Resource Library

PURPOSE OF REVIEW: To describe the unique stressors of surgical training and fellowship and how grit and resilience influence trainee wellness

RECENT FINDINGS: Surgical training is an intense, high-stress experience. For fellows-in-training, unique stressors are associated with this chapter of training, from financial pressors to the stress of job acquisition. Wellness is essential for surgical fellows, not just for the critical need for quality mental health of providers, but also for the patients who are also affected by provider burnout. There are various wellness programs that can be instituted nationally and institutionally to optimize fellow wellness, but one of the most high-yield foci for fellow wellness is focused mentorship, the key to assuring wellness and harnessing grit.

SUMMARY: Surgical residency and fellowship are prodigiously demanding experiences, which mandate grit and resilience. It is imperative that widespread cultural and institutional changes take place to best support surgical trainees.

BACKGROUND: The global coronavirus disease 2019 (COVID-19) pandemic has necessitated considerable changes in the delivery of pharmacy services, with pharmacists experiencing increasing demands and a high rate of burnout. The ability to categorize pharmacists based on their burnout risk and associated factors could be used to tailor burnout interventions. OBJECTIVE: This study aimed to identify subgroups (profiles) of pharmacists and use these profiles to describe interventions tailored to improve pharmacist’s well-being. METHODS: A survey was disseminated to pharmacists working in Australia during April and June 2020. The survey measured demographics, burnout, and psychosocial factors associated with working during COVID-19. A two-step cluster analysis was used to categorize pharmacists based on burnout and other variables. RESULTS: A total of 647 survey responses contained data that were used for analysis. Participants were mostly female (75.7%) and working full time (65.2%). The final cluster analysis yielded an acceptable two-cluster model describing 2 very different pharmacist experiences, using 10 variables. Cluster 2 (representing 53.1% of participants) describes the “affected” pharmacist, who has a high degree of burnout, works in community pharmacy, experiences incivility, is less likely to report sufficient precautionary measures in their workplace, and has had an increase in workload and overtime. In contrast, cluster 1 (representing 46.9% of participants) describes the profile of a “business as usual” hospital pharmacist with the opposite experiences. Interventions focused on the “affected” pharmacist such as financial support to employ specialized staff and equitable access to personal protective equipment should be available to community pharmacists, to reduce the risk to these frontline workers. CONCLUSION: The use of cluster analysis has identified 2 distinct profiles of pharmacists working during COVID-19. The “affected” pharmacist warrants targeted interventions to address the high burnout experienced in this group.

Nurse leaders are thinking outside the box to solve some of nursing's current challenges and bring joy back to practice. Find out how chief nursing executive Kathy Howell is working to solve three of nursing's common challenges at UCHealth, transforming patient care delivery, and creating a better working environment for nurses.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention) and Improving Workload & Workflows (Optimizing Teams).

BACKGROUND: It has been shown that the burnout rate for emergency medicine providers is among the highest seen in healthcare. While resilience and grit have been studied as protective against burnout, the ability to thrive may be a more useful target. Thriving has previously been defined as a combination of vitality—having energy available and feeling “alive”—and learning—acquiring and applying valuable knowledge. Thriving has been found to be dependent on several categories, one of which is unit contextual features (UCFs). UCFs are factors such as challenge or hindrance stressors, autonomy, and trust. OBJECTIVES: This study is being done to determine if Emergency Medicine residents are thriving, and what UCFs are contributing to their ability or inability to thrive during residency. Methods: We administered a mixed-methods survey developed from previously validated surveys regarding the UCFs and overall thriving to emergency medicine residents at one four-year emergency medicine residency training program in March of 2022. RESULTS: We received 38 responses (out of 58 residents) with 8-11 respondents per PGY level. Overall thriving score for all residents was 3.2/5. First-year residents had a score of 3.5/5 while 2nd-4th years each had a score of 3.1/5. Social support was the UCF that most contributed to thriving while hindrance stressors, challenge stressors, and autonomy negatively affected the residents’ thriving. CONCLUSIONS: We found ideal targets for interventions from the survey, with qualitative responses that can help guide those interventions to increase thriving. Other residencies could similarly use this survey to identify targets for intervention. Responses highlighted hindrance stressors present in the ED that would be ideal targets for intervention, while targeting social support may not have as much of an impact. The study was limited due to administration once during the year as time during the academic year may affect the level of thriving.

[This is an excerpt.] Nurses have long been a vital component of the healthcare ecosystem, providing critical care to patients, communicating with families, and helping other members of their healthcare team stay in step, working together to provide care. As a former ICU nurse, I know how busy and stressful the nursing profession can be, often balancing work, kids and family, hobbies, and more. After particularly emotionally draining days, I would remind myself of my “Why.” Why am I in healthcare? Why do I do what I do? For me, it was the faces of patients looking for answers or hope, my relationships with fellow exhausted coworkers putting in long hours, and friends and family members as they waited for updates on their loved ones. [To read more, click View Resource.]

BACKGROUND: There is increasing concern about the prevalence and impact of moral distress among healthcare workers. While this body of literature is growing, research specifically examining sources of moral distress among surgeons remains sparse. The unique attributes of the surgeon-patient relationship and the context of surgery may expose surgeons to sources of distress that are distinct from other healthcare providers. To date, a summative assessment of moral distress among surgeons does not exist. METHODS: We conducted a scoping review of studies focused on moral distress among surgeons. Using guidelines established by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), relevant articles were identified in EBSCOhost PsycINFO, Elsevier EMBASE, Ovid MEDLINE, and Wiley Cochrane Central Register of Controlled Trials Library from January 1, 2009 to September 29, 2022. Detailed data abstraction was performed on a predetermined instrument and compared across studies. A mixed-methods meta-synthesis was employed for data analysis, and both deductive and inductive methodology was used in our thematic analysis. RESULTS: A total of 1,003 abstracts were screened, and 26 articles (19 quantitative and 7 qualitative) were included for full-text review. Of these, 10 focused only on surgeons. Our analysis revealed numerous definitions of moral distress and 25 instruments used to understand the sources of distress. Moral distress among surgeons is complex and influenced by factors at multiple levels, The most frequent sources originate at the individual and interpersonal levels. However, the environmental, community and policy levels also noted sources of distress. CONCLUSIONS: The reviewed articles identified several common themes and sources of moral distress among surgeons. We also found that research investigating sources of moral distress among surgeons is relatively sparse and confounded by various definitions of moral distress, multiple measurement tools, and frequently conflated terms of moral distress, moral injury, and burnout. This summative assessment presents a model of moral distress delineating these distinct terms, which may be applied to other professions at risk for moral distress.

OBJECTIVE:
- To study the contributors of Burn out in Women Neurologists in the face of the COVID pandemic, resulting in women moving away from a career in clinical neurology
- To offer solutions to help prevent Moral Injury in all Neurologists - Based on our experience in an Academic Urban Medical Center

BACKGROUND: The term Burnout implies that the neurologist is at fault. More recently, we have come to understand Moral Injury which drives the onus on the system rather than on the person. When we find systemic problems, we can find strategies to manage them. This is a first step in coming up with effective solutions to help us sustain so that we prevent moral injury and attrition of neurologists in a world where there is already a predicted shortage of neurologists.

DESIGN/METHODS: An online survey of a 100 Women neurologists who moved away from Neurolology, revealed surprising results. The survey covered the key drivers that made women leave neurology, the phase in their career when the change was made, subspecialty, practice setting and eventually what turn their career took.

RESULTS: Career women in their early phase of career were moving away while they should have been looking at academic growth. Burnout/Moral Injury was a huge driver - administrative interference contributing largely to it. The COVID-pandemic didn’t seem to be a key player.

CONCLUSIONS: The survey revealed a lot of potential fixable issues which were brought together as a project for our department to work on. We came up with practical solutions at our academic center - addressing the challenges of administrative burden, introducing flexible schedules, providing physician autonomy, ensuring fair and transparent compensation for the women physicians, and trying to close the gender gap. In addition to everything else, a collegial work environment played a huge role in retaining the work force at our institution.

AIM: To describe positive and negative spiritual responses to providing COVID-related nursing care among nurses working in hospitals. BACKGROUND: The COVID pandemic has intensified and publicised the threats to nurse well-being. Absent from the recommendations for promoting nurse well-being is recognition of how nurses' spirituality and/or religiosity is affected by the strain of COVID caring or how it may be affecting their well-being. DESIGN: Cross-sectional, descriptive observational, mixed methods study. METHODS: Data were collected from 523 registered nurses employed in three Southern California hospitals during March–May, 2022 when these hospitals' COVID case counts were <15%. Using Online survey methods, data were obtained using the Religious/Spiritual Struggles Scale–Short Form, Moral Injury Symptom Scale–Healthcare Professionals, Post-traumatic Growth Inventory and demographic and work-related items. STROBE guidelines for cross-sectional observational studies were observed. RESULTS: The mean for religious/spiritual struggles was 1.98 (range of 1–5, comparable to a little bit). Although roughly half of the sample reported the struggles were not experienced/did not apply, 23%–36.5% reported experiencing these struggles at least somewhat. The most frequent struggle was to find ultimate meaning. The mean observed for moral injury was 6.5 (range of 1–10); applying established criteria indicated it was troubling for at least 50%. The mean for post-traumatic growth was 4 (on a scale of 0–6); using established criteria, 41% experienced PTG. Quantitative findings were illustrated by the qualitative responses that occasionally expressed spiritual tragedy and transformation concurrently. CONCLUSION: The professional work of nursing impacts nurses in invisible, spiritual ways that can be tragic and/or transformative. Relevance to Clinical Practice: Interventions to address nurses' mental health challenges must include attention to these invisible struggles. Nurses' mental health challenges must be met in part by addressing how they can surmount spiritual tragedy—and allow spiritual transformation.

[This is an excerpt.] As the COVID-19 pandemic wore on, multiple surveys and news reports described rising levels of burnout and fatigue among clinicians on the front lines. Among the many nurses and physicians reporting they were stressed out and overwhelmed, some said they were ready to leave their jobs. While it’s unclear how many clinicians have quit practicing, workforce shortages continue in some regions. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Acknowledge/Address Moral Distress & Moral Injury).

BACKGROUND: Burnout among surgeons is increasingly recognized as a crisis. However, little is known about changes in burnout prevalence over time. We evaluated temporal trends in burnout among surgeons and surgical trainees of all specialties in the US and Canada. STUDY DESIGN: We systematically reviewed MEDLINE, Embase, and PsycINFO for studies assessing surgeon burnout from January 1981 through September 2021. Changes in dichotomized Maslach Burnout Inventory scores and mean subscale scores over time were assessed using multivariable random-effects meta-regression. RESULTS: Of 3,575 studies screened, 103 studies representing 63,587 individuals met inclusion criteria. Publication dates ranged from 1996 through 2021. Overall, 41% of surgeons met criteria for burnout. Trainees were more affected than attending surgeons (46% vs 36%, p = 0.012). Prevalence remained stable over the study period (?4.8% per decade, 95% CI ?13.2% to 3.5%). Mean scores for emotional exhaustion declined and depersonalization declined over time (?4.1 per decade, 95% CI ?7.4 to ?0.8 and ?1.4 per decade, 95% CI ?3.0 to ?0.2). Personal accomplishment scores remained unchanged. A high degree of heterogeneity was noted in all analyses despite adjustment for training status, specialty, practice setting, and study quality. CONCLUSIONS: Contrary to popular perceptions, we found no evidence of rising surgeon burnout in published literature. Rather, emotional exhaustion and depersonalization may be decreasing. Nonetheless, burnout levels remain unacceptably high, indicating a need for meaningful interventions across training levels and specialties. Future research should be deliberately designed to support longitudinal integration through prospective meta-regression to facilitate monitoring of trends in surgeon burnout.

The Great Resignation marked a dramatic return to the steady, rising rate of job turnover that began over a decade ago, and recent reports suggest the profession of pharmacy is no exception. Rising concerns about pharmacist turnover follow a wave of articles about the prevalence of burnout in nearly every corner of the profession. However, this should come as no surprise, as burnout and turnover are often progressively worsening symptoms of the same disease: a toxic work environment. This review suggests that many current efforts to improve burnout in pharmacy will have limited impact because they place too much emphasis on individuals and not enough of it on the environments in which they work. Scientific frameworks for understanding burnout as a problem originating from work are discussed, distinguishing burnout from other dimensions of health and well-being. These frameworks are then followed by an integration of empiric evidence from the organizational sciences and illustrative examples from pharmacy practice to explain how burnout emerges from an imbalance of job demands (e.g., workload, time pressure, work-life conflict) and job resources (e.g., autonomy, rewards, social support). The review concludes with a proposed course correction—one that positions organizational leaders as the people who are best equipped to address burnout at its source through a structured process known as work redesign. By doing so, leaders can create work environments that not only reduce the risk of burnout among pharmacists but also enhance their ability to thrive.

BACKGROUND: The COVID-19 pandemic resulted in negative consequences for nurse well-being, patient care delivery and outcomes, and organizational outcomes. OBJECTIVE: The purpose of this study was to explore the experiences of nurses working during the COVID-19 Pandemic in the United States. DESIGN: This study used a qualitative descriptive design. SETTING(S): The setting for this study was a national sample of nurses working during the COVID-19 pandemic in the United States over a period of 18 months. PARTICIPANTS: Convenience and snowball sampling were used to recruit 81 nurses via social media and both national and state listservs. Methods: Using a single question prompt, voicemail and emails were used for nurses to share their experiences anonymously working as a nurse during the COVID-19 pandemic. Voicemails were transcribed and each transcript was analyzed using content analysis with both deductive and inductive coding. RESULTS: The overarching theme identified was Unbearable Suffering. Three additional themes were identified: 1) Facilitators to Nursing Practice During the COVID-19 Pandemic, 2) Barriers to Nursing Practice During the COVID-19 pandemic, with the sub-themes of Barriers Within the Work Environment, Suboptimal Care Delivery, and Negative Consequences for the Nurses; and lastly, 3) the Transitionary Nature of the Pandemic. CONCLUSIONS: The primary finding of this study was that nurses experienced and witnessed unbearable suffering while working during the COVID-19 pandemic that was transitionary in nature. Future research should consider the long-term impacts of this unbearable suffering on nurses. Intervention research should be considered to support nurses who have worked during the COVID-19 pandemic, and mitigate the potential long-term effects.

This chapter seeks to analyze the impact the COVID-19 pandemic has had on nurses and how it has affected the prevalence of compassion fatigue, moral injury, and overall job satisfaction. It examines current intervention strategies and frameworks and offers recommendations for how these systems may be improved to better support nurses. Numerous instruments have been developed in an attempt to study compassion fatigue. One of the most widely used of these instruments is the professional quality of life (ProQOL) scale. Using the ProQOL scale as a foundation, the author conducted an anonymous survey of nurses (n = 91) employed at a major university-affiliated hospital in Chicago. The author also conducted two longer individual interviews with nurses who are employed at this hospital. The pandemic has profoundly harmed nurses and triggered a cascading stream of consequences. The pandemic has increased the prevalence of both compassion fatigue and moral injury. Nurses are chronically overworked and lack critical resources and support from hospital management.

BACKGROUND AND OBJECTIVES: Burnout is a widespread problem in medicine, especially among trainees. Despite this, data on effective interventions are limited. An organizational context for burnout entitled Areas of Worklife identified six areas of the work environment that can affect burnout through mismatches between individuals expectations of that area and the reality of the work environment. This study aimed to gain a deeper understanding of pediatric residents’ perspectives of the Areas of Worklife to allow programs to utilize this framework in the development of future interventions. METHODS: Using qualitative methodology founded in grounded theory, we employed an iterative data collection by conducting semi-structured interviews, until data saturation was achieved, with 15 pediatric residents in 2018. We recorded interviews and transcribed them verbatim. Content analysis was conducted concurrently with data collection using constant comparison methods; the principal investigator and co-investigators worked jointly to gen­erate codes and identify themes. RESULTS: Themes were identified for the individual Areas of Worklife that represented resident perspectives and mismatches with the work environment. Overall, patient care was a central focus connecting the areas of control, reward, values, and workload; themes in these areas concentrated on resident’s ability to interact with and learn from patients. CONCLUSIONS: Residents’ definitions of the Areas of Worklife can be used to identify mis­ matches between residents’ expectations and their work environment, which can inform organizational interventions. These findings highlight the importance of a patient-focused approach to residency training, which is consistent with literature that shows patient care is a means to find meaning in their work. Resident definitions of the Areas of Worklife offer residency programs a practical approach in their battle against burnout by providing focused direction to respond to resident needs and identify tangible targets for intervention.

This capstone project aims to address burnout among behavioral health workers through research and survey development. The research component involves reviewing existing studies and conducting interviews with staff members of Valley Health Associates to identify key factors contributing to high burnout rates and their consequences. Contributing factors researched include organizational culture, increasing workloads, and demand for behavioral health workers, and organizational climate. The consequences of burnout include physical and emotional health impacts, overwhelming caseloads, and low retention rates. The research findings inform the development of an employee satisfaction and engagement survey that includes questions related to burnout, workload, company culture, job satisfaction, organizational support, and opportunities for growth and development. The survey serves as a tool for Valley Health Associates to help identify and prevent burnout among staff. By addressing burnout, this project aims to improve the well-being of behavioral health workers at the agency and ultimately enhance the quality of care provided to patients.

GOAL: Span of control is a multidimensional concept requiring a comprehensive definition that captures the complexities of the nurse manager's role in acute care settings. This concept analysis aimed to identify factors associated with span of control and provide a comprehensive definition outlining the breadth of this concept. METHODS: ProQuest, PubMed, and Scopus databases were used to search peer-reviewed literature addressing the span of control in acute care nurse management. The search produced 185 articles; 177 titles and abstracts were screened for eligibility. Data from 22 articles were included in this analysis. PRINCIPAL FINDINGS: This analysis includes antecedents, attributes, and consequences of expanded nurse manager spans of control. Work-related factors such as staff and manager experience levels, work complexity, and patient acuity are attributes of a nurse manager's span of control. Our findings suggest that expanded spans of control can have negative consequences on nurse managers such as role overload and burnout. Low satisfaction among staff and patients can result from excessive spans of control. PRACTICAL IMPLICATIONS: An awareness of span of control can promote sustainable nursing practices by improving workplace conditions, staff satisfaction, and patient care quality. Our findings may translate across other health disciplines and thus contribute to scientific knowledge that can support changes in job designs and encourage more manageable workloads.

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED). From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems’ EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process. We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences. Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR’s architecture and primary purpose. While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

BACKGROUND AND AIMS: Healthcare workers (HCWs) throughout the world have been exposed to economic and existential stress during the Covid-19 pandemic. The American Medical Association (AMA) has documented that increased healthcare burden correlates with increased stress, burnout, and psychological burden in HCWs. However, limits on personnel, time, and in person interactions make it challenging to assess mental health outcomes during a pandemic. This pilot study used virtual technology to efficiently assess these outcomes. SETTING: Data were collected based on voluntary participation in the Coping with Covid-19 for Caregivers Survey created by AMA. The survey was sent out to approximately 300 participants who included local physicians, medical residents, medical students, and allied health professionals and students who attended a virtual Mental Health Summit. METHODS: The AMA developed survey included questions about demographics, overall stress, fear of infection and transmission of the virus, perceived anxiety or depression due to Covid-19, work overload, childcare issues, and sense of meaning and purpose. The AMA allows for up to five additional questions to be added to their survey, therefore five questions regarding support service utilization, perseverance, and resilience during the Covid-19 pandemic, and two items to further understand students’ areas of medical interest. The survey was administered using an online platform through the AMA. The data were analyzed using descriptive statistics. RESULTS: There were 81 survey respondents. Based on the results of the survey, “high stress” was found in 52 (64%) participants. 66 (81%) were afraid (moderately or to a great extent) of exposure or transmission, 61 (75%) described high levels of anxiety or depression, and 67 (84%) noted work overload. Despite this increase in stress, most respondents (77%) said they were not likely to reduce their devoted hours to clinical care or research in the next 12months, and 81% answered that they would not leave their practice or research within two years. CONCLUSION: Covid-19 has negatively affected the well-being of HCWs. This is a similar trend seen during other times of healthcare strain. Mental health support, work modulation, and various provisions should be explored as means to reduce Covid-19-related negative impacts. The use of an online summit and online data collection methods were appropriate for collecting data on the impact of the Covid-19 pandemic on mental health. This pilot study supports the larger scale implementation of this technology for health informatics research.

BACKGROUND: Health information technology is a leading cause of clinician burnout and career dissatisfaction, often because it is poorly designed by nonclinicians who have limited knowledge of clinicians’ information needs and health care workflow. OBJECTIVE: Describe how we engaged primary care clinicians and their patients in an iterative design process for a software application to enhance clinician-patient diet discussions. DESIGN: Descriptive study of the steps followed when involving clinicians and their at-risk patients in the design of the content, layout, and flow of an application for collaborative dietary goal setting. This began with individual clinician and patient interviews to detail the desired informational content of the screens displayed followed by iterative reviews of intermediate and final versions of the program and its outputs. PARTICIPANTS: Primary care clinicians practicing in an urban federally qualified health center and two academic primary care clinics, and their patients who were overweight or obese with diet-sensitive conditions. MAIN MEASURES: Descriptions of the content, format, and flow of information from pre-visit dietary history to the display of evidence-based, guideline-driven suggested goals to final display of dietary goals selected, with information on how the patient might reach them and patients’ confidence in achieving them. KEY RESULTS: Through three iterations of design and review, there was substantial evolution of the program’s content, format, and flow of information. This involved “tuning” of the information desired: from too little, to too much, to the right amount displayed that both clinicians and patients believed would facilitate shared dietary goal setting. CONCLUSIONS: Clinicians’ well-founded criticisms of the design of health information technology can be mitigated by involving them and their patients in the design of such tools that clinicians may find useful, and use, in their everyday medical practice.

Physician burnout is a ubiquitous dilemma impacting learners and veteran clinicians in medicine. Residency is a high stakes period of medical education where physicians are given greater clinical responsibilities and educated on the specifics of their chosen field. Psychiatry residents are consistently challenged by engaging in therapeutic interventions with patients suffering from a wide range of pathologies, including cluster B personality disorders. These patients are more likely to be high health care utilizers and require intensive psychotherapy and inpatient hospitalizations to treat their disorder. The burden of psychiatry residency, such as dealing with unconsciously manipulative and affectively unstable patients, can precipitate feelings of burnout and exhaustion. Through a case study contextualizing a patient exhibiting cluster B traits, we discuss the benefits of utilizing an empathetic approach to patients with personality disorders, how to ameliorate burnout, and potential benefits to patient outcomes using empathy in clinical practice throughout psychiatry residency.