 445 possible, 120 (26.9%) responded to demographic and burnout questions. Of these, 23.3% endorsed burnout, 21.7% high emotional exhaustion (EE) and 10.8% high depersonalisation (DP). High levels of student-related burnout symptoms were reported by fewer than 5% of respondents and were correlated with overall EE and DP. Content analysis revealed four emergent themes: positive effect of student-related role, need to balance medical education and clinical roles, impact of protected time and medical education-related autonomy on educator well-being, and the burden of the administrative portion of educational roles. DISCUSSION: Participating paediatric educators had low rates of burnout compared with paediatricians as a whole in prior studies. The vast majority found working with students rewarding and described the overall positive impact of their medical education role on wellness. CONCLUSION: Physician involvement in rewarding non-clinical activities may improve their overall well-being. Providing dedicated time for these activities may ameliorate the difficulty that many medical educators described in balancing their clinical and educational roles. Future studies should continue to explore how we can better support medical educators and the impact of this support on burnout.
Educational Roles Impact Burnout in Paediatric Undergraduate Medical Educators
We examine how the Affordable Care Act Medicaid expansion affected the insurance coverage and the sources of coverage among low-income nursing home aides using the 2010–2019 American Community Survey data. Insurance coverage for low-income nursing home aides increased from about 60% to nearly 90% in expansion states but rose to only about 80% in nonexpansion states. Using a difference-in-differences regression design, we find that Medicaid expansion was associated with a 5.1 percentage-point increase in overall insurance coverage. Expansion states had a 12.2 percentage-point gain in Medicaid that was partially offset by a 6.4 percentage-point reduction in private insurance coverage. Our results show that ACA Medicaid expansion increased insurance coverage for low-income nursing home aides; however, there was substantial crowd-out of private insurance coverage in this population. Policymakers should consider expanding Medicaid while incentivizing affordable private health insurance options for low-income nursing home aides to improve insurance coverage.
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).
Effect of Medicaid Expansion on Health Insurance for Low-Income Nursing Home Aides
BACKGROUND: Nursing students experience higher stress and burnout compared to students in other health professions, with a prevalence rate of as high as 20%. More recently, they have been affected by changes in nursing education due to the COVID-19 pandemic, such as requirements for social isolation and distance learning. Although there are existing studies on interventions that address academic burnout among nursing students, there is no synthesis of randomized trials on this topic. Aim This study aimed to systematically synthesize studies of interventions for academic burnout among nursing students. METHODS: A systematic search for randomized controlled trials was performed in PubMed, CINAHL, CENTRAL, Web of Science, and Scopus. Eligibility criteria were based on study directness in relation to the Patient, Intervention, Comparison, and Outcome (PICO) question. Two review authors independently screened articles for inclusion, collected data from the included studies, and performed risk of bias assessments using the Cochrane Risk of Bias Tool 2.0. A narrative synthesis was performed. This review was registered a priori in PROSPERO (CRD42022350196). RESULTS: Six papers were included in this review. Various interventions were studied: Qigong exercises, progressive muscle relaxation, autogenic therapy and laughter therapy, didactic behavioral sessions focusing on personal and professional development, and coping skills enhancement. The effects of these interventions on academic burnout, depression, and stress among nursing students were short term and their benefits over time remain uncertain. LINKING EVIDENCE TO ACTION: Progressive muscle relaxation and cognitive behavioral interventions demonstrated short-term positive effects on academic burnout, depression, and stress among nursing students. These findings may support the development of individual-level and organizational-level initiatives for nursing students aimed to lessen or prevent academic burnout. Large-scale, high-quality studies on the effect of interventions on academic burden in various settings and cultures are needed.
Effectiveness of Interventions for Academic Burnout Among Nursing Students: A Systematic Review
OBJECTIVES: Professional burnout has been a significant problem for the US healthcare workforce for years, and particularly during the COVID-19 pandemic. It is known that mindfulness-based interventions (MBIs) can reduce stress and symptoms of burnout in healthcare workers. We aimed to assess the effectiveness of group mindfulness-based interventions on individuals who attended prior to the COVID-19 pandemic, and those who attended intra-pandemic. METHODS: Validated survey instruments were administered to participants before and after the courses to assess stress, mindfulness and burnout. Mean scores were compared between groups at baseline. Pre- and post-course responses were gathered and compared within both the pre-pandemic and intra-pandemic cohorts, and within-group effect sizes were calculated. Finally, the change in effect size was calculated between the pre-pandemic and intra-pandemic conditions. RESULTS: Mindfulness groups were associated with significant score changes on specific mindfulness skills (Observe, Act with Awareness, Non-Judge) within both the pre-pandemic and intra-pandemic time periods. The effectiveness of mindfulness skill acquisition varied between these conditions. Mindfulness courses were more effective at reducing stress and burnout during COVID-19, compared with the pre-pandemic time. CONCLUSIONS: Our results demonstrate the adaptability and effectiveness of mindfulness-based interventions in reducing symptoms of stress and burnout among healthcare workers during adverse circumstances.
