Public health officials played a critical role in COVID-19 mitigation and response efforts. In Kansas, 51 local health department (LHD) administrators and/or local health officers left their positions due to the pandemic between 15 March 2020 and 31 August 2021. The purpose of this study was to identify factors that led to turnover of Kansas local public health officials during the COVID-19 pandemic. Those eligible to participate in this study included former LHD administrators and/or health officers who were employed at or contracted by a Kansas LHD on 15 March 2020 and resigned, retired, or were asked to resign prior to 31 August 2021. Researchers used a demographic survey, a focus group, and key informant interviews to collect data. Twelve former LHD leaders participated in this study. Four themes emerged from phenomenological analysis: politicization of public health; a perceived lack of support; stress and burnout; and the public health infrastructure not working. The findings of this study can guide the Kansas public health system to address the issues leading to turnover of leadership and prevent future turnover. Future research must explore strategies for mitigating leadership turnover and identify alternative public health structures that could be more effective.
Reasons for Turnover of Kansas Public Health Officials During the COVID-19 Pandemic
Even before RaDonda Vaught was found guilty of criminally negligent homicide, nurses were fearful of being held individually accountable for systemic errors. Leaders are now faced with repairing the loss of faith in just culture. This article provides an understanding of the erosion of just culture and interventions needed to improve trust.
Rebuilding Trust in Just Culture
Caring for patients with substance use disorder (SUD) can be challenging. Lack of knowledge of SUD treatment may add to nurses' feelings of burnout and intent to leave the workplace. This article describes a novel program for patients with SUD admitted for long-term antibiotic treatment and its impact on the nurses' work environment, particularly burnout.
Reducing Nurse Burnout When Caring for Patients with Substance use Disorder
Police, firefighters, and emergency medical technicians and paramedics are frequently exposed to potentially traumatic events (PTE) in their work as public safety personnel (PSP). PTE are a risk factor for posttraumatic stress disorder, depression, anxiety, substance abuse, and suicidal ideation. This systematic rapid scoping review summarizes evaluation research on psychosocial interventions to reduce the negative consequences of exposure to work-related PTE on the mental health of PSP. Articles were identified using PubMed and PsycInfo. Publications from January 1, 2013, to December 1, 2020, were retained because the research published before 2013 was covered by other reviews. We identified 601 unique documents; 30 met preliminary eligibility criteria; and 18 were retained. Most studies were limited to police officers and firefighters. Participants exposed to prevention measures reported improvements of symptoms of depression, burnout, anxiety, sleep problems, and well-being. Most articles identified factors that may hinder or facilitate the use of program components. Studies on ways to support PSP recently affected by a PTE are lacking. There are little data on the efficacy of prevention programs in reducing the prevalence of mental disorders associated with PTE. More studies should focus on identifying participant characteristics and intervention components that influence program use, adherence, and efficacy. Realistic evaluations combined with participatory research could help address important knowledge gaps.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Providing a Continuum of Support)
Reducing the Impacts of Exposure to Potentially Traumatic Events on the Mental Health of Public Safety Personnel: A Rapid Systematic Scoping Review
BACKGROUND AND OBJECTIVES: Given their broad scope of training, family medicine residents were uniquely situated to care for the American public throughout the COVID-19 pandemic, yet little has been written about their experiences. The objective of this report is to capture the diversity of experiences and contributions of family medicine residents across the United States to the care of the American public during the COVID-19 pandemic. METHODS: Investigators recruited resident interviewees from four residencies throughout the United States via convenience sample. These residencies represented a diversity of geography, rurality, and structure (hospital based vs community based). Investigators conducted 30 to 60-minute, semistructured interviews with family medicine residents. Interviews were recorded and examined for themes. RESULTS: Three major themes emerged through the interview process. First, family medicine residents were a critical component of the inpatient response to COVID-19 in a variety of geographies from urban centers to rural towns to Native American reservations. Second, family medicine residents continued to provide expanded outpatient care to include telehealth, immunization clinics, and public health campaigns to meet the needs of the community. Finally, not only did these residents have an immense impact in the response to COVID-19, but the pandemic also had an immense impact on them, both personally and professionally. CONCLUSIONS: The story of family medicine contributions to the care of the public during COVID-19 reflects the history of COVID-19 in the United States, and the critical role trainees and family medicine physicians have in the US health care system.
Reflections From Family Medicine Residents on Training During the COVID-19 Pandemic
PHENOMENON: While part-time clinical work options are popular for physicians, part-time residency training is uncommon. Some residency training programs have offered trainees the option to complete their training on a modified schedule in the past. These part-time tracks often involved extending training in order to complete equivalent hours on a part-time basis. Having experience with trainees in such programs, we sought to explore the impact of completing residency training part-time on the professional and private lives of physicians. APPROACH: Between 2019 and 2020, we conducted interviews with physicians who completed portions of their residency training part-time between 1995 and 2005 in our institution’s pediatrics, combined medicine-pediatrics, and family medicine programs. FINDINGS: Seven female physicians who completed at least some portion of residency part-time were interviewed. To better characterize their experiences, we chose phenomenology as our analytic framework. Members of the research team independently coded each interview and met to resolve conflicts. Codes were then combined and discussed to determine four overarching themes as reasons and benefits of part-time training: The pursuit of extended-time training, logistics, effects on career trajectory, and wellness. These themes highlighted the utility of part-time training and the need for programmatic support to ensure their success. INSIGHTS: Based on our findings, adaptability for training and a sense of agency from their part-time experiences persisted throughout interviewees’ careers. Each felt empowered to make career choices that fit their personal and professional needs. These findings suggest further investigation into the benefits of offering time-variable training in residency programs.
Reflections on Part-Time Residency Training, 15–25 Years Later: A Qualitative Study on Wellness and Career Impact
An innovative program for nurse leaders offered virtually by the American Organization for Nursing Leadership to build resilience and combat burnout was implemented and evaluated. It consisted of strategies to build a community of support. The evaluation plan included analysis of preintervention and postintervention results of the Maslach Burnout Inventory – General Survey and open-ended questions for qualitative analysis. Participants' burnout levels remained consistent throughout the program. Resiliency practices learned and implemented are reported. Strategies nurse leaders can use to impact nurse burnout are described.
Reignite: Fighting Burnout With a Virtual Resiliency Program for Nurse Leaders
Clinicians in acute care hospitals experience highly stressful situations daily. They work long, variable hours, complete complex technical tasks, and must also be emotionally engaged with patients and families to meet the caring demands of this profession, which can lead to burnout. In response to these challenges, a multi-disciplinary team from Virginia Tech collaborated with Steelcase to study the impact of medical workspaces on the clinician experience and how those workspaces could be improved to reduce some of the sources of burnout. The team sought to identify conditions that could either aid or hinder clinician workflow and affect burnout rate, then based on interviews and in-situ ethnographic studies, generated design concepts for nurse stations, both centralized and mobile. Using digital and physical full-scale prototypes, we enacted clinical care scenarios to seek feedback and reflect on the design.
Reimagining Medical Workspaces Through On Site Observations and Bodystorming
BACKGROUND: Burnout is a “normal” albeit concerning response to workplace stress, whereas Major Depressive Disorder (MDD) is a serious illness associated with impairment and suicide risk. Because of symptomatic overlap between the two conditions and MDD-associated stigma, individuals reporting work-related stress and depression often are “diagnosed” with burnout at the expense of recognizing and treating MDD. Our study aimed to leverage organizational implementation of the American Foundation of Suicide Prevention's Interactive Screening Program to elucidate relationships among burnout, depression, and other suicide risk factors. METHODS: 2281 of about 30,000 (~7.6 %) medical trainees, staff, and faculty responded to an anonymous online stress and depression questionnaire. Respondents were grouped into four cohorts: screened positive for burnout alone (n = 439, 19 %), depression alone (n = 268, 12 %), both conditions (n = 759, 33 %), or neither condition (n = 817, 36 %), and compared on multiple measures of distress and other suicide risk factors. RESULTS: Burnout alone and depression alone each predicted greater distress and suicide risk compared with neither condition. Depression was a stronger predictor than burnout and demonstrated a consistent association with other suicide risk factors regardless of whether burnout was present. In contrast, burnout was not consistently associated with other suicide risk factors when depression was present. Limitations The sample was limited to one state-supported academic medical center; to individuals who elected to take the online survey; and relied on a single item, non-validated measure of burnout. CONCLUSION: When emotional distress is reported by healthcare workers, attention should not stop at “burnout,” as burnout frequently comingles with clinical depression, a serious and treatable mental health condition.
Relationship Between Burnout and Major Depressive Disorder in Health Professionals: A HEAR Report
BACKGROUND: Reducing nurse turnover is a top priority for nursing management globally. While evidence has demonstrated that working in a favorable environment with greater interprofessional teamwork is essential in increasing nurse retention, few studies have explored the mechanism underlying this relationship. AIM: To examine the direct and indirect effects of interprofessional teamwork on nurses' intentions to leave their jobs via the intermediary roles of job satisfaction and burnout. METHODS: A cross-sectional study was conducted to collect data from 2113 nurses working in 21 hospitals in Oman. Data were collected using a survey questionnaire measuring teamwork, job satisfaction, burnout, and intention to leave. Logistic regression was used to investigate the direct effect of teamwork on intent to leave. A sequential mediation model was conducted to examine the mediating role of job satisfaction and burnout. RESULTS: Interprofessional teamwork was directly associated with nurses' intentions to leave. The influence of teamwork on intention to leave was indirectly mediated by both job satisfaction and job burnout. CONCLUSION: Findings illustrate the potential benefits of enhancing interprofessional teamwork in reducing nurses' intentions to leave. Interventions intended to foster teamwork could create satisfying workplaces, reduce perceived burnout, and ultimately contribute to organizational strategy for reducing nursing shortages.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing and Optimizing Teams).
Relationship Between Interprofessional Teamwork and Nurses' Intent to Leave Work: The Mediating Role of Job Satisfaction and Burnout
Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.
Repairing Moral Injury Takes a Team: What Clinicians Can Learn from Combat Veterans
Since the start of the COVID-19 pandemic, nursing home residents have accounted for roughly one of every six COVID-19 deaths in the United States. Nursing homes have also been very dangerous places for workers, with more than one million nursing home workers testing positive for COVID-19 as of April 2022. Labor unions may play an important role in improving workplace safety, with potential benefits for both nursing home workers and residents. We examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes, using proprietary data on nursing home–level union status from the Service Employees International Union for all forty-eight continental US states from June 8, 2020, through March 21, 2021. Using negative binomial regression and adjusting for potential confounders, we found that unions were associated with 10.8 percent lower resident COVID-19 mortality rates, as well as 6.8 percent lower worker COVID-19 infection rates. Substantive results were similar, although sometimes smaller and less precisely estimated, in sensitivity analyses.
This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)
Resident Mortality and Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020–21
OBJECTIVES: Religion and spirituality are important aspects of many physicians and patients’ lives and may impact their views of death and the way they interact with terminally ill patients, specifically comfort discussing end-of-life care and death and dying. This study explores the religious and spiritual beliefs of resident physicians, if they affect interactions with their patients and if burnout impedes this interaction. METHODS: A 28-item questionnaire was administered to residents and fellows at an urban academic hospital. RESULTS: 65 residents and fellows answered the survey. Religiosity but not spirituality correlated with reported comfort interacting with patients dealing with death or dying. Resident specialty, biological sex and spirituality were not associated with comfort and conversations about religion and end-of-life care. The majority (60%) reported that the pandemic has not affected how they speak to their patients about death and dying. Caring for a higher volume of terminally ill patients was not associated with high levels of burnout though 71% reported increased burnout due to COVID-19. CONCLUSION: Further research can be done to determine whether additional training or resources should be provided to resident physicians to cope with death and dying in the setting of a pandemic.
Resident Physician Outlook on Death, Dying and End-Of-Life Care During the COVID-19 Pandemic: Effect of Religion and Burnout
The past 3 years mark the largest wave of activism by resident physicians advocating for physician well-being since the mid-1970s. As the COVID-19 pandemic has magnified systemic factors driving persistent burnout in medicine, resident physicians and fellows are increasingly rejecting the status quo of long hours and low pay during medical training. Burnout is commonly defined as a work-related syndrome of emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. Driven by a desire to counteract physician burnout, improve health care equity, and reprioritize the patient-physician relationship, house staff (ie, resident physicians and fellows) are increasingly taking action through labor unions.
Resident and Fellow Unions: Collective Activism to Promote Well-being for Physicians in Training
LEARNING OBJECTIVES: 1) Anonymously survey residents to obtain rates of burnout and identify gaps in resident wellness. 2) Create a resident-led, self-sustaining wellness committee 3) Integrate wellness education into a formal grand rounds curriculum 4) Reduce self-reported resident burnout rates. INTRODUCTION/BACKGROUND: Residents suffer from numerous stressors that lead to poor mental health and significant rates of burnout. The Madigan Army Medical Center Emergency Medicine (EM) residency program had aspects of wellness built into its program but lacked a formal wellness curriculum or internal evaluation system. CURRICULAR DESIGN: To address the lack of formal wellness resources, anonymous surveys were sent to residents, a formal wellness curriculum developed, and a resident-led wellness committee was formed. Following an introductory wellness lecture, residents were anonymously surveyed to assess knowledge of local wellness resources, rates of burnout, and gaps in resident wellness. This survey will be administered biannually, at the beginning and middle of each academic year. A resident-led wellness committee was formed with the goals of serving as a monitoring group for resident mental health and wellness, serving as a think tank to address identified mental health and wellness gaps, and creating and planning wellness interventions. A wellness curriculum was added into the current grand rounds curriculum, covering burnout, mindfulness, financial planning, professionalism, peer support, local behavioral health resources, sleep hygiene, and faculty experiences on work-life balancing. IMPACT/EFFECTIVENESS: This innovation will provide an anonymous before and after evaluation of a multi-faceted approach to resident wellness in an EM residency program. Formal reevaluation of resident wellness and burnout rates are pending repeated surveying. The initial survey generated multiple initiatives, which the wellness committee has already addressed such as EM food pantry creation and shift schedule alterations. Anecdotally, residents have responded very positively to these interventions and the renewed focus on resident wellness. Program leadership is supportive of this program and plans are in place to sustain this initiative for the foreseeable future.
Resident-Led Wellness Program
OUTCOMES: 1. Explain feasibility and acceptability of the PRISM at Work program for healthcare providers 2. Explain the preliminary efficacy of the PRISM at Work program for healthcare providers on reducing stress, resilience, and burnout IMPORTANCE: Healthcare workers face serious mental health challenges as a result of ongoing work stress. The COVID pandemic exacerbated that stress, highlighting the critical need for evidence-based stress interventions. OBJECTIVE(S): The goal of this study was to examine feasibility, acceptability, and preliminary efficacy of PRISM at Work, a skill-based program designed to reduce stress and build resilience. METHOD(S): In response to COVID-19, we translated the Promoting Resilience in Stress Management (PRISM) program, a manualized, skill-based program originally developed for adolescents and young adults with medical illness, to a program that could support healthcare workers. It included 6 weekly 1-hour sessions on Zoom, covering topics including stress management, goal setting, cognitive reframing, and meaning making. Feasibility and acceptability were assessed by enrollment and completion rates and satisfaction surveys. Preliminary efficacy was assessed with pre-post assessments of resilience, stress, anxiety, and burnout. Descriptive statistics were used to summarize feasibility and acceptability outcomes. Linear mixed effects regression models were used to examine the impact of PRISM on outcomes. RESULTS: Of the 153 participants who enrolled, 92% were female, 46% were ?40 years old, 87% were White, 53% worked in a clinical role, and 59% were married. Feasibility was demonstrated in that all 15 courses were filled to capacity and 91% completed the program. 91% reported being satisfied with PRISM, and 89% were likely to recommend PRISM to colleagues. Regression analyses demonstrated improvements in resilience (1.74, 95% CI [1.00, 2.47]), anxiety (–2.06, 95% CI [–2.75, –1.36]), stress (–2.43, 95% CI [–3.30, –1.55]), and burnout (–0.37, 95% CI [–0.56, –0.18]) (all ps < .001). CONCLUSION(S): PRISM at Work is a feasible and acceptable program that shows promise in managing stress, building resilience, and reducing burnout for healthcare workers. IMPACT: A continuation of this work, beyond the scope of the COVID pandemic, is critical given the historical and ongoing burden and distress prevalent in the healthcare profession.
Resilience Training for Hospital Employees in the Era of COVID-19: A Pilot Study of Promoting Resilience in Stress Management (PRISM) at Work (RP413)
BACKGROUND: Transitioning to practice during the COVID-19 pandemic multiplied the stressors and challenges typically encountered by new graduate nurses (NGNs), yet research exploring mental health variables of this subset of nurses remains sparse. METHOD: This study used an observational design and convenience sampling. NGN alumni (n = 192) from a pre-licensure nursing program were surveyed during the summer of 2021 regarding their experiences with resilience, anxiety, depression, and stress while transitioning to practice during the COVID-19 pandemic. RESULTS: Participants reported moderate to severe levels of stress (76%), anxiety (27.6%), and depression (31.2%) while transitioning to practice. Most (79%) described themselves as resilient. The highest mean scores for stress, anxiety, and depression occurred during the fourth to eighth month of practice. CONCLUSION: Nursing professional development specialists, managers, and other stakeholders need effective strategies to monitor and promote NGNs' well-being and mental health to prevent burnout and turnover throughout the first year of practice. [J Contin Educ Nurs. 2022;53(12):533–543.]
Resilience, Stress, Anxiety, and Depression: Exploring the Mental Health of New Graduate Nurses Transitioning to Practice During COVID-19
BACKGROUND: Medical training program and hospital response to the COVID-19 pandemic has varied greatly and has impacted trainee well-being. Which factors have specifically related to trainee wellness, however, has not yet been examined in depth. The aim of the study was to understand trainee perspectives on the individual psychiatry trainee programs' hospitals' objective COVID-19 preparedness management. We also sought and to gauge how program changes, and general pandemic-related concerns, have been associated with trainee satisfaction and burnout. METHODS: A cross-sectional survey study of psychiatric trainees was distributed electronically throughout the country via various psychiatry residency program listservs in April 2020. Statistical analyses were performed utilizing simple linear regression. RESULTS: From 352 respondents (346 complete responses and 6 partial responses), the most frequent program changes were "decreased number of rotations requiring in-person patient care" and "increased call hours or duties." Of pandemic-related concerns surveyed, the two greatest were "spreading COVID-19 to family/friends" and "co-residents' burnout and anxiety." A positive relationship was found between trainee satisfaction with perceived COVID-19 departmental response and comfort level of residents/fellows in expressing concerns with attending clinicians and department leadership. CONCLUSIONS: Since the start of the COVID-19 pandemic, trainees have experienced a variety of changes to trainee program policies and guidelines. Overall, poor communication and trainee dissatisfaction with departmental response correlated with concern of infection and anxiety/burnout. Insights garnered from this study could provide scaffolding for the best practices to reduce trainee physician anxiety/burnout for the current and future pandemics of this variety and magnitude.
Response of US Psychiatric Programs to the COVID-19 Pandemic and the Impact on Trainees
BACKGROUND: Effective team communication is an essential aspect of care delivery and the coordination of patients in primary care settings. With the rapid evolution of health information technology (HIT), including the implementation of electronic health records, there remains a gap in the literature about preferred methods of primary care team communication and the subsequent impact of provider and team outcomes (e.g., team cohesiveness; burnout). This study explores the impact of varying modes of communication across provider disciplines and by geographic settings during primary care delivery. METHODS: We used a cross-sectional survey design to collect data from a random convenience sample of PCPs (physicians, nurse practitioners, and physician assistants) (n = 314) in New York State (NYS). We mailed a paper survey with validated measures for communication methods, team cohesiveness, and provider outcomes (burnout, job dissatisfaction, and the intention to leave position). Descriptive statistics, linear regression models, and crude and adjusted odds ratios while controlling for individual and practice characteristics were calculated. RESULTS: In-person communication was found to yield greater job satisfaction and less intention to leave current position in the next year () compared to other forms of communication including electronic health record features. The odds of job satisfaction was 1.51 times higher with in-person communication (OR: 1.51, 95% CI: 1.05, 2.19), and the odds of intending to leave a position was 45% less with in-person communication (OR: 0.55, 95% CI: 0.36, 0.85). The odds of reporting burnout at work was 36% less with in-person communication (OR: 0.64, 95% CI: 0.43, 0.92) compared to other communication modalities. There was no significant association between team communication via the EHR and team cohesiveness, provider burnout, or job satisfaction. CONCLUSION: This study demonstrates evidence that in-person communication is more likely to reduce burnout and job dissatisfaction compared to other forms of communication infrastructure in primary care settings. More research is needed to understand PCP perspectives about the functionality and potential burden that inhibits the use of EHR features for provider-provider communication. In addition, attention to the needs of teams by geographic location and by workforce discipline is warranted to ensure effective HIT communication application adoption.
Revisiting Provider Communication to Support Team Cohesiveness: Implications for Practice, Provider Burnout, and Technology Application in Primary Care Settings
Hospital epidemiologists, infection preventionists, and antimicrobial stewards are integral to the pandemic workforce. However, regardless of pandemic surge or postsurge conditions, their workload remains high due to constant vigilance for new variants, emerging data, and evolving public health guidance. We describe the factors that have led to burnout and suggest strategies to enhance resilience.
