Hi, and welcome. I'm Stephanie Schwartz, and I'm a Pediatric Intensivist at the University of North Carolina at Chapel Hill. I'm excited to have the opportunity to discuss provider wellness, burnout, and the learning environment with you all today. I have no relevant financial disclosures or conflicts of interest with the presented material. In this presentation, we're going to talk about provider wellness, burnout, and the learning environment. The three objectives are to define wellness, stress, and burnout syndrome in the medical environment, to discuss the potential risks that stress and burnout syndrome pose regarding professional careers and learning, and finally, to explore potential interventions to maximize the well-being of clinicians and to enable them to continue successful and meaningful careers. So let's get started. The first step in addressing burnout syndrome is to be aware of what it is and why it happens. What is burnout syndrome, and what are the risk factors and warning signs that we need to be aware of? Why is it important to change these factors and address burnout syndrome? The next step is to take action. We need to understand how to address burnout on the individual level, the hospital unit level, and the organizational level as a whole. We also need to know what tools we have to achieve these goals and be aware of the current research and where more research is needed. Finally, we need to understand the benefits of resolving burnout syndrome, which include enabling us as clinicians to enjoy healthy, lasting careers, improvement in patient safety, and a decrease in medical errors, resulting in cost savings overall. Burnout syndrome is not unique to healthcare professions. It is prevalent in the most high-stress positions, and it occurs in settings worldwide. What are stress and wellness? The SECM-3 Thrive definition says wellness is an integration of the mind, body, and spirit. Stress, on the other hand, is defined as an uncomfortable emotional experience accompanied by predictable biochemical, physiological, and behavioral changes, as defined by the American Psychological Association. Stress occurs in many occupations and in all socioeconomic environments, and its negative consequences can reach beyond the workplace and into an individual's personal life as well. As we discuss burnout and wellness, an additional term we should define is resilience. Resilience is not simply the absence of burnout, but is a state of psychological health allowing an individual to cope with and recover from a psychological insult. Resilience is a function of the ability to cope and the availability of resources related to health and well-being. The idea or concept of burnout really came to the forefront in the 1970s with some of the work by researchers Maslach and Frudenberger. The first published articles got a lot of attention, but there still wasn't a lot of interest among academicians, which meant there wasn't a big push for standardized research. At this point, burnout was considered more of a social problem rather than one with medical consequences. The data in these early works was largely non-empirical, looking at trending behaviors and individual symptoms. In the 1980s, there was a shift toward empirical studies. Researchers began looking at working models, collaborative evidence, and interventions to prevent burnout. Standardized measures were developed during this time period. Research was being translated into other languages, and the concept and consequences of burnout finally started to gain recognition. There are currently two tools that are used to measure and assess burnout. The first of these is the Maslach Burnout Inventory from 1981. It's the tool that's most used and most widely accepted, especially in critical care. The Maslach Burnout Inventory uses 22 questions to assess emotional exhaustion, depersonalization, and personal accomplishments. A lot of institutions are using this in the hospital setting at the point of hire. However, as many of us in this room know, there can be a lot of stress associated with a new job. When it's used in this capacity, it needs to be repeated about six months later, or at least annually. The second tool to measure burnout is the Burnout Measure Tool, which was developed in 1988. It's not as widely used as the Maslach Burnout Inventory, but it also measures the physical and emotional impacts of stress and burnout. Even though burnout has been discussed for a long time, there's significantly more discussion about it now. That's probably because there's less stigma surrounding mental health issues in general, and burnout specifically. This is Maslach's definition of burnout syndrome, shown graphically. There are three components – exhaustion, depersonalization, and reduced personal accomplishments – and in burnout syndrome, they are all combined. Depersonalization is an indifferent attitude towards work, and it manifests in negative, sarcastic, or unprofessional attitudes towards co-workers and others. In the healthcare setting, that can include patients as well. Reduced personal accomplishments refers to poor professional self-esteem and an inability to really evaluate or appreciate your self-worth. This is when you begin doubting both the purpose and the quality of the work that you're doing. Exhaustion can be either emotional or physical. Emotional exhaustion has several unique attributes and is generally the most widely used domain of the Maslach burnout inventory. Alone, it has shown adequate reliability for individual and unit-specific measurements of burnout. Sometimes we hear the term compassion fatigue or alternatively, vicarious traumatization or secondary stress. Compassion fatigue differs from burnout, but it can coexist with burnout. Typically, the onset of compassion fatigue is more abrupt than burnout, with an acute onset of symptoms. It can develop as a result of one traumatic interaction, or it may develop over time from the cumulative effects of many interactions. It can also occur after being exposed to someone else's trauma. With compassion burnout, there's a feeling of numbness about what you're doing and why it matters. This slide provides risk factors for burnout syndrome. Age is the first risk factor. Most people think of burnout as something that occurs when you're older and you've been in your career for some time. But actually, it tends to be more common among younger people and people early in their training. In fact, it's almost twice as likely to occur in younger people compared to older people. Personality traits include people who are perfectionists, those who are overcommitted, and those who are idealistic. A lot of the traits we consider to be ideal in critical care employees, yet they can also make someone more prone to burnout. People with neurotic personalities are also more likely to develop burnout syndrome, while extroverted people are less at risk. Organizational factors include scheduling constraints, staffing problems and shortages, no advancement model in place, and a poor work or leadership structure. Unit and location specific factors include environments that are high acuity or high census, palliative and end-of-life care environments, and critical care units. Obviously, these units tend to have a higher patient turnover, increased mortality, and an increased number of ethical and moral considerations involved in care and decision-making. Obviously, these words are all used to describe intensive care units. The last factor is sleep disruption, including decreased quality of sleep, decreased quantity of sleep, and poor sleep recovery. These are the 12 stages of burnout. Most of us are somewhere along this scale. At the top levels, you're driven by an ideal, you're ambitious and hardworking, you hate saying no when you're asked to complete projects or take on extra responsibilities, and you don't want to let your colleagues down. As you move down this chart towards higher stages of burnout, you increase your workload and you begin to put your own needs and goals last. In stage four, you wind up feeling miserable, but you don't know why. Stage five is the death of values. You're losing sight of those ideals that motivated you in the beginning. You wind up getting frustrated, cynical, and even aggressive in your attitudes. In stage seven, you're emotionally disengaged and you're becoming more socially isolated and cut off from other people outside of work. In stage eight, your friends and family may begin to become outwardly concerned about the changes that they've seen in you. This is when you begin asking yourself, what have I become? In stage nine, you'll pull away from social contact and begin to see other people as burdens rather than a support network. This is when a lot of people turn to drugs and alcohol. At stage 10, you begin to feel a sense of inner emptiness and you feel that everything is useless. By stage 11, you feel completely indifferent and you just don't care. Then finally, stage 12 is physical and emotional breakdown when rates of suicide ideation increase. Suicide or not has both physical and psychological symptoms. On the psychological side, we have anxiety, anger, fear, irritability, cynicism, negativity, and detachment. There's a loss of hope, empathy, and happiness, and you might feel frustrated, discouraged, or dehumanized. It's also common to feel overwhelmed, incompetent, and unsuccessful at what you are trying to accomplish, and you begin to have problems with your memory. For the physical symptoms, you can experience fatigue or exhaustion, sleep problems, muscle aches or muscle fatigue, GI problems, headaches or migraines, and decreased libido. Burnout is especially prevalent in healthcare settings. Published studies show physicians are 36% more likely to develop burnout syndrome than other at-risk populations, and that number increases to more than 40% for physicians who are on the front line, like those working in emergency departments and trauma units. Pediatric critical care physicians are 71% more likely to have burnout syndrome. About a third to one half of physician trainees and about a quarter of residents experience burnout symptoms. This is not unique to physicians, but is present in all disciplines of the healthcare setting. For nurses, up to a third have symptoms of severe burnout syndrome, and almost 9 out of 10 have at least one of the three classic symptoms of burnout. This is a simplistic representation of how stress affects learning. On the left, in the upper left-hand corner, we see that when something stressful happens, it causes glucocorticoids to be released from the hypothalamic-pituitary-adrenal axis, stimulating neurotransmitters and ultimately initiating the fight-or-flight response. Catecholamines are released, resulting in increases in heart rate, blood pressure, respiratory rate, metabolism, and body temperature. All of these effects decrease your ability to process and synthesize data. Stress has a similar effect on memory. Here we see that acute stress causes a release of stress hormones that act on the hippocampus. Dendritic bodies start to degrade, preventing information from passing from one neuron to another. When that information is no longer passing repeatedly across the neural synapses, learning and memory storage are negatively affected. As those dendritic spines continue to degrade, it becomes much more difficult for information to be identified and stored by the hippocampus. When you are continually exposed to stress, you're in a prolonged state of hyperarousal. That consistent exposure leads to a strengthening of the neural pathways that are responsible for controlling stress responses. Now the brain begins to act and behave as if it's in a constant state of stress, giving it little to no time to recover from stressful stimuli. Hyperarousal affects the prefrontal cortex and prevents syncing and communication across these prefrontal lobes. At the same time, high levels of cortisol are continually expressed, weakening the immune system. Burnout syndrome causes different effects, but they're all linked together. It increases the risk of substance abuse, especially in the higher stages of burnout. Substance abuse also tends to be higher among physicians compared to the general population. The rates of post-traumatic stress disorder or PTSD and suicide ideation are increased in people with burnout syndrome. And again, these numbers are higher in medical professionals. Impaired mental health affects the sleep cycle and sleep hygiene, decreases the desire for physical exercise, and can cause overeating or loss of appetite. Social activity decreases as burnout syndrome becomes worse, resulting in a major work-life imbalance. Published studies show that almost 50% of physicians are dissatisfied with their work-life integration. Work-life integration and burnout are linked to other safety climates as well. Comparing units with high work-life integration scores versus units with low work-life integration scores, t-tests demonstrate that positive work-life climate was associated with better teamwork and safety climates, as well as lower personal burnout and burnout climate, all with p-values less than .001. This figure, published in our paper in BMJ Quality and Safety in 2019, demonstrates a quartile division of 440 work settings assessed in a safety climate survey. Work settings with the best work-life climate scores are portrayed in white, while work settings with the worst work-life climate scores are portrayed in black. Focusing first on teamwork climate here on the left, work settings with the best work-life integration also had the best teamwork climate scores. Statistically, these scores were significantly different when compared to teamwork scores in the poorest work-life climate quartiles. The climates with the best work-life integration also had the best safety climate, better leadership, increased readiness for quality improvement, and lower burnout in oneself and one's colleagues. The strongest association is with personal burnout and burnout climate. So it's clear, burnout has numerous effects on our patients and organizations as well. Burnout among health care workers has been linked to adverse patient safety events, including increased rates of infections and lower patient satisfaction. Patient safety and medical errors are other effects we see with burnout syndrome, and there's actually a bi-directional relationship. Burnout syndrome causes medical errors, which then increases the person's stress. As stress levels rise, the risk of medical errors continues to increase as well, creating a cycle. With medical errors come workforce costs associated with lengths of stay, morbidity rates, and mortality rates. Burnout also increases the rate of employee turnover, which means onboarding and training costs increase. When we think about validated ways to address burnout, first we need to think about the causes. I love the schematic created by one of my mentors, Dr. Kyle Rader from Duke Children's Hospital. There's a lot of things that play into burnout and resilience, but we often put these factors into two main categories. One is the institution category, or the environment you work in that's really setting you up for burnout. That's things like production pressure, lack of control over the job, over your schedule, conflicts with colleagues. And the other category is personal factors, things like work-life imbalance, poor sleep, social isolation, positive versus negative thoughts. When I'm talking to clinicians about burnout, I often use a microbiological analogy. It's easy to imagine the environment you work in as the pathogen that's trying to make you sick, and your personal resilience is your immune system. Certainly you can do things that reduce the pathogen's capability to attack you, so you can improve the work environment, but if you don't have an immune system, even a weak pathogen can set you up for burnout. In the same way, if you work in a toxic environment, you can boost your immune system or your resilience, and that can help with burnout, but certainly won't always prevent it. Additionally, there may be a time as well that the environment can serve as an attenuated pathogen, like a vaccine. That is, a supportive environment can be protective against burnout. And this is what we should really strive for, while also supporting personal resilience. Ultimately, it has to be a balance between these two categories. How do we address burnout? On the individual level, the first step is to develop positivity, purposely focusing on the positives in our work. That can be especially difficult in high census or high acuity positions, but it's essential for optimizing those neural pathways that can be hindered by stress. Next, we need to practice self-care. That means focusing on whatever you personally find beneficial or positive. That could include getting more exercise, eating healthier, improving your sleep hygiene, or taking part in certain activities that help you build positivity and pleasure into your life. The third component involves support, and that means you want to both be supportive of others and be receptive to others who try to support us. Being supportive helps build resilience, and it also acknowledges good works, especially when support comes in the form of praise. Next is to practice mindfulness. That could be deep breathing exercises or taking a brief pause during a particularly stressful situation to decompress and regroup. The goal is to shut off that external stimuli, ideally recreating a more positive situation before moving on to the next task. Next, follow your passion. Depending on your goals and your job, that could be learning something new in the career field that you're in, taking on a new project, joining a committee, or embarking on a new research project. The goal here is to regenerate passion and enthusiasm for your work. The next step is to build resilience or the ability to bounce back. You can develop resilience by learning and practicing coping skills, problem-solving skills, and even by working on being more optimistic or having a better sense of humor. Finally, manage your symptoms. Seeking outside help can be especially difficult for physicians, but the goal is to make sure the treatment you receive is objective and on track. At the institution level, we can manage burnout in many different ways, starting with the top of this triangle. We can start by developing a safe and supportive work culture. When employees feel safe, they feel respected, and they're more likely to speak up. They're more likely to be involved in problem-solving and more likely to bring new ideas to the table. Next is enhancing the quality of work life. This means doing things outside of work with your colleagues to help establish connections outside of the work environment. Optimizing staff fit really starts with hiring when you should think about the workplace culture and other factors to ensure new hires are a good fit and don't feel stressed out right from the start. Avoid hiring just to fill a position, but try to hire people who will mesh well with the staff that are already on board. Supporting resilience includes encouraging good self-care habits. In the healthcare setting, having regular meetings or debriefings after specific events has been shown to be very helpful in decreasing stress and burnout as well as improving morale. Encouraging professionalism and holding everyone to the same standard improves morale as well as trust. Opportunities for career growth and offering incentives is important for keeping people motivated and for helping them feel valued. Giving employees time to work on their projects during the workday reduces stress by allowing employees to reserve their personal time for relaxation and de-stressing when the workday is done. Having family meeting protocols helps decrease the stress associated with giving patients' family members discouraging news. Finally, enhancing residency mentorship and providing resources to help with mental and physical well-being is critical. Many residents don't know that employee assistance programs exist, so you need to make sure all staff members are aware of what's available. This is especially important for residents, considering younger people are at a greater risk for burnout syndrome, as mentioned earlier. In a recent review on the science of healthcare worker burnout, Dr. Rader and colleagues highlighted existing evidence supporting effective tools to reduce burnout and improve healthcare worker well-being and sought to provide actionable and evidence-based interventions. Two published meta-analyses of interventions to reduce burnout in healthcare workers demonstrate that organizational interventions targeting the work environment and interventions targeting individuals each have a benefit in reducing burnout. Each of these studies also demonstrates a larger potential cumulative benefit with organizational interventions when compared to the interventions focused on individuals included in the studies. Unfortunately, these organizational interventions tend to be more resource-intensive than personal interventions and may also be more difficult to sustain. In this figure from their paper, the multifactorial contributors of burnout in both categories are listed. As already stated, institutional factors include the characteristics of the work environment, including work culture, work schedule, growth opportunities, participation in decision-making, peer support, and prioritized opportunities to cultivate well-being, potlucks, happy hours, group debriefs around stressful situations. Individual contributors include such factors as self-care, such as yoga, meditation, exercise, fatigue management, one's ability to cultivate meaning, work-life balance, and having supportive relationships. A lack of any of these factors predicts vulnerability to burnout, whereas having these factors appears to prevent and help reduce burnout. Therefore, it is not surprising that institutional and individual interventions are often aimed at increasing these factors. About 40 years after it was initially discussed as a serious health concept, burnout syndrome is getting a lot more attention. In December of 2017, the Critical Care Society Collaborative held an event with 50 experts across the spectrum of health care, including experts in medicine, psychology, sociology, occupational health, nursing, holistic medicine, and allied health. The goal was to identify meaningful and actionable ways to identify, prevent, and manage burnout among medical professionals using an array of interventions. The findings from that initiative will help formulate research and practices moving forward. Critical Care Society Collaboratives will disseminate and publish their findings in the future. What about future implications for burnout syndrome and its study and treatment? There are some trials currently underway, but there needs to be more research, ideally in the form of randomized controlled trials, with an emphasis on identifying interventions that can reduce burnout, improve health, and decrease attrition among health care professionals. We need to continue to educate people and reduce the stigma associated with burnout and mental health in general, letting people know that they are not alone. Ideally, we want to look for ways to prevent burnout, or at least to halt its progress so we can reverse it earlier and avoid more serious symptoms. Finally, we need to focus on improving access to resources as well as utilization of these resources. In summary, burnout syndrome is very real, and it's becoming more prevalent in health care settings. Recognition and prevention are very important. Burnout syndrome affects the entire person, and it directly affects brain function, learning, memory, and work. Both individual and institutional interventions can be undertaken to help decrease burnout syndrome and hopefully prevent it. Work-life integration affects burnout, but there's so much more. Finding meaning in your work, having a voice in decision-making, opportunities for personal growth, feeling respected and included by teammates, and many more. Self-care and effective communication are critical, and as noted in the previous slide, there's so much work and research that needs to be done. Here are a list of additional references for this talk. Thank you for taking the time to listen to this discussion of provider wellness, burnout, and the learning environment.

provider wellness

burnout syndrome

healthcare professionals

individual interventions

institutional interventions

future implications