All right, good morning, everybody. Thank you to the Society for inviting me here today to speak with this distinguished panel. My name is Heather Meissen, and I'm an acute care nurse practitioner at Emory HealthCare in Atlanta, Georgia. And I'm going to talk a little bit about our work that we've done within the Emory Critical Care Center, as well as within our APP Critical Care Fellowship Program. I have no financial disclosures, but I do want to identify that part of this work was supported by the IOTA chapter of the Vanderbilt University School of Nursing, Nurses' National Honor Society. And our objectives here. So the profession of nursing is one that is highly regarded and valued by society. However, providing continued care to the sick and injured can come with internal and external consequences. The role of the critical care advanced practice provider has become a high-intensity, high-stress, high-demand profession in which constant exposure to suffering population can potentially lead to burnout syndrome. The incidence and prevalence of burnout is difficult to quantify among healthcare providers just due to its abstract and subjective nature of the concept. Additionally, many times this issue goes unreported or underreported, leading to more questions surrounding the true impact of this disease. But what we do know from surveys is that about 18 to 46 percent of critical care providers report feelings of depression or despair, suggesting that high-intensity work environments could lead to higher levels of burnout syndrome. Burnout syndrome is not specific to healthcare-related professions, but is found more commonly in professions with service-related careers. Healthcare professionals are at an increased risk of burnout due to work conditions directly related to patient care activities. Burnout can occur at any time in a professional's career, but is typically found to occur within two to six years of service. Prolonged job dissatisfaction and work-related health complaints frequently precede burnout. Other antecedents include prolonged negative work environments, outside work stressors, and toxic work personalities. An alarming number of providers are leaving the healthcare workforce due to increasing rates of burnout syndrome, and the gaps in provider care coverage are caused by burnout may lead to increased workload for those left behind. The population is aging, and technologies are expanding to provide more sophisticated support. Therefore, more patients are receiving advanced therapies and higher acuity care, such as critical care. The U.S. healthcare system cannot afford to lose highly trained and experienced providers to burnout syndrome. Targeted programs and interventions to combat burnout syndrome must be supported to prevent a workforce crisis. And I am echoing some of the information that has been presented earlier, but burnout syndrome impacts the individual provider, the healthcare system, and ultimately the patient and their associated outcomes. In regards to the impact of burnout syndrome on the provider themselves, burnout syndrome leads to job dissatisfaction, loss of career engagement, and feelings of despair. Burnout syndrome has been linked to increased healthcare provider depression, and unfortunately, increasing rates of provider suicide. In regards to what that impact looks like on the healthcare system, burnout syndrome exacerbates provider shortages impacting quality of care. Burnout syndrome leads to high job turnover, and decreased quality of care, and decreased patient satisfaction. And then finally, and most importantly, burnout syndrome impacts the patient. Burnout syndrome leads to loss of compassion, depersonalization, which has been linked to medical errors that can negatively impact patient mortality. In my DNP program, I did do an extensive review of the literature, so if you want to do a lit search, save yourself some time, reach out to me, I've got it for you, I can provide that at the end. But I did find some common themes and common attitudes. One important theme to note was that there was an association between high acuity patient care and higher reported symptoms of burnout syndrome. I also found that work environments or work culture impacts wellness. High acuity work environments include supportive administration, opportunities for professional growth, and colleagues who are friends. And then on the flip side, negative work environments had limited resources or support. Because of the research I was running during my DNP program, I had the honor of participating when this study, led by Dr. Vanessa Mull. This was a longitudinal, cross-sectional study that sought to determine the impact of coronavirus patient management on burnout syndrome in a multi-professional ICU team, and to identify factors associated with burnout syndrome. At the time, this was the first and only study looking at the team as a unit, as a whole, and to identify common themes across professions. We ran two cross-sectional surveys that were conducted at our large academic institution. The first survey was performed in March to May of 2017, and I'll talk a little bit more about that, because we did not know that COVID was going to hit at that time. And then the second was performed during the pandemic from June to December of 2020. All right, so let's look at our timeline here. The Emory Critical Care Center, you might hear me refer to it as the ECCC, that's how we lovingly refer to it at home, but the Emory Critical Care Center was concerned about the growing problem of burnout syndrome well before COVID hit. As mentioned, we rolled out our first survey in March of 2017, which was part of a needs assessment to identify and quantify burnout syndrome in our critical care teams. The leadership team at the ECCC then sought to address burnout syndrome by allowing providers and colleagues of units and teams the opportunity to submit project proposals which would target reduction of burnout syndrome in their local space. I will talk about what those projects look like in a minute, but they were well received by the units. The teams loved them, and it was determined to be successful at the time. So a second phase rolled out in 2019, and unfortunately in 2020, COVID hit, and we had to halt all of our projects at that time. There were some problems here that I did identify, at least from my perspective, and eventually what led me to work on my DNP project of resiliency training. These prior pilot projects did not address the underlying issues. These projects offered only temporary solutions, so basically putting a Band-Aid on the issue, and it was my goal to really help with resiliency training to create a robust evidence-based project to prevent burnout by teaching resiliency strategies. Resiliency training programs address individual needs with the goal to prevent burnout. Okay, so before we go into the resiliency training project, which I implemented into our APP Fellowship Program, I want to talk about the project ideas that were submitted from providers and unit teams at our critical care center. Project proposals which were submitted and implemented included things such as pet therapy, and you can see here in these photos a few of our providers and nursing colleagues that are enjoying some pet therapy with some cute doggos. Additionally, some folks put in proposals for things like team apparel, hoodies, sweat jackets, team T-shirts, or having meals sponsored at their faculty meetings. My unit actually created what we called the doctor's lounge for our APP team, which was essentially a cardboard box filled with snacks and goodies that we kept in our office, but our medical director made sure to keep that stocked every month, and it still continues to this day. We love it. People like food, I guess. We also used some funds to create a reference library where our physician trainees, our residents, and our APP team can come in, grab a book, and use that to reference or help them in their practice. For example, too, the books that I really like out of that library include The Ventilator Book and The Advanced Ventilator Book, and I don't know if you all know those books, but they're great for helping you troubleshoot some difficult ventilation strategies. And then finally, I think the most impactful project that came from this initiative was the ECCC 5K Run Walk, which is now called the Alyssa Majesco Memorial 5K Walk, and I have a picture here from this. This was last spring, one of our 5Ks that we held. We do invite back survivors to come and talk about their experience. This is for families of providers, families of survivors and patients, and the brains behind this project is in the upper right-hand corner, Sandy Aukers, who is a PA in critical care, and then you guys might recognize Craig Coopersmith down in the bottom. He seems excited to be walking. And if you don't know Alyssa Majesco, she was a shining light physician educator who passed away a few years ago due to complications from cancer. So, okay, now we're going to switch gears into discussing what our survey looked like, and we did implement the Maslow Burnout Inventory Survey for Health and Human Services associated with the Areas of Work-Life Survey. The Maslow Burnout Inventory Survey is a validated survey tool to assess levels of burnout in healthcare providers. Here are some of the examples of what questions would look like on this for the participants. It's broken down into the three major concepts or domains that create burnout syndrome, which are depersonalization, emotional exhaustion, and personal accomplishment. An example of a question that supports depersonalization is, I don't really care what happens to some patients. Participants can answer either zero, which is never, on a Likert scale, all the way up to six, which is this feeling this way every day. An example of a question which targets emotional exhaustion, I feel emotionally drained from my work. I feel this zero, never, or I feel this six every day. And then finally, an example of personal accomplishment, I have accomplished many worthwhile things in my job, zero, which is never, or six, which is every day. You will see that that is a reciprocal of the other two domains. The areas of work life survey was also used in our survey to identify areas of work life that drive burnout. This survey looks at six work environment areas, workload, stress of self, sense of control, reward, community, fairness, and values. So what did we find? The pre-pandemic survey was sent to 1,200 critical care clinicians, of which 570 responded, which is a 46% response rate. Again, this was in 2017. The pandemic survey was sent to 1,400 clinicians, in which 700 responded, about 49.9% response rate. Response rates for nurses, APPs, and physicians were all over 50%, the highest being a response rate from our APP colleagues at 79%, and lowest for our other clinicians at 29%. Other clinicians were defined as respiratory therapists, pharmacists, dieticians, social services, and our pastoral care colleagues. Burnout syndrome worsened in our female clinicians during the pandemic, primarily driven by our nursing colleagues. Burnout syndrome worsened in the multi-professional ICU team during the pandemic, with a disproportionate increase in our nursing colleagues. Before the pandemic, 59% of respondents demonstrated burnout syndrome, and this increased to 69% of participants reporting burnout in our pandemic survey, which is statistically significant. Nurses had the highest increase in burnout during the pandemic. Emotional exhaustion and depersonalization both increased, whereas the levels of personal achievement decreased during the pandemic. Specialty differences were noted, with the biggest differences seen in nurses. Nurses had the absolute worst score in each domain. As far as the areas of work-life survey, workload was the only domain that significantly increased during the pandemic, predominantly driven by our nurses and our APPs. Control and value were not affected as a result of the pandemic. This study demonstrates that not all professions were equally impacted, with a disproportionate increase in burnout in our nursing colleagues and our female clinicians. Our results also surprisingly demonstrated similar levels of burnout in ICU clinicians, whether or not they took care of COVID patients, which strongly suggests that simply practicing critical care during the pandemic put all members of the ICU team at risk. So let's talk about the resiliency training program that I piloted. This pilot project intended to translate evidence into practice to improve health and well-being of critical care advanced practice providers. The project included the implementation of an established resiliency educational program and subsequent evaluation of the impact of the program on feelings of burnout in our providers. The design included a small group of participants in an intervention arm, as well as an in-control arm. We used the Maslock burnout survey that I'd recently discussed as a pre- and post-test. Project implementation did occur within the ECCC, the Emory Critical Care Center, which is part of the Emory Healthcare Network. Our Emory Critical Care Center operates 16 intensive care units across five hospitals, servicing a total of 250 inpatient intensive care beds, as well as over 140 tele-ICU beds. The ECCC consists of over 70 critical care trained physicians and over 140 advanced practice providers in our multidisciplinary team approach to critically ill patients. This project included only new graduate, new hire nurse practitioners and physician assistants. What did we use? We used an established resiliency training program called Realizing Resilience, which is a master class for psychologists. This program was broken into six modules, which taught attention, motivation, action, and thoughts, which all grouped together to help improve your defense mechanisms in times of stress. So what did we find? Here are the results from our control group. The average mean emotional exhaustion for the control group pre-intervention was 2.5, and I will kind of discuss what that means here in a minute. For depersonalization, the average mean was 2.1, and for personal accomplishment, 5.1. This group score correlates to an engaged burnout profile. Over four months of basic training or on-the-job training with no access to resiliency training, surveys were completed in our control group. We found that the control group emotional exhaustion score was 2.9, depersonalization 2.3, and personal accomplishment 4.7. This group score, again, correlates to the engaged profile showing no change in feelings of burnout. Regarding the intervention group, pre-intervention surveys completed and resulted in an emotional exhaustion average of 2.9, depersonalization average of 2.7, and average mean of 5.0. This group as a whole demonstrates to an engaged profile. After the intervention was complete, emotional exhaustion average mean 2.0, depersonalization 1.6, and personal accomplishment 4.6, which is still consistent with an engaged profile. And while this group average profile did not change significantly during the study, we did find some interesting trends in individual scoring. Individual analysis of pre-survey showed that three of the intervention group exhibited signs of burnout syndrome, while three had profiles consistent with being engaged. One had a profile consistent with being disengaged, and one with being ineffective. After completion of the intervention, two of the profiles improved to feeling overextended, while the remaining profiles remained unchanged. Individual analysis of pre-surveys showed that three of the control group exhibited burnout syndrome, three had profiles consistent with being engaged, and one exhibited profiles consistent with being overextended. Individual analysis of post-surveys showed that three burnout profiles remained burned out, while the overextended profile improved to an engaged profile. However, two of the engaged profiles did change to feeling overextended and ineffective. Participants in the intervention group were engaged in the resiliency training class, and qualitative results demonstrated approval of the training program with over 87% of the participants being satisfied with the content and actually requesting to continue the program annually. Collectively speaking, while not statistically significant, the intervention group did demonstrate a decrease in emotional exhaustion and depersonalization, while the control group demonstrated an increase in those, as well as a decrease in personal accomplishment. Many limitations do exist due to our convenience sampling, our single center sampling and sample size, as well as our restricted timeline. As a reminder, most burnout syndrome does occur within two to six years of your career, and this was only conducted over a six-month period. However, this pilot program project does serve as a starting point for further investigation to measure and help reduce burnout. So where do we go from here? Well, we have learned that burnout syndrome impacts the individual provider, the healthcare system as a whole, and ultimately the patient and their associated outcomes. We learned that nurses have high burnout rates, female ICU providers have high burnout rates, the pandemic worsened those feelings of burnout, and resiliency education may improve feelings of burnout. Developing resiliency strategies is an important factor in combating burnout among healthcare professionals. This project demonstrated techniques on how to integrate resiliency training modules into a structured onboarding process. And results from the study, however inconclusive, the qualitative data did suggest that participants valued this instruction and these modules. Results from the study also highlight the need to have multiple tactics to combat burnout, such as providing debriefing sessions for staff. Burnout syndrome is a prevalent phenomenon which impacts the healthcare workforce and ultimately healthcare delivery. It is imperative that future research projects start strategies to develop resiliency. And I will end with just a picture of one of my PA fellow graduates leading a code during the pandemic. I'm extremely proud of their work that they do to provide care to our critically ill patients. And here's all the references. Like I said, if you want to do a lit church, just call me. Thank you.

burnout syndrome

critical care providers

healthcare industry

resiliency training

workforce crisis