Resource Library

OBJECTIVE: Test web-based implementation for the science of enhancing resilience (WISER) intervention efficacy in reducing healthcare worker (HCW) burnout. DESIGN: RCT using two cohorts of HCWs of four NICUs each, to improve HCW well-being (primary outcome: burnout). Cohort 1 received WISER while Cohort 2 acted as a waitlist control. RESULTS: Cohorts were similar, mostly female (83%) and nurses (62%). In Cohorts 1 and 2 respectively, 182 and 299 initiated WISER, 100 and 176 completed 1-month follow-up, and 78 and 146 completed 6-month follow-up. Relative to control, WISER decreased burnout (-5.27 (95% CI: -10.44, -0.10), p = 0.046). Combined adjusted cohort results at 1-month showed that the percentage of HCWs reporting concerning outcomes was significantly decreased for burnout (-6.3% (95% CI: -11.6%, -1.0%); p = 0.008), and secondary outcomes depression (-5.2% (95%CI: -10.8, -0.4); p = 0.022) and work-life integration (-11.8% (95%CI: -17.9, -6.1); p < 0.001). Improvements endured at 6 months. CONCLUSION: WISER appears to durably improve HCW well-being.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).

The current landscape of mental health services reflects both tremendous challenges and opportunities. With the impact of COVID-19 front and center in the national discourse, and the planning for a system involving a 988-crisis response, there is much work ahead. This paper, Ready to Respond, is the umbrella paper for the 2021 technical assistance coalition series developed through the National Association of State Mental Health Program Directors in partnership with the Substance Abuse and Mental Health Services Administration. It aims to lay out a roadmap as states emerge from the pandemic and need, more than ever, a full continuum of psychiatric care. As an outgrowth of a policy framework looking “beyond beds” within inpatient state hospitals as a single solution to improving mental health outcomes, the current discourse centers around access to crisis services. Yet, in order to best respond to demand, an entire array of services is needed both to prevent crises in the first place and to provide longer term supports beyond a crisis period for diverse populations of all ages with mental illness and substance use disorders, as well as those with co-occurring complex conditions. These services will require coordinated funding and planning with a broad group of stakeholders to address among other things equity and reducing the likelihood of suicide, overdose, criminal legal entanglements, homelessness, unemployment, or other untoward outcomes. The paper reviews recent behavioral health system demands and highlights seven key priority areas for consideration to build a sustainable, robust and more complete psychiatric care continuum.

BACKGROUND: Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds 'work' to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. METHODS: Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. RESULTS: Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a 'slow intervention' the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. CONCLUSIONS: Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).

BACKGROUND: The COVID-19 health crisis has disproportionately impacted populations who have been historically marginalized in health care and public health, including low-income and racial and ethnic minority groups. Members of marginalized communities experience undue barriers to accessing health care through virtual care technologies, which have become the primary mode of ambulatory health care delivery during the COVID-19 pandemic. Insights generated during the COVID-19 pandemic can inform strategies to promote health equity in virtual care now and in the future. OBJECTIVE: The aim of this study is to generate insights arising from literature that was published in direct response to the widespread use of virtual care during the COVID-19 pandemic, and had a primary focus on providing recommendations for promoting health equity in the delivery of virtual care. METHODS: We conducted a narrative review of literature on health equity and virtual care during the COVID-19 pandemic published in 2020, describing strategies that have been proposed in the literature at three levels: (1) policy and government, (2) organizations and health systems, and (3) communities and patients. RESULTS: We highlight three strategies for promoting health equity through virtual care that have been underaddressed in this literature: (1) simplifying complex interfaces and workflows, (2) using supportive intermediaries, and (3) creating mechanisms through which marginalized community members can provide immediate input into the planning and delivery of virtual care. CONCLUSIONS: We conclude by outlining three areas of work that are required to ensure that virtual care is employed in ways that are equity enhancing in a post–COVID-19 reality.

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This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows) 

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While long-term care (LTC) facilities serving older adults have long struggled with low employee morale and high rates of staff turnover, the COVID-19 pandemic brought unprecedented challenges to these facilities and the frontline staff working in them. This study aimed to explore factors that influenced the personal and professional wellbeing of care providers working in LTC facilities across New York City (NYC) during the pandemic. Fourteen semi-structured qualitative interviews were conducted with frontline care providers working in LTC facilities across NYC. Interviews were audio-recorded, transcribed, and systematically coded according to both pre-existing and emergent topics. Four main themes emerged from the data: the toll of the virus; home and work-life balance stressors; workplace stressors; and participants’ recommendations for facility leadership. Findings from this study may inform strategies for supporting the wellbeing of frontline care providers in LTC environments, especially during future public health emergencies.

BACKGROUND: Nursing practice is highly demanding and has been related to risk of substance use (SU) and SU disorders (SUDs). Despite this, education on registered nurse (RN) SUDs is extremely limited, and this knowledge gap has been related to nurses’ inability to address SU problems among colleagues. PURPOSE: We assessed whether practicing nurses recognized signs of SUDs, what actions they would take if a colleague had a SUD, and their knowledge of RN SUDs interventions. We examined these findings in relation to demographic and work characteristics. METHODS: A mixed modes survey (online, mailed) was conducted between November 2020 and February 2021, with randomly selected RNs in nine states being contacted up to six times. Balanced stratified sampling (balanced to the U.S. RN population), a technique that aims to obtain a nationally representative sample, was used. Measures of potential workplace signs of SUD (seven items), actions one would take (seven items), and attitudes toward RN SUD interventions (10 items) were assessed, and prevalence of these items is described. Logistic regression models were used to assess associations between each item and demographic and work characteristics. RESULTS: Of the 1,215 surveys returned (31% response rate), 1,170 were included in the analyses. Most RNs (82%) correctly selected frequent medication errors, medication wasting, and frequent absences/breaks as potential signs of SU problems, yet only half felt confident in their ability to identify an colleague with a SUD. Although the majority (93%) would tell a supervisor, higher proportions of younger (aged < 45 years) and Asian nurses reported feeling unsure of what to do and were more afraid to get involved with nurse SU problems than older nurses and nurses of other races/ethnicities. Variation in recognition and actions were also found for workplace factors. Charge nurses were more likely to think that nurses with a potential SUD should have their license revoked than those in the reference group (educators/researchers) (adjusted OR = 1.89; 95% CI = 1.03, 3.49). CONCLUSIONS: Findings suggest nurses can benefit from clear guidelines and educational initiatives to address RN SU problems. A culture of safety and accountability could help nurses feel more comfortable addressing these issues.

BACKGROUND: In health care, burnout remains a persistent and significant problem. Evidence now exists that organizational initiatives are vital to address health care worker (HCW) well-being in a sustainable way, though system-level interventions are pursued infrequently. METHODS: Between November 2018 and May 2020, researchers engaged five health system and physician practice sites to participate in an organizational pilot intervention that integrated evidence-based approaches to well-being, including a comprehensive culture assessment, leadership and team development, and redesign of daily workflow with an emphasis on cultivating positive emotions. RESULTS: All primary and secondary outcome measures demonstrated directionally concordant improvement, with the primary outcome of emotional exhaustion (0–100 scale, lower better; 43.12 to 36.42, p = 0.037) and secondary outcome of likelihood to recommend the participating department’s workplace as a good place to work (1–10 scale, higher better; 7.66 to 8.20, p = 0.037) being statistically significant. Secondary outcomes of emotional recovery (0–100 scale, higher better; 76.60 to 79.53, p = 0.20) and emotional thriving (0–100 scale, higher better; 76.70 to 79.23, p = 0.27) improved but were not statistically significant. CONCLUSION: An integrated, skills-based approach, focusing on team culture and interactions, leadership, and workflow redesign that cultivates positive emotions was associated with improvements in HCW well-being. This study suggests that simultaneously addressing multiple drivers of well-being can have significant impacts on burnout and workplace environment.

This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Organizational Infrastructure for Well-Being).

BACKGROUND: Interventions to decrease burnout and increase well-being in health care workers (HCWs) and improve organizational safety culture are urgently needed. This study was conducted to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture. METHODS: This study was conducted in a large academic health care system in which senior leaders were encouraged to conduct PosWR. The researchers used data from a routine cross-sectional survey of clinical and nonclinical HCWs, which included a question about recall of exposure of HCWs to PosWR: "Do senior leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?"—along with measures of well-being and safety culture. T-tests compared work settings in the first and fourth quartiles for PosWR exposure across SCORE (Safety, Communication, Operational Reliability, and Engagement) domains of safety culture and workforce well-being. RESULTS: Electronic surveys were returned by 10,627 out of 13,040 possible respondents (response rate 81.5%) from 396 work settings. Exposure to PosWR was reported by 63.1% of respondents overall, with a mean of 63.4% (standard deviation = 20.0) across work settings. Exposure to PosWR was most commonly reported by HCWs in leadership roles (83.8%). Compared to work settings in the fourth (< 50%) quartile for PosWR exposure, those in the first (> 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%, p < 0.001); good readiness to engage in quality improvement activities (60.6% vs. 76.6%, p < 0.001); good leadership accessibility and feedback behavior (51.9% vs. 67.2%, p < 0.001); good teamwork norms (36.8% vs. 52.7%, p < 0.001); and good work-life balance norms (61.9% vs. 68.9%, p = 0.003). Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%, p < 0.001), and in their colleagues (60.5% vs. 47.7%, p < 0.001). CONCLUSION: Exposure to PosWR was associated with better HCW well-being and safety culture.

This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.

In this cross-sectional quantitative study, we employed survey research to examine the differences in school counselors' (N = 327) burnout, job stress, and job satisfaction based on their student caseload size. The results indicated that higher caseloads were associated with higher degrees of burnout and job stress, along with lower job satisfaction. The results produced small to medium effect sizes. We discussed how such factors relate to the effectiveness of providing student services and school leaders' support for school counselors.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).

BACKGROUND: During the COVID-19 pandemic, health care workers are sharing their challenges, including sleep disturbances, on social media; however, no study has evaluated sleep in predominantly US frontline health care workers during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to assess sleep among a sample of predominantly US frontline health care workers during the COVID-19 pandemic using validated measures through a survey distributed on social media. METHODS: A self-selection survey was distributed on Facebook, Twitter, and Instagram for 16 days (August 31 to September 15, 2020), targeting health care workers who were clinically active during the COVID-19 pandemic. Study participants completed the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI), and they reported their demographic and career information. Poor sleep quality was defined as a PSQI score ≥5. Moderate-to-severe insomnia was defined as an ISI score >14. The Mini-Z Burnout Survey was used to measure burnout. Multivariate logistic regression tested associations between demographics, career characteristics, and sleep outcomes. RESULTS: A total of 963 surveys were completed. Participants were predominantly White (894/963, 92.8%), female (707/963, 73.4%), aged 30-49 years (692/963, 71.9%), and physicians (620/963, 64.4%). Mean sleep duration was 6.1 hours (SD 1.2). Nearly 96% (920/963, 95.5%) of participants reported poor sleep (PSQI). One-third (288/963, 30%) reported moderate or severe insomnia. Many participants (554/910, 60.9%) experienced sleep disruptions due to device use or had nightmares at least once per week (420/929, 45.2%). Over 50% (525/932, 56.3%) reported burnout. In multivariable logistic regressions, nonphysician (odds ratio [OR] 2.4, 95% CI 1.7-3.4), caring for patients with COVID-19 (OR 1.8, 95% CI 1.2-2.8), Hispanic ethnicity (OR 2.2, 95% CI 1.4-3.5), female sex (OR 1.6, 95% CI 1.1-2.4), and having a sleep disorder (OR 4.3, 95% CI 2.7-6.9) were associated with increased odds of insomnia. In open-ended comments (n=310), poor sleep was mapped to four categories: children and family, work demands, personal health, and pandemic-related sleep disturbances. CONCLUSIONS: During the COVID-19 pandemic, nearly all the frontline health care workers surveyed on social media reported poor sleep, over one-third reported insomnia, and over half reported burnout. Many also reported sleep disruptions due to device use and nightmares. Sleep interventions for frontline health care workers are urgently needed.

This study builds on the existing research in the field of interprofessional collaboration (IPC) and burnout among social workers. The authors sampled field instructors from a mid-Atlantic school of social work, comparing self-reported burnout scores among social workers on interprofessional teams with those of social workers who do not work on interprofessional teams, and completed a regression analysis of the relationship between burnout and participation in interprofessional teams, perceptions of IPC, and several individual and practice factors. Findings suggest that although members of interprofessional teams reported lower burnout scores, there was no significant relationship between working in an interprofessional team and burnout when controlling for other factors. Although the study provides an interesting first look at burnout among social workers in interprofessional teams, further research with a larger, more representative sample is needed.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Optimizing Teams).

BACKGROUND: Healthcare workers are at increased risk of adverse mental health outcomes during the COVID-19 pandemic. Studies are warranted that examine socio-ecological factors associated with these outcomes to inform interventions that support healthcare workers during future disease outbreaks. METHODS: We conducted an online cross-sectional study of healthcare workers during May 2020 to assess the socio-ecological predictors of mental health outcomes during the COVID-19 pandemic. We assessed factors at four socio-ecological levels: individual (e.g., gender), interpersonal (e.g., social support), institutional (e.g., personal protective equipment availability), and community (e.g., healthcare worker stigma). The Personal Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise scales assessed probable major depression (MD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD), respectively. Multivariable logistic regression models were used to assess unadjusted and adjusted associations between socio-ecological factors and mental health outcomes. RESULTS: Of the 1,092 participants, 72.0% were female, 51.9% were frontline workers, and the mean age was 40.4 years (standard deviation = 11.5). Based on cut-off scores, 13.9%, 15.6%, 22.8%, and 42.8% had probable MD, GAD, PTSD, and AUD, respectively. In the multivariable adjusted models, needing more social support was associated with significantly higher odds of probable MD, GAD, PTSD, and AUD. The significance of other factors varied across the outcomes. For example, at the individual level, female gender was associated with probable PTSD. At the institutional level, lower team cohesion was associated with probable PTSD, and difficulty following hospital policies with probable MD. At the community level, higher healthcare worker stigma was associated with probable PTSD and AUD, decreased satisfaction with the national government response with probable GAD, and higher media exposure with probable GAD and PTSD. CONCLUSIONS: These findings can inform targeted interventions that promote healthcare workers’ psychological resilience during disease outbreaks.

[This is an excerpt.] States are increasingly engaging in efforts to address behavioral health workforce shortages. Relatively low wages and high caseloads, elevated stress and burnout levels, and an aging workforce have contributed to these persistent shortages, which have been exacerbated by the COVID-19 pandemic. To address these disparities, state policymakers are exploring opportunities to improve behavioral health outcomes among BIPOC communities, and to address the systemic factors that foster disparities, including the lack of diversity among providers. A behavioral health workforce that more closely aligns to the community it serves may alleviate some of these factors, as working alliances have been shown to be stronger when clinicians and clients are of the same ethnic background. Building on existing work to expand behavioral health workforce capacity, states are focusing on policies that foster equity and inclusion in recruitment and retention efforts, looking to increase workforce capacity and workforce diversity at all levels. This brief explores existing state strategies that target increasing engagement of BIPOC across the workforce. NASHP is including lessons learned from states that have implemented programs and policies to address disparities in behavioral health workforce in particular, as well as strategies for workforce diversity more generally that may be applicable for behavioral health workforce. [To read more, click View Resource.]

Police officers are continuously involved in various roles that prove to be highly stressful and require a developed skill set. Consequently, demands from this career put officers at an increased risk for a range of mental-health related concerns. Although officers who suffer from these mental health concerns may need to seek psychological services, there is, unfortunately, a stigma that surrounds mental health causing officers to be reluctant to seek help. This research examines public perceptions and attitudes toward law enforcement professionals seeking mental health treatment. Findings suggest that when a higher level of self-stigma toward mental health is reported, there is also a higher level of stigma toward law enforcement. Males also showed higher levels of stigma toward officers. Implications of the findings and limitations of the study are discussed.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Operational Breakdown)

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[This is an excerpt.] Similar to physical stress, psychological stress can cause injury to the mind and body. These injuries go beyond burnout: a stress injury is any severe and persistent distress or loss of ability to function caused by damage to the brain, mind, or spirit after exposure to the overwhelming stressors of fatigue (burnout), trauma, loss, or moral injury. In particular, there is a significant risk of moral injury in high-stress, service-oriented professions where valued qualities such as selflessness, loyalty, a strong moral code, and excellence can also create vulnerabilities, such as prioritizing the needs of others above one's own needs. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience) AND Actionable Strategies for Workers & Learners: What Workers & Learners Can Do

The COVID-19 pandemic has dramatically altered the 2020 residency application cycle and resulted in many changes to the usual application processes. Particular attention should be placed on the obstacles faced by applicants who are underrepresented in medicine (URiM) as they may be disproportionately affected by the changes in 2020. These challenges are especially relevant in competitive surgical specialties, where racial and gender diversity already lags behind other medical specialties. Inclusive excellence is a guiding philosophy in creating equitable resident selection processes. It focuses on the multilayered processes that form the foundation of inclusive institutional culture, while recognizing that excellence and inclusivity are mutually reinforcing and not mutually exclusive. A key tenant in inclusive excellence for resident recruiting involves applying an equity lens in all decision making. An equity lens allows programs to continuously evaluate resident selection policies and processes through an intentional equity-forward approach. In addition to using an equity lens, programs should emphasize the importance of equity-focused skill building, which ensures that all individuals engaged in the resident selection process have the tools and knowledge to recognize biases. Finally, institutions should implement specific programming for URiM applicants to provide them with information about key aspects of department culture and mechanisms of support for URiM trainees. Every residency program should adopt a sustained perspective of inclusive excellence, in this application cycle and beyond. The status quo has existed for far too long, and COVID-19 offers institutions and their residency programs a unique opportunity to try new and innovative equity-forward practices.

Clinical workflow represents the instantiation of all clinical activities. The transition from paper to electronic health records (EHRs) over the past decade has been characterized by profound challenges supporting clinical workflow, impeding frontline clinician ability to deliver safe, efficient, and effective care. In response, there has been substantial effort to study clinical workflow as well as workarounds – exceptions to routine workflow – in order to identify opportunities for improvement. In this paper, we describe predominant methods of studying workflow and workarounds as well as provide examples of the applications of these methods along with the resulting insights. We also present challenges to studying workflow and workarounds, along with recommendations for how to approach such studies. While there is not yet a set of standard approaches, our work helps advance workflow research that ultimately serves to inform how to coevolve the design of EHR systems and organizational decisions about processes, roles, and responsibilities in order to support clinical workflow that more consistently delivers on the potential benefits of a digitized healthcare system.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).

OBJECTIVE: To evaluate the prevalence of suicidal ideation (SI) and attitudes regarding help seeking among US physicians relative to the general US working population. PARTICIPANTS AND METHODS: A secondary analysis of a cross-sectional survey of US physicians and a probability-based sample of the US working population was conducted between October 12, 2017, and March 15, 2018. Among 30,456 invited physicians, 5197 (17.1%) completed the primary survey. Suicidal ideation in the last year, attitudes regarding help seeking, symptoms of depression, and burnout were assessed by standardized questions. RESULTS: Among the 4833 physicians who responded regarding SI, 316 (6.5%) reported having suicidal thoughts in the last 12 months. Most physicians (3527 [72.9%]) reported that they would seek professional help if they had a serious emotional problem. Physicians with SI were less likely to report that they would seek help (203/316 [64.2%]) than physicians without SI (3318/4517 [73.5%]; P¼.001). On multivariable analysis, symptoms of depression (odds ratio [OR], 4.42; 95% CI, 1.89 to 11.52), emotional exhaustion (OR, 1.07 each 1-point increase; 95% CI, 1.03 to 1.11), and selfvaluation (OR, 0.84 each 1-point increase; 95% CI, 0.70 to 0.99) were associated with SI. Among individuals aged 29 to 65 years, physicians were more likely than workers in other fields to report SI (7.1% vs 4.3%; P<.001), a finding that persisted on multivariable analysis. CONCLUSION: In this national study conducted before the COVID-19 pandemic, 1 in 15 US physicians had thoughts of taking their own life in the last year, which exceeded the prevalence of SI among US workers in other fields.

The COVID-19 pandemic has taken a heavy toll on health care workers. At the onset of the pandemic, there was a limited understanding of the unique experiences of minoritized and marginalized physicians* during this national health crisis. This was concerning because of the anecdotal and media reports documenting that Black, Indigenous and other physicians of color, LGBTQ+ physicians, and physicians with disabilities experienced unique negative experiences and undue burden during this public health crisis. Early in the epidemic it became clear that Black, American Indian and Indigenous, Latino/Latina/Latinx† and Hispanic and Pacific Islander communities, as well as historically marginalized and medically vulnerable populations, were disproportionately affected by COVID-19. Minoritized and marginalized physicians are more likely to serve other marginalized patients, practice primary care, and serve in medically marginalized areas.1,2 They therefore often bear a larger portion of the toll of this pandemic, compared to their counterparts. This study aims to center the unique experiences of these physicians and to explore the specific ways that the epidemic impacted them more negatively than their non-minoritized nonmarginalized counterparts. Understanding these unique experiences is essential to making the field of medicine more inclusive and aware of the unique tolls these physicians face. Various factors have historically contributed to the increased burden and negative experiences of minoritized and marginalized physicians. This study focused specifically on discrimination and burnout, as these factors have emerged as areas of necessary attention over the course of the pandemic, specifically as they relate to direct experiences of discrimination, mental health and well-being, physician practice sustainability, and availability of and access to telehealth services. Themes that emerged from the survey responses demonstrate that the COVID-19 pandemic has exacerbated existing health inequities in the U.S.; Black physicians were negatively impacted by the epidemic in various ways; physician burnout remains a primary concern for all physicians regardless of race; and the increase in telehealth use, although accompanied by challenges, has been a positive development of the pandemic. These and other compelling findings are described in further detail in this report.

Organizational factors impacting burnout have been underexplored among providers in low-income, minority-serving, safety-net settings. Our team interviewed 14 health care administrators, serving as key decision makers in Federally Qualified Health Center primary care clinics. Using a semistructured interview guide, we explored burnout mitigation strategies and elements of organizational culture and practice. Transcribed interviews were coded and analyzed using the Braun and Clark (2006) Thematic Analysis method. Mission-Driven Ethos to Mitigate Provider Burnout emerged as the primary theme with 2 categories: (1) Promoting the Mission: "Bleeders" and (2) Competing Priorities: "Billers." These categories represent various properties and reflect administrators' use of organizational mission statement as a driver of staff recruitment, training, retention, and stratification. Data collection occurred before and during the COVID-19 global pandemic, as such additional themes associated with administrative behaviors during a prolonged, clinical crisis provide insight into possible strategies that may mitigate burnout in this setting.

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Invest/Advocate for Patients, Communities, & Workers).‍