[This is an excerpt.] Chatbots are software applications that use steps or scripts to automate natural communication with users [1, 2]. Chatbots were first trialed in 1964 with ELIZA created by Joseph Weizenbaum, designed to act as a Rogerian psychotherapist [2,3]. Chatbots have been used in virtually every industry to afford customers communication via messaging without speaking with a human associate [3]. There are over 5100 chatbot programs today, with over 100 used in healthcare applications [4]. In 2020, the chatbot market was valued at US$ 17.17 billion and is projected to reach $102.29 billion by 2026. Major stakeholders in the market include IBM, Google, Amazon, Creative Virtual Ltd, LiveChat, and Facebook [5]. [To read more, click View Resource.]
Chatbot Utilization in Dermatology: A Potential Amelioration to Burnout in Dermatology
IMPORTANCE: Childcare stress (CCS) is high during the COVID-19 pandemic because of remote learning and fear of illness transmission in health care workers (HCWs). Associations between CCS and burnout, intent to reduce (ITR) hours, and intent to leave (ITL) are not known. OBJECTIVE: To determine associations between CCS, anxiety and depression, burnout, ITR in 1 year, and ITL in 2 years. DESIGN, SETTING, AND PARTICIPANTS: This survey study, Coping with COVID, a brief work-life and wellness survey of US HCWs, was conducted between April and December 2020, assessing CCS, burnout, anxiety, depression, workload, and work intentions. The survey was distributed to clinicians and staff in participating health care organizations with more than 100 physicians. Data were analyzed from October 2021 to May 2022. MAIN OUTCOMES AND MEASURES: The survey asked, “due to…COVID-19, I am experiencing concerns about childcare,” and the presence of CCS was considered as a score of 3 or 4 on a scale from 1, not at all, to 4, a great extent. The survey also asked about fear of exposure or transmission, anxiety, depression, workload, and single-item measures of burnout, ITR, and ITL. RESULTS: In 208 organizations, 58 408 HCWs (15 766 physicians [26.9%], 11 409 nurses [19.5%], 39 218 women [67.1%], and 33 817 White participants [57.9%]) responded with a median organizational response rate of 32%. CCS was present in 21% (12 197 respondents) of HCWs. CCS was more frequent among racial and ethnic minority individuals and those not identifying race or ethnicity vs White respondents (5028 respondents [25.2%] vs 6356 respondents [18.8%]; P < .001; proportional difference, −7.1; 95% CI, −7.8 to −6.3) and among women vs men (8281 respondents [21.1%] vs 2573 respondents [17.9%]; odds ratio [OR], 1.22; 95% CI, 1.17 to 1.29). Those with CCS had 115% greater odds of anxiety or depression (OR, 2.15; 95% CI, 2.04-2.26; P < .001), and 80% greater odds of burnout (OR, 1.80; 95% CI, 1.70-1.90; P < .001) vs individuals without CCS. High CCS was associated with 91% greater odds of ITR (OR, 1.91; 95% CI, 1.76 to 2.08; P < .001) and 28% greater odds of ITL (OR, 1.28; 95% CI, 1.17 to 1.40; P < .001). CONCLUSIONS AND RELEVANCE: In this survey study, CCS was disproportionately described across different subgroups of HCWs and was associated with anxiety, depression, burnout, ITR, and ITL. Addressing CCS may improve HCWs’ quality of life and HCW retention and work participation.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Adequate Compensation)
Childcare Stress, Burnout, and Intent to Reduce Hours or Leave the Job During the COVID-19 Pandemic Among US Health Care Workers
[This is an excerpt.] The wellbeing of health care workers is a prime concern in the functioning and performance of health care organizations. While the Triple Aim—enhancing patient experience, improving population health, and reducing health care costs—has contributed to health system reforms worldwide, scholars have asserted the need for a fourth aim to improve the professional lives of health care workers (1). Such improvements promote work engagement, job satisfaction, and talent retention; protect against the increasingly prevalent phenomenon of burnout among clinicians; and are essential for the quality and safety of care (2). They prompt health care leaders and managers to pay more attention to issues such as physicians’ experiences of autonomy loss and stress related to malpractice liability, as well as nurses’ experiences of disrespectful behaviors at work for example. More specifically, the Quadruple Aim is a call to help health care workers restore and maintain “joy and meaning in work” (3). Similarly, the Institute for Healthcare Improvement has promoted joy in work as a goal for organizations to work towards (4). [To read more, click View Resource.]
Clarifying the Concepts of Joy and Meaning for Work in Health Care
OBJECTIVE: To determine whether participation in an employer-sponsored mental health benefit was associated with improvements in depression and anxiety, workplace productivity, and ROI as well as to examine factors associated with clinical improvement. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included participants in a US workplace mental health program implemented by 66 employers across 40 states from January 1, 2018, to January 1, 2021. Participants were employees who enrolled in the mental health benefit program and had at least moderate anxiety or depression, at least 1 appointment, and at least 2 outcome assessments. INTERVENTION: A digital platform that screened individuals for common mental health conditions and provided access to self-guided digital content, care navigation, and video and in-person psychotherapy and/or medication management. MAIN OUTCOMES AND MEASURES: Primary outcomes were the Patient Health Questionnaire-9 for depression (range, 0-27) score and the Generalized Anxiety Disorder 7-item scale (range, 0-21) score. The ROI was calculated by comparing the cost of treatment to salary costs for time out of the workplace due to mental health symptoms, measured with the Sheehan Disability Scale. Data were collected through 6 months of follow-up and analyzed using mixed-effects regression. RESULTS: A total of 1132 participants (520 of 724 who reported gender [71.8%] were female; mean [SD] age, 32.9 [8.8] years) were included. Participants reported improvements from pretreatment to posttreatment in depression (b = -6.34; 95% CI, -6.76 to -5.91; Cohen d = -1.11; 95% CI, -1.18 to -1.03) and anxiety (b = -6.28; 95% CI, -6.77 to -5.91; Cohen d = -1.21; 95% CI, -1.30 to -1.13). Symptom change per log-day of treatment was similar post-COVID-19 vs pre-COVID-19 for depression (b = 0.14; 95% CI, -0.10 to 0.38) and anxiety (b = 0.08; 95% CI, -0.22 to 0.38). Workplace salary savings at 6 months at the federal median wage was US $3440 (95% CI, $2730-$4151) with positive ROI across all wage groups. CONCLUSIONS AND RELEVANCE: Results of this cohort study suggest that an employer-sponsored workplace mental health program was associated with large clinical effect sizes for employees and positive financial ROI for employers.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Mental Health).
Clinical and Financial Outcomes Associated with a Workplace Mental Health Program Before and During the COVID-19 Pandemic
In response to the acute challenges and staffing shortages of COVID-19, the Clinician Well-Being Collaborative assembled industry leaders, C-Suite members, and frontline health care workers to unite in our journey to share perspectives on challenges and barriers, pinpoint solutions, and discuss actionable strategies to mitigate burnout and strengthen the health care workforce. The free public meeting highlighted: Individual-level stressors in the context of COVID-19 Institutional-level challenges and opportunities to support workforce well-being National-level levers for improving workforce well-being, the pipeline of health workers, and stemming the shortage
Clinician Retention in the Era of COVID: Uniting the Health Workforce to Optimize Well-Being
OBJECTIVES: To describe relationships between compromised integrity (CI), burnout, and intent-to-leave (ITL) practice in critical care (CC) and noncritical care (non-CC) nurses and physicians. DESIGN: CC nurses (RNs) and physicians (MDs) from the American Medical Association Coping with COVID survey were matched by gender, race, years in practice, and role with non-CC clinicians to determine likelihood of ITL in relation to burnout and CI. SETTING: U.S. Healthcare organizations; July—December 2020. SUBJECTS: One hundred sixty-five CC RNs and 148 CC MDs (n = 313) matched with 165 non-CC RNs and 148 non-CC MDs from 83 healthcare organizations. MEASUREMENTS AND MAIN RESULTS: Burnout was measured with a single, validated question that mainly reflects emotional exhaustion (EE), and CI was determined by asking if respondents worried about doing things that compromised their integrity moderately or to a great extent. ITL included those moderately, likely, or definitely, intending to leave. Burnout correlated strongly with CI (tetrachoric r = 0.704 [0.606–0.803]; P < 0.001). Of 626 subjects, 59% experienced burnout, 24% CI, and 33% ITL. CC RNs experienced burnout more often (76%) than non-CC RNs (62%; P < 0.01) and CC MDs (51%; P < 0.001). CI was more frequent in CC RNs (44%) than non-CC RNs (23%) and CC MDs (16%; P < 0.001). In multivariate regressions, CC clinicians experiencing burnout had 50% greater odds of ITL than non-CC clinicians experiencing burnout; odds of ITL were substantially higher (odds ratio, 2.8–3.2) in those with CI regardless of location or burnout. In the ICU, those feeling valued by their organization had one-third the odds of ITL. CONCLUSIONS: Burnout (EE) is high (>50%) among CC RNs and MDs, which may result in losses of CC clinicians while demand rises. Preventing CI independent of burnout may reduce turnover in all settings and especially in ICUs. Feeling valued may promote staff retention.
Compromised Integrity, Burnout, and Intent to Leave the Job in Critical Care Nurses and Physicians
OBJECTIVE: The objective of the present work was to characterize the coping strategies used by first responders to emergencies in the face of exposure to traumatic events. METHODS: A systematic search was performed in the databases MEDLINE (Ovid), EMBASE, LILACS (Latin American and Caribbean Literature in Health Sciences), and the Cochrane Central Registry of Controlled Clinical Trials (CENTRAL) from their inception through February 2022. First responders to emergencies with training in the prehospital area and who used validated measurement instruments for coping strategies were included. RESULTS: First responders to emergencies frequently used nonadaptive coping strategies, with avoidance or disconnection being one of the main strategies, as a tool to avoid confronting difficult situations and to downplay the perceived stressful event. The nonadaptive coping strategies used by these personnel showed a strong relationship with posttraumatic stress disorder (PTSD) symptoms, burnout syndrome, psychiatric morbidity, and chronic stress. As part of the adaptive strategies, active coping was found, which includes acceptance, positive reinterpretation, focusing on the problem, self-efficacy, and emotional support, either social or instrumental, as protective strategies for these personnel. CONCLUSIONS: Developing adaptive coping strategies, whether focused on problems or seeking emotional support, can benefit emergency personnel in coping with stressful situations. These coping strategies should be strengthened to help prevent people from experiencing long-term negative effects that could arise from the traumatic events to which they are exposed. Active coping strategies instead of avoidance strategies should be promoted.
This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Operational Breakdown) AND Outcomes AND Actionable Strategies (Providing a Continuum of Support)
Coping Strategies for Exposure to Trauma Situations in First Responders: A Systematic Review
The Mini Z is a psychometrically sound measure of worklife and wellness in practicing clinicians. Measures in residents address slightly different issues and are moderately longer, potentially limiting response rates. We adapted the Mini Z for use in residents (the Mini ReZ), using the Mini Z core 10 questions and 5 additional questions reflecting domains identified by Trockel. Validating the new variation on the Mini Z would provide program directors the means to assess well-being within their programs (in collaboration with their residents), and determine actionable steps for improvement. The objective of this report is to demonstrate the validation of the Mini ReZ.
Correction to: The Mini Z Resident (Mini ReZ): Psychometric Assessment of a Brief Burnout Reduction Measure
In an effort to reduce unintended burdens for clinicians, health system leaders can consider de-implementing processes or requirements that add little or no value to patients and their care teams. Physicians themselves are often in the best position to recognize these unnecessary burdens in their day-to-day practice. The following list includes potential deimplementation actions to consider. Learn more on how to reduce the unnecessary daily burdens for physicians and clinicians at stepsforward.org.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens) AND Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).
De-Implementation Checklist
During the Covid-19 pandemic, nurses requested a clean, streamlined, and intuitive view of the adult nursing assessment(s) within the electronic medical record (EMR). We created a more efficient method during a national disaster to reduce duplicative efforts and allow additional time with patients. This project was added as part of the clinically led EMR optimization strategy to eliminate unnecessary EMR assessment data elements in the adult medical, surgical, and critical care areas. This was completed in a 5-month period and decreased 20% of the data points entered by nursing. A total of 433 data points were excluded or relocated to achieve the desired result.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Decreasing the Nursing Documentation Burden During the Covid-19 Surge
OBJECTIVES: Healthcare personnel have faced unprecedented mental health challenges during the COVID-19 pandemic. The study objective is to assess differences in depression, anxiety, and burnout among healthcare personnel with various occupational roles and whether financial and job strain were associated with these mental health outcomes. METHODS: We employed an anonymous survey between July and August 2020 at an urban county hospital in California, USA. We assessed depression, anxiety, and burnout using validated scales, and asked questions on financial strain and job strain. We performed logistic and linear regression analyses. RESULTS: Nurses (aOR 1.93, 95% CIs 1.12, 3.46), social workers (aOR 2.61, 95% CIs 1.35, 5.17), service workers (aOR 2.55, 95% CIs 1.20, 5.48), and administrative workers (aOR 2.93, 95% CIs 1.57, 5.61) were more likely than physicians to screen positive for depression. The odds of screening positive for anxiety were significantly lower for ancillary workers (aOR 0.32, 95% CIs 0.13-0.72) compared with physicians. Ancillary (aB = -1.77, 95% CIs -1.88, -0.47) and laboratory and pharmacy workers (aB -0.70, 95% CI -1.34, -0.06) reported lower levels of burnout compared with physicians. Financial strain partially accounted for differences in mental health outcomes across job categories. Lack of time to complete tasks and lack of supervisory support were associated with higher odds of screening positive for depression. Less job autonomy was associated with higher odds of screening positive for anxiety and higher burnout levels. CONCLUSIONS: We found significant disparities in mental health outcomes across occupational roles. Policies to mitigate the adverse impact of COVID-19 on health workers' mental health should include non-clinical staff and address financial support and job characteristics for all occupational roles.
Depression, Anxiety, and Burnout Among Hospital Workers During the COVID-19 Pandemic: A Cross-Sectional Study
Inclusion is a core value for the National Association of Colleges and Employers (NACE), which fosters and supports individual and organizational diversity and inclusion in all facets of the association. NACE embraces and derives value from the variety of views that diverse organizations and individuals bring to a task at hand, and creates a supportive learning environment to foster open communication of diverse perspectives and realities.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Diversity & Inclusion Self-Assessment
OBJECTIVE: Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS. METHODS: Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed (“gray”) literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively. RESULTS: We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes. CONCLUSIONS: Existing EMS workforce research demonstrates continued underrepresentation of women and nonwhite personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.
This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Relational Breakdown)
Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review
Learning Objectives
- Implement standard workflows for message routing and common inbox tasks
- Decide which team members should be responsible for various inbox tasks
- Create filters to separate inbox signal from noise
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
EHR Inbox Management: Tame Your EHR Inbox
Many who work in EMS roles are suffering from significant mental health conditions, or are just plain burnt out. Under-resourced, taken for granted, and expected to be impervious to severe workplace stress—it seems unsustainable. Is it time to rethink responder “resiliency” and examine the obligations of organizational leadership to protect the mental health of their most valuable asset? The articles and research in this supplement were authored by Mark Layson, a first responder and PhD researcher at Charles Sturt University in Australia who has worked in police and firefighter roles as well as an ambulance chaplain in Sydney, Australia.
EMS Workplace Stress: Rethinking Resilience and Examining the Role of Moral Injury
OBJECTIVE: Burnout is a healthcare quality problem, linked to negative impacts in patient care and healthcare providers. The pandemic prompted clinicians to adapt virtual practices and adopt more flexible, autonomous schedules. However, the impact of flexible scheduling and autonomy on provider burnout is unknown. The study aim was to evaluate the effect of flexible schedules versus standard schedules, and the amount of digital care, on burnout. METHODS: This was a prospective survey study at two time points 6 months apart. Providers from Rheumatology, Neurology, and Pediatrics completed surveys at baseline, between 6/22/2020-9/8/2020, and six months later, between 12/20/20-3/12/21. The primary outcome was the Mini-Z work life survey which measured burnout in 2 different groups: flexible schedules (FS) and standard schedules (SS) during the height of the pandemic. RESULTS: The study included 149 providers, 47 with FS and 102 with SS, who completed the survey at baseline and 6 months later. At baseline providers reported high job satisfaction (85.9%) and low burnout (29.7%), which remained consistent at 6 months. Compared to those with SS, clinicians with FS participated in a greater number of telemedicine activities at baseline, but did not differ significantly in degree of burnout (25.5% FS, 31.7% SS, p=0.45). Participants in the FS group were significantly more likely to indicate improvement in control over workload and experience reduced work-related stress compared to those in the SS group. There was no association between amount of telemedicine visits and burnout. Predictors of burnout at 6 months included Rheumatology providers and those in the 20-39 year old age group. DISCUSSION: Schedule flexibility does not appear to influence overall burnout; however it does impact variables associated with burnout such as control over workload and perceived job stress. CONCLUSIONS: Participants reported overall job satisfaction, and FS did not impact overall burnout. FS was more likely to indicate improvement in control over workload and experienced reduced work-related stress compared to SS. In addition, burnout was more likely in the 20-39 year old age group, suggesting that special focus should be paid to this age group.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows)
Effects of Flexible Scheduling and Virtual Visits on Burnout for Clinicians
Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses’ emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses’ worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.
Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic
Research examining correctional staff indicates that there are far-reaching negative consequences related to job burnout, including, but not limited to, diminished physical and mental health, increased risk of substance use, and decreased job performance. One area that may contribute to correctional staff job burnout is work–family conflict, which occurs when work and home domains spill into one another, causing conflict and problems. Using a sample of Southern correctional staff, this study investigates whether the four major types of work–family conflict—time-based, strain-based, behavior-based, and family-based—influence the three recognized job burnout dimensions: emotional exhaustion, depersonalization, and feeling ineffective at work. The findings provide partial support for the notion that work–family conflict influences job burnout. These findings are contextualized in previous research with a full discussion of their implications.
Effects of Work–Family Conflict on Southern Correctional Staff Burnout
There is a paucity of research on the use of the electronic health record (EHR) by gastroenterology and hepatology providers and its effect on work–life balance. Our aim was to study the after-hour EHR work completed among providers within a multispecialty academic practice.
Electronic Health Record Work Demands for Gastroenterology and Hepatology Providers: A Prospective Use Analysis and Survey Study
OBJECTIVE: Healthcare provider (HCP) burnout is on the rise with electronic medical record (EMR) use being cited as a factor, particularly with the rise of the COVID-19 pandemic. Burnout in HCPs is associated with negative patient outcomes, and, therefore, it is crucial to understand and address each factor that affects HCP burnout. This study aims to (a) assess the relationship between EMR use and burnout and (b) explore interventions to reduce EMR-related burnout. METHODS: We searched MEDLINE (Ovid), CINAHL and SCOPUS on 29 July 2021. We selected all studies in English from any publication year and country that discussed burnout in HCPs (physicians, nurse practitioners and registered nurses) related to EMR use. Studies must have reported a quantitative relationship to be included. Studies that implemented an intervention to address this burnout were also included. All titles and abstracts were screened by two reviewers, and all full-text articles were reviewed by two reviewers. Any conflicts were addressed with a third reviewer and resolved through discussion. Quality of evidence of all included articles was assessed using the Quality Rating Scheme for Studies and Other Evidence. FINDINGS: The search identified 563 citations with 416 citations remaining after duplicate removal. A review of abstracts led to 59 studies available for full-text assessment, resulting in 25 studies included in the scoping review. Commonly identified associations between EMR-related burnout in HCPs included: message and alert load, time spent on EMRs, organisational support, EMR functionality and usability and general use of EMRs. Two articles employed team-based interventions to improve burnout symptoms without significant improvement in burnout scores. CONCLUSIONS AND RELEVANCE: Current literature supports an association between EMR use and provider burnout. Very limited evidence exists for burnout-reducing interventions that address factors such as time spent on EMRs, organisational support or EMR design.
