Thank you for the invitation to speak at the 2023 Society of Critical Care Medicine Congress. My name is Mark Moss, and I'm the head of the Division of Pulmonary Sciences and Critical Care Medicine at the University of Colorado School of Medicine, and I'm going to talk about a NEA-funded research lab called the Colorado Resiliency Arts Lab, or CARL. I do not have any disclosures in relation to commercial interests with this type of research. The research has been funded in the past by the National Institute of Health, and is currently funded by the National Endowments of the Arts. I'd like to start with a few caveats about burnout in healthcare professionals. This is something I saw in Medscape a few, a year ago, and it basically shows the depth of the problem. I think it's important to realize that this epidemic of burnout is going to require intensive interventions, and that feeding people pizza alone is not going to fix the problem. I think it's also important to demonstrate that we use the term burnout, and I think that is acceptable and important. However, there are what I might call deeper forms of psychological distress that healthcare providers are suffering from, including depression, symptoms of anxiety, post-traumatic stress disorder, suicidal thoughts, and substance abuse. And when we think of developing therapies for healthcare professionals to improve their well-being, we have to think about interventions that will address some of these deeper forms of psychological distress. With funding from the National Endowment of the Arts, we created the Colorado Resiliency Art Labs in 2018. The goal of CARL is to create a vibrant, collaborative creative arts therapy community that's committed to enhancing healthcare professional well-being and alleviating psychological stress in the workplace and beyond. I would recommend you visit our website, which is listed here, that will have more information about CARL. So what is creative arts therapy? The basis is that when people experience trauma, it's sometimes hard to verbalize the impact of that trauma on the individual. What creative arts therapy does is it gives individuals a medium, whether it's dance movement, writing, music, or arts, that allows them to describe or process the event in a non-verbal way. It's also important to realize creative arts therapy is therapy, and it is guided and supported by a licensed creative arts therapist, and that therapist helps the individual or the group identify, explore, and process their feelings and learn new ways to cope with their stress and trauma. So I'd like to show a video that we made of our arts therapy program that will explain the basis and impact of creative arts therapy for healthcare professionals. Hi, I'm Stephanie, and I am a certified child life specialist. The thing I love most about my job is the fact that this is really the perfect blend of what I wanted. I wanted to be in healthcare, but I didn't have to do those invasive procedures, and I could help children understand their experience and really master it. But my job is really hard. I have had to explain to kids when they're going to die, and that's not easy. I'm Catherine, and I am an art therapist. It's taxing emotionally on our healthcare professionals to be there every day for these kids when your heart is breaking. And what do we do with the pain, with the trauma, with the sadness? And what we found is that bringing creative arts therapy into the room, there is a natural healing element that is almost magical in a sense. As a child life specialist, I use play as a way to educate children, to help them feel that this environment that they're in, the hospital, the clinical setting, is normal. And I think art really translates that for healthcare professionals, because sometimes it can be really hard to verbalize the frustration or the sadness or the grief that you're feeling. Having that task that everyone is doing, it puts us all in this normal, calm space. And then we can reflect on what we've done and go even deeper, and I think that's where that therapeutic level comes in, is the combination of that facilitator and the group discussion. What is happening across the country is that healthcare professionals are getting exhausted. We are often asked to do more than what is emotionally healthy for us. We don't really expect our nurses and our doctors to admit that they are sad, or to admit that they are tired, even. The world is a potential answer to that problem. To have a place where those truths can come out and can be explored and processed and then shared with other people, I think is an incredible way to build community. This program has helped me understand that I am a strong person and I do have skills and I am capable of being a really great child life specialist, but sometimes the scenarios that I go through are just really hard. Having that resource available to team members, to staff, to employees, is just invaluable. So we conducted a randomized, controlled trial of creative arts therapy for healthcare professionals. The inclusion criteria were healthcare professionals who worked at least 20 hours per week in a hospital setting, that also had at least one of the three positive symptoms of burnout, whether emotional exhaustion, depersonalization, or decreased personal accomplishment. The trial was conducted from September 2020 through July 2021, with three different cohorts, each of which, as you will hear, lasted three months. The study design is that individuals were randomized to one of four intervention groups or a common control group. The four intervention groups were art, dance movement, music, or writing. The intervention lasted 12 weeks. Individuals in groups met once a week for 90-minute sessions. The first four weeks were focused on creating a safe space. The second four weeks were focused on developing coping and expressing mechanisms and helping people to understand what their challenges at work are and how do they cope with the intense challenging feelings. The last four weeks revolved around a group project that the individuals did and built on the coping and expressing and translated that into how to integrate and relate as a community. Individuals in the control group and in the intervention groups completed pre and post surveys at the beginning and at the end of the 12-week period of time. Overall, we enrolled 146 individuals in the intervention group for each one in the control group. As you can see, on average, individuals were in their 30s, the majority were women, and the majority were single. The majority were also white. 50% of the participants were nurses, however, 10% were doctors, and there were other health care professionals, including behavioral health specialists, social workers, et cetera. On average, participants had worked in health care for eight to 10 years, and importantly, these individuals had sought other help for their stress. Approximately 25% to 30% were taking medications for anxiety, about 25% were taking medications for depression, and about 30% to 40% were participating in other forms of therapy or counseling in addition to the intervention. Here are the results of the study. These are pre-post changes in measures of psychological distress. You can see that the first is symptoms of anxiety, symptoms of depression. This is symptoms of post-traumatic stress disorder, and the last three are the three domains of burnout, emotional exhaustion, depersonalization, and decreased personal accomplishment. Improvement in scores would be a negative value. So you can see here in anxiety or symptoms of anxiety, the intervention in black had greater improvements in their symptoms of anxiety compared to the control group. It's the same for depression, post-traumatic stress disorder, where the control group got worse over the 12-week period of time. Emotional exhaustion, again, improvements in depersonalization. When you talk about improvements in decreased personal accomplishment, a positive score shows benefit, and you can see, again, the intervention had a beneficial effect on decreased personal accomplishment when compared to the control group. This is another way of looking at the results where the data is dichotomized into either having positive or negative symptoms for anxiety, emotional exhaustion, or depersonalization. You can see the intervention group, when compared to the control group, had improvements in whether they were positive or negative for these symptoms. For example, in anxiety, the control group, about 60% or 59% had symptoms of anxiety at a baseline. At the post-intervention questionnaire, it was 58%, so no real change. When the intervention group had gone from 72% had symptoms of anxiety, where after the intervention, it dropped to 39%, and all of these were statistically significant. We also followed the individuals for a year after the intervention had ended. You can see here the solid lines are those that were randomized to the intervention. The dotted lines were those that were randomized to the control group. Purple is PTSD, red is anxiety, and yellow is depression, and you can see that there were persistent beneficial effects in anxiety and depression in the intervention group compared to the control group. There were also continued improvements in symptoms of PTSD in the intervention group. However, the control group also improved over time, so that 12 months, the results were not significantly different. What this slide shows is that even after the intervention ended, the effects of the intervention on symptoms of psychological distress remained in healthcare professionals up to 12 months. The study does have some limitations. The control group was not an intention control. The individuals randomized to the control group filled out surveys pre and post the 12-week period of time. The study is unblinded, and it was also conducted during the COVID pandemic, which was an extremely stressful time. It's unclear whether the benefits of the intervention would remain in a less normally stressful time. The study also has some strengths. There were rigorously developed protocols. We included a variety of healthcare professionals, and there was extensive outcomes and excellent follow-up in the study. We also conducted qualitative interviews with participants at the conclusion of the intervention, and several themes came across to try to understand what was the essence of the intervention that seemed to be the most effective. One of the key components was developing a sense of community. It was important that participants were from different disciplines, had different roles, other doctors, nurses, and also worked in more than one hospital, showing commonality of the problems and difficulties with psychological stress across domains, hospitals, et cetera. It was also important that there was physical separation between where the creative arts therapy program was conducted and the primary place of employment, and this helped create a safer space. The participants also mentioned that the facilitator skills was very important, and it's something we'll have to think about how to reproduce and expand. The individuals felt that contributing to a group project was important in a way for them to utilize some of the skills they'd learned in a group setting. It's also important they were pushed out of their comfort zone through the creative activities, and when we asked them if they would want to just do the arts or just do the therapies, a theme that came across is that it was important to do both at the same time. So in regard to next steps, we are currently conducting a similar trial for non-patient facing employees in our academic medical centers. This would be administrators, support staff, and PhD researchers to see if the benefits are the same in that patient population. We also are conducting a monthly lecture series on arts and medicine that if you go to our website, you can figure out how to sign into that. Those occur the third Friday of every month, and we have speakers from around the world. It's a remote lecture series. We're also implementing the creative arts therapy program for employees at Children's Hospital, and we're developing a traveling exhibit to show the impact of creative arts therapy on healthcare professionals. So I'd like to thank the large group of people that have participated in this research. Most importantly, I'd like to thank the members of CARL, who are Catherine Reed at Children's Hospital, Tony Adebuli, also at Children's Hospital, Hillary Sin at Children's Hospital, Michael Henry at the Lighthouse Writers Workshop. Thank you very much for the invitation, and enjoy the rest of the symposium.

Mark Moss

Colorado Resiliency Arts Lab

burnout in healthcare professionals

creative arts therapy

psychological distress