All right. Thank you. My name is Kwame Asante Ikuamwa Bwate. Thank you again. Obviously, we're three girls, I have to learn how to handle burnout. And so I think I have a very good experience dealing with the issue of burnout. But I don't have any financial disclosure for this talk. I wanted to just share this slide with you first, because I think it really captured exactly what we need to talk about when we talk about the issue of burnout. I think it speaks on the fact that disease, and I call, I think I really believe burnout is a disease, right? Because I think a lot of times we look at it as an isolated context that we look at. But I think it's a disease that gradually, as we know, the end result of someone who's extremely burned out is something negative, such as suicide, or, you know, we can name it. The research is out there already. So how do we handle this disease? And I think we have to look at it from the standpoint of not just as an opportunity, but really how do we create wellness within a practice model for APPs? And I think that's one of the things that's been missing in the sense that we have to look at the medicine of burnout as wellness. So where does wellness fall into place? Is wellness only in the place of just looking at how we do recruitment? Or is wellness really in the place of how we actually practice? Or is wellness in the place of our everyday skill set? You know, what skills do we have opportunities to do as APPs? I think we really have to step back and look at truly how we dose this disease process of burnout from wellness, I mean, lenses, right? So everything that we do as APPs, from the hiring, and even from the academia standpoint, everything has to look from the perspective of wellness. And where does wellness fall in place in all these different areas? And we have to really drive it and create it. And that's what I'm hoping today I will be able to get across. So my learned objective is looking at the explore the role of the advanced practice provider in critical care medicine, the impact of burnout on advanced practice providers, which I'm not probably going to spend too much time on, but also the path to mitigate burnout among advanced practice providers. So exploring the role of advanced practice providers, I think that is the fundamental, right? And we all know that foundation does matter. You can always say it with me, foundation does matter. Oh, can I, I mean, again, remember, I'm a pastor as well. So I know how to preach. You know what I mean? Yeah. So foundation does matter, right? So you can build a house today, but if the foundation is weak, then it doesn't matter what kind of storm that you may face, that house, it doesn't matter how luxury it looks, it's not going to be able to sustain the storm that you face, right? And that is where I feel like a lot of times when we are dealing with the issue of burnout, we lose sight of, let's go to the foundation. So when we talk about advanced practice providers, I laid out four key components here, the direct patient care. So we have, you know, all advanced practice providers provide direct patient care. They see patients every day, they manage patients, they put in procedures in the ICU. We do all these different skills, centralized, A-lines, name it, right? And then you go to the other aspect of it, and keep in mind that the direct patient care itself is 100%, right? That's what we do every day, every second, the 13 hours or 10 hours that you're working. On top of that, you also have another 100%, which is the indirect, where you are dealing with the social aspect of things, the coordination of care. You are dealing with the length of stay, how's your patient going to move from the ICU to the acute care ward or to go to rehab, especially the patients that are ventilator dependent. Then you also have, on top of all that, trying to precept new APPs or educate the nurse, I mean, the APP students, and then leadership and policy, all this stuff. Guess what? It's 100% as well. Most APPs that I know don't have a dedicated time set for this, right? So you actually have those two concepts that is working for every APP that work. But then I think the root of it is that there is also that component of diversity, whereby we sometimes don't always think of, but if we look at the APPs practice, both nurse practitioners and PAs, there is diversity of our roles. If you go to one hospital to the next hospital next to the block, it's a different sort of like autonomy of practice. The scheduling processes are very different from one place to another place. The number of procedures I used to do from one of my old institutions is very different from what I can do now in my current institution. So there's all this diversity component, and plus now, added to that is also the state. So your scope of practice, then either you have full scope of practice or reduced or restricted. So all that stuff, sometimes you're not even sure who you are as an APP. True point? Yes. Right? And so we see that diversity issue that we are dealing with. And on top of that, the disconnect. The disconnect really speaks of the fact that in practice, we see the advancement of how most places your providers and your medical directors are pushing you sometimes to say you should be able to do A, B, C, and D. But then if you go back and look, and the reason why I can speak on this with so much interest is that from the academia standpoint, it's very different. The expectation is very different. So you have a certain number of hours to complete. And where you do your hours, sometimes in some institutions, it doesn't really matter, right? In some universities. So the APP then all of a sudden graduates, goes to a practice, and they are totally lost because their entire clinical experience does not even match the job that they currently have. Am I speaking to somebody here? Oh, yeah. Good. And what are the influential factors for the role? Now I want to speak about three key components that we are going to look at. And these three components, research has demonstrated that if any one of these are sort of like, you know, at a deficit, obviously the APP becomes more burnt out. Now what has not yet been studied, which I think we may be pursuing that very soon, is looking at all three at the same time to really measure the component of burnout. In the mix of all of that, the global aspect of it is the role transition. And what role transition is, is that I think, I want to make sure I clarify this, you know, I think we've done such a lot of work with, you know, fellowship programs where we've moved most, we've developed fellowship programs and orientation models so that newer APPs transition to this role called being an APP. When I speak of role transition, I'm speaking about the day you became an APP to the day you retire. And, you know, from being a novice to an expert, because a lot of times I think some people can practice for five years or ten years and you realize that there is still quite a huge, vast deficit that they may even experience in their own practice model. And so role transition has to really be from the beginning to the end. And how does that happen? And these are the three things I want to make sure I highlight quickly. Professional identity. Who are we as an APP? And not just only just basically in general, like a PA or a nurse practitioner, I'm really speaking about your subset group, where you work. What is the professional identity in that very place? What are the things, the knowledge, the skills that makes your practice unique of itself? And then let's go a little bit further down there. What is your professional identity? You know, are you able to identify who you truly are as a clinician? Are you able to really demonstrate the fact that maybe I might be stronger just being a clinician, but I also like to also be an educator as well. And I think those differences as well sometimes we can't seem to figure out. So obviously you see that whenever there's any, you know, hindrance to the practice model, there is that burnout already flowing through, because we can't even figure out exactly who we truly are. So there's that struggle of that professional identity. Next to it is the professional development. You know, who am I going, who am I becoming? What do I want to become? Am I becoming just a clinician, or am I becoming a clinician and a researcher, or am I becoming a clinician and an educator? You know, my dear friend Zach talks about the fact of him having, you know, an appointment with the School of Medicine, you know. And so with that, great, you know, but where we go further on is that how does that opportunity build on the next phase of his career, right? And so those are the things we want to really highlight on. And then lastly, professional relationship, which is the core of what we've heard already, and my dear friend Zach talked about it already as well, about mentorship or professional relationship. Who is around us? You know, in your individual places, what is the relationship among the colleagues? Is there someone that really stands up to be able to really help your growth? And so these three influential factors is what truly I believe is the core center of our role, and they do tend to really impact our role. How do I know that? Because some of these papers does demonstrate that, right? So in this very paper they talked, they looked at 1,400 nurses and looked at the relationship between their professional identity and job satisfaction, intention to stay. And what they found was that newly nurses demonstrated lower professional identity, job satisfaction, and intention to stay, right? So they had that, you know, lower performance of professional identity, and obviously that's why we see a lot of newer nurses sometimes tend to leave the field of nursing, and we have this nursing shortage. Professional identity also was significantly correlated with job satisfaction as well. So it's necessary. This other study is one that I actually am very passionate about, because when I read it, it kind of like really spoke to me as a clinician and also as an academic person as well. They looked at 1,200 PA students and also looked at 300 PAs and compared their burnout level. And what they saw was that it was quite close to being the same, both the PAs and the students. Now the amazing thing I want us to really leave here thinking about is this. What happens to those PA students that were severely burnt out? When they graduated, did their burnout all of a sudden vanish, or did that burnout actually follow them along to their new practice? So these are key essential things that we need to be asking ourselves. When we hire someone into the work field, do we even have a baseline of how their burnout level is before they came in, right? We may not even know that. So then we have someone that comes in already extremely burnt out, because as a manager of my division, I've seen it, where I hired someone that I think, honestly speaking, I knew this person from the past and I thought the person was amazing, but came and it was something else. And we try to figure out, man, who is this person? I was like, I actually advocated for this person to be hired, but I'm like, I don't know this person, right? Because the person has experienced so much burnout, so when they transitioned, that burnout didn't go away. They came in with someone who was severely burnt out, and obviously, I didn't even catch up on it. And so now, this person is able to perform to the best of their ability. They are showing signs of decline every single day. At some point, you have to say, maybe you are not safe to practice any longer. And so we have to really look at how it also fosters from the academia and also practice. And I think that's where those who are in academia and academic positions as well, we could do a better job of working with the health systems, right? So how do we fix this disease process? I don't have all the answers, but I can tell you what I do for a living, and being part of my health system, wellness committee within the health system, this is something that is very dear to me, right? So the concept I like to really look at is the job demand and job resources. Now, Baker and his team said that basically, if the demand of the job is extremely high and there is nothing done with the resources, then obviously, that clinician will end up becoming burnt out. And it's true. But the truth is that sometimes there are some jobs that you cannot change the demand. So working in the trauma service, for example, you can't change the demand. You can come in one day with five patients, and the next hour, you may end up having 20 patients. And you can't help that, right? So the demand sometimes cannot be changed. Nevertheless, we have to also look at how do we optimize and mitigate the resources that we have. And so when I speak of job demand, I'm not just speaking about just coming in and just working in the resource, I mean, the census, but the system-identified process. When we speak about system-identified process, I'm speaking of change. Does your institution or your setting of work, do they embrace change? How does change work through your place of service, culture? What are the barriers that it's seen in your individual places? Barriers really speaks of the things that this is how we like to do things, and we don't want to change, workload. And obviously, next to it is looking at the job resources, which I will outline these three things that we talked about already. So the first recommendation I want to give is integrating professional identity into the APP practice model. And how do we do that? How we do that is that, one, we have to understand the fact that we need to be mindful and conscious of the fact that we need to make sure that the APP practice and APPs do have a professional identity. Now, this is something that is niche, and we have to look at targeting self-efficacy as the ultimate goal. And so when we speak of self-efficacy, we are speaking about the things that really bring someone a measure of strength and confidence and leadership in their role. And there's tons of studies out there that demonstrates that providers that have a higher level of self-efficacy, they are able to withstand more obstacles when they face obstacles. They are able to do better. They have a clear identified goals. They are able to improve in their growth. They have a clear professional development plan in place. Why? Because they have that confidence, because we have created and built opportunities around that person to make sure that person becomes successful in what they do, right? So it is necessary that we are looking at how does one build on their success as a clinician. So when your APP does a central line and they do a good job getting the first central line, what is next? If they don't do a good job getting the first central line, what can we do to help that person build that confidence or build that self-efficacy knowing that they can also do it? So it's really building up on self-efficacy, and that's something that I think sometimes we are not mindful of. So professional, when you are doing your outcomes and you are sitting down with your APPs at the end of the year and talking about the next phase of the cycle, how do you support them? How do we encourage them? What are the choices of words we choose? So building and integrating professional identity into the practice model. Secondly, is really integrating professional development. Now Zach spoke a lot about this, so I'm not going to spend too much time on it, but professional development is one that I know that being in leadership, I know we talk about this. And in most APP practice, we talk about APP1, APP2, the clinical ladders. And I think those are good. Those are very good to build clinical ladders. But we have to step back a little bit and ask ourselves, does the clinical ladder of professional development, is it done looking at the individual APP? Or is it done looking at the collective body? I think we need to have the mindset that it should be done looking at the individual APP and how it impacts the collective body, if that makes sense. And so if we have all the APPs in APP1, APP2, they are similar, but there has to be diversity in it. So how are we creating a professional development from the lens of diversity, equity, and inclusion? Does one APP who may not want to do research have to also want to do research? Probably not. They may have other different interests. So that is why I believe that professional development cannot be this big collective thing that everybody falls into either this or that or this other basket. It has to be dealt with from the leadership standpoint based on every individual person and from the lens of diversity, equity, and inclusion as well. The third recommendation, and I'll be almost done, is looking at this was from the US Surgeon General Framework of Workplace Mental Health and Well-Being. And he highlights the five key things that I feel like is very important. And I think I've already mentioned some of these things already, but looking at protection from harm. Now, we know the safety aspect of things within our health system now and the security issues that we are faced now with sometimes our patients and the assault and et cetera, but I don't want us to go too far. Let's even look at when we are rounding, do our APPs feel inclusive and do they feel included in their recommendations? When an APP recommends a certain plan for a patient, are we supporting that plan? Are we coaching that APP during rounds? Let's not look too far. So we have to look at issues like even bullying. Are our APPs being supported from these areas? So protection from harm. The other thing is connection and community, social support and belonging. That also, again, we have to look at it from the standpoint of as a collective team, who is around that person? Sometimes I always like to speak on this with leadership. If you have an APP that does not have any other APP within it, get that APP connected to the Society of Critical Care Medicine, right? Let them build a collective family around that group. But it is essential. I think we all need each other. I know my career has been built over the years because of the friends that I've found within my career, right? And I'm sitting here today talking to you all, and my boss is sitting right there, my medical director is sitting right there, and I'm excited that he's watching me, right? So he's probably going to grade me when I get back home. But that is the relationship that we have. We have fostered our relationship that we support each other. When he's doing something, I support him. When I'm doing something, he supports me. And that is the culture that we have to make sure that we create and develop. You know, work-life harmony. What is the autonomy? Do people have autonomy over their schedule? Do they have autonomy over their way, you know, their practice model? And I think we need to start looking at all these areas because they are very essential in how someone feels brought out. Mattering at work, do they feel that there is a sense of meaning? Do we appreciate our APPs at the end of the fiscal year? Is there any awards or anything like that that is being recognized for the achievement? And not just as a collective, you know, division, but as individuals. Opportunities for growth, that's something I'm always there about. It's really about the mentorship aspect of things. And looking at what are the things. So for example, if someone is interested in research, et cetera, how do we connect that person with someone that can help that person become better in research? And lastly, Mark Lanza's model, really look at four key components. Institutional matrix, work conditions, career development, and self-care. Institutional matrix, which I love because he talks about the fact that, you know, we need to start looking at, we have all these different matrix that the hospital, you know, always likes to talk about. The number of VAP rates that we have, the number of fall rates that we have. Why don't we have something about, you know, the wellness of the team? Why don't we speak about that? Because if we are not doing well, then guess what? We have to really make it a part of our process to improve. So why don't we actually make it publicly to everyone to know what is our wellness? The work condition. The work condition looking at schedule, looking at do people feel comfortable, do they feel inclusive? Do they feel like there's a place where they can also engage in other things such as global health, other things like that, right? Career development. Now, career development, there's a lot that he said in that very place. But the last, what I want to say is this. We cannot say we are going to develop a career development plan without dedicated time to support it. I know that's how we used to do, those who have been doing this for a long time, that's how we used to do it in the past. We just do it on our own time. But I don't think we can continue to do that. It is not an answer, it's not a solution. I think we have to look at professional career development whereby people are being supported, they have dedicated time to work on their career development. So whatever the case is, we need to start looking at those different areas as well. And lastly, self-care. Take care of yourself, right? And for those who are managers here, make it meaningful and intentional to make sure that your team is taken care of, right? If your APP is staying late at all times, really address that issue. Make sure they are able to balance things and figure out what is the reason why they are staying so late. And I believe that's the end of my talk, and thank you very much.

burnout

advanced practice providers

critical care medicine

wellness approach

nurse practitioners

physician assistants